Renew Your MAP Before It Expires!
It is important to renew your MAP coverage before it expires. Look at your MAP card – the expiration date is on the right side (xx/xx/20xx).
If your card expires in less than 30 days Call Central Health Customer Service at 512-978-8130 to renew your coverage or go to http://apply4map.net.
Central Health’s Medical Access Program and MAP BASIC (collectively, Program(s)) help people access health care by paying for certain health care services. Whether you qualify for MAP or MAP BASIC depends on your income, where you live, the availability of other health care coverage, and the existence of alternate sources of payment for health care. Your ethnicity, color, religion, creed, national origin, gender, disabling condition, sexual orientation, or political belief(s) will not be considered and will not affect your eligibility for these Programs.
I swear that all the statements I have made in connection with my application for these Program benefits, including my answers to all questions about income, county of residence, and other payment sources are true and correct to the best of my knowledge and belief. I understand that, because my eligibility of these Programs is based on my answers to these questions, any omission, failure or refusal to provide Central Health to terminate my Program benefits and to seek recovery of any payment Central Health made, on my behalf for health care services.
I agree to report any of the following life changes to Central Health within 14 days of the date of change:
- Mailing address and telephone number
- Address where I live
- any change in income that may affect my eligibility
- number of people who live with me/or a household member becomes pregnant
- enrollment in Medicaid, CHIP, Medicare, or other private health insurance or notification that I am eligible for any other coverage program that may pay for my care
If Central Health identifies an unreported change to any of these five material areas of my application, I understand that my Program benefits may be terminated and that Central Health can take any other action within its authority, including filing civil or criminal charges against me.
I understand that my enrollment in MAP and MAP BASIC is conditioned on my agreement to allow Central Health to verify that statements I have made in connection with my application for Program benefits and that enrollment status may remain pending until such agreement is given and verification is obtained from a credible source (e.g., Social Security Administration of the Texas Workforce Commission). I further understand and agree that Central Health may request that I pay for a portion of the cost of my health care and that Central Health may recover any costs paid for my health care from a third party in the event that I file a claim for personal injury damages.
Finally, I acknowledge and agree:
My authorization for my employer, the Social Security Administration, The Texas Health and Human Services Commission, the Texas Department of State Health Services, and the Texas Workforce Commission to release benefits, enrollment, claims, wage, and other records to Central Health; and
My authorization will be valid for a period of twelve months from the date I sign this Application Responsibilities form or until I revoke my authorization in a signed writing delivered to Central Health;
My acknowledgement that I am responsible for ensuring that my mailing address, telephone number, and any cell phone number or email address I list beneath that next paragraph are accurate and are up to date (i.e current) at all times during my Program enrollment.