New Patient Forms

Individuals interested in becoming a patient at TOMAGWA must email the below-completed documents before a free tele-screening.

English

Requirements for TOMAGWA
Eligibility Application
HIPAA Disclosure
Statement of Support
Wage Verification
Self Employment Form

Español

Requisitos para TOMAGWA
Solicitud de elegibilidad
Divulgacion de HIPAA
Declaracion de apoyo
Verificacion de salario
Declaración de ingresos del negocio propio

Email Forms Here

Click here to download an app for android and iphone to scan your forms for free

Become a Patient

Click here for the full requirements to be a patient at TOMAGWA

1

Live in our service area within Harris, Montgomery and Waller county

2

Have a household income of 200% or below the federal poverty level

3

Complete new patient forms and submit through email

4

Complete a tele-screen eligibility appointment