Application

to Receive Al lowable Services for • AIDS Drug Assistance Program (ADAP)

• ADAP Premium Plus (Insurance Services)
H IV/AI DS Patient Care Programs
• State Housing Opportunities for Persons With AIDS (HOPWA)
• Ryan White Part B Consortia and other HIV/AIDS Programs

HIV positive diagnosis is an eligibility requirement.

Part Check if you are HIV Positive: Yes No Unknown (Provide a copy of an HIV Laboratory Test that shows your HIV status.)

Applicant Name:
Information
______________________________________________________________ ____ __________________________________________________________________

/ /
First M.I. Last

Date of Birth: ________ ________ _______________ Male Female Transgender

M M D D Y Y Y Y

Race: ________________________ Ethnicity: ______________________ Language Spoken: ____________________________

Are you a veteran? Yes No Are you receiving veteran’s benefits? Yes No
Are you pregnant? Yes No Don’t Know
Do you have a housing need? Yes No
Do you rent? Yes No Monthly Payment $________________
Do you own your own house? Yes No Monthly Payment $________________
When were you first diagnosed with HIV? ________________________

Address where you currently live:

Part
___________________________________________________________________________________________________________________________________________
Living Street Address

Arrangements ______________________________________________________ ________ ________ ___________________________________________________________

City State Zip County

Mailing address (if different):

___________________________________________________________________________________________________________________________________________
Street Address

______________________________________________________ ________ ________ ____________________________________________________________

City State Zip County

Telephone:
( )
________________________ - ________________ ( )
_______________________ - ________________ ( )
________________________ - ________________
Home Work Other Contact

Email:_____________________________________________________________________________________________________________________________________
How many adults live with you?____________ How many children live with you?____________(under 18 years of age)
Check how you prefer staff to contact you:
Home Phone Work Phone Other Contact Phone Mail Other____________________________________________________

Do you have an existing health insurance policy? Yes No

Part If Yes, provide name of insurance company:__________________________________________________________________________________________

Medicaid If No, does your employer offer health insurance as a benefit? Yes No

Insurance If No, provide proof from employer showing insurance is not available. Proof provided? Yes No
and Other Are you taking a prescription drug(s)? Yes No
Programs If Yes, please list:_______________________________________________________________________________________________________________________
DH150-884, 08/2014, Rule 64D-4.003(5), F.A.C.
 SCReenIng fOR OtHeR PROgRAmS
Please check if you are participating in one of the following programs; and bring the award letter, eligibility letter, or card as proof:
Medicaid Medicare Project AIDS Care (PAC) Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF) Women, Infants, and Children (WIC)
Other:__________________________________
If you have a case manager, please provide his or her name: __________________________________________________
SKIP PART 4 IF YOU HAVE PROOF OF ELIGIBILITY FOR ONE OF THE ABOVE PROGRAMS.

Household Income means gross income from all sources received by the applicant and the applicant’s spouse (if married).
Household Monthly Income Before Taxes and Deductions
(Gross Income)

Part Name Relationship

of person
Monthly
Work
Monthly
Social
Monthly SSI
Retirement
Unemployment,
Child Support, Monthly
Totals
Check
if No
(First & Last) Public Assistance,
to you Income Security Income Income*
Other
Household
Applicant $ $ $ $ $
Monthly
Income $ $ $ $ $

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

*If you checked “no income,” provide a statement as to how food, Total Monthly Household Income

clothing, and shelter are being provided to you.

Do you have a checking account? Yes No If Yes, what is your current balance?__________________________
Do you have a savings account? Yes No If Yes, what is your current balance?___________________________
Name of employer(s):_____________________________________________________________________________________________________________________
Are you self employed? Yes No If Yes, what type of business?_______________________________________________

___________________________________________________________________________________________________________________________________________
Business Street Address

__________________________________________________________________ ________ ____________________ ___________________________________

City State Zip County

_______ I understand that I am responsible for giving truthful and correct information on this application to the best of my knowledge. Failure to
be truthful may prevent or delay a determination of eligibility to receive services.
_______ I understand if I knowingly give information that is not true or withhold information and receive services that I am not eligible to receive, I
Part may be lawfully punished and have to reimburse the Department of Health for services.
_______ I understand the information I provide may be verified that may include computer matching, and the information I give about my income
Rights & may be checked.
_______ I understand that the information will be kept confidential in accordance with Florida and Federal law.
Responsibilities _______ I understand not all services I am eligible to receive may be available, accessible, or funded; and I may not meet specific program
(initial each qualifications for some programs.
item shown) _______ I understand that at any time during the application process, I can be denied eligibility if my actions are uncooperative, disruptive of office
procedures, threatening, or hostile toward staff.
_______ I understand that the Department of Health eligiblity staff cannot discriminate because of race, color, sex, age, disability, religion,
nationality, or political beliefs.
_______ I understand I have the right to ask for a fair hearing if I think the decision of my case was unfair or incorrect.

Client ___________________________________________________________________________________________ ______________________________________

Signature Client Signature Date

Walk-in Mail Other:________________Date determined eligible:_______________

For
Eligibility Date of appointment:_________________ Eligibility staff:_______________________________________________________
Staff Only Date referred to: Case Management___________ADAP___________ADAP Premium Plus___________HOPWA___________Other____________
(optional)
Date determined ineligible:_______________ Date supervisory review:_______________

Fair hearing information was provided? Yes No

'

DH150-884, 08/2014, Rule 64D-4.003(5), F.A.C.