Adap Colorado Form – Fill Out and Use This PDF

10. At what phone numbers can we reach you during daytime hours?

Phone Number (	)	☐ Home	☐ Work	☐ Cell Phone
May we leave a message on this phone? ☐ Y		☐N
Phone Number (	)	☐ Home	☐ Work	☐ Cell Phone
May we leave a message on this phone? ☐ Y		☐N

11. Is there anyone that our staff may call if your mail is returned to us (or your phone number does not

work)? ☐ Y	☐N
Name:	Phone Number: (	)

Does this person know that you are HIV positive? ☐ Y ☐N

12. Do you have a case manager/social worker at an AIDS Service Organization or Medical Clinic? ☐ Y ☐N If yes, list them below:

Name	___	Agency/ Clinic ______________________________________
Name	___	Agency/ Clinic ______________________________________

If you do not currently have one, would you like ADAP to make a referral to a case manager or social worker?

☐Y ☐N

13. What is your current relationship status?

☐Single ☐ Married ☐Divorced ☐Legally Separated ☐Other __________________

For ADAP purposes, "married" refers to legally recognized marriages in Colorado.

This information affects your income eligibility for ADAP.

14. How many children do you have living with you? ______ How many other children do you have that don’t

live with you for whom you provide 50% or more of their monthly support? ______

15 If you are female, are you pregnant? ☐ Y ☐N ☐ Not Applicable If yes, when are you due to deliver?___________(Month)

16. What is your Social Security Number (if you have one)? __________‐________‐______________

MEDICAL INFORMATION

17.Who currently writes your HIV medication prescriptions?

18.When was your last visit with your HIV doctor? Month_________ Year________

19. Have you ever been told by your doctor or a laboratory that you have AIDS?	☐ Y	☐N	☐ Not Sure
20. Have you ever been told that you have Hepatitis C?	☐ Y	☐N	☐ Not Sure
21. In the past six months, have you had labs drawn to check your CD4 count?	☐ Y	☐N	☐ Not Sure
22. In the past six months, have you had labs drawn to check your viral load?	☐ Y	☐N ☐ Not Sure

Page 2

v03202012

ADAP Certification and Authorization of Release of Information

I certify that the information provided in this application is complete and accurate, to the best of my knowledge.

I understand that my failure to be accurate and complete may prevent or delay a determination of eligibility to receive assistance from ADAP.

I understand that, for the purposes of determining my eligibility for ADAP, the CDPHE, its contractors and subcontractors may request further documentation to verify my HIV positive serostatus, my Colorado residency, and my financial, employment or insurance information as necessary.

I authorize my prescribing physician, case manager, other departments and programs of the State of Colorado, and other information sources to release information necessary to complete the application process, to verify the accuracy of any information provided in this application, and to verify my ongoing eligibility for ADAP. I further authorize the CDPHE to utilize data from public health records to verify that I am living with HIV.

I authorize the CDPHE to release information to my physicians, case manager, treatment centers, and other healthcare providers to facilitate provision of ADAP services.

I understand and agree to submit periodic information regarding my continued eligibility for ADAP, including proof of income, proof of residency, health insurance coverage, and general updates on forms provided by the CDPHE. I understand that changes in my situation will be evaluated to determine my continued eligibility for ADAP. I will be notified in writing if I am to be discontinued from ADAP.

I agree to notify, or have my case manager notify, the CDPHE of any circumstances affecting my participation in, or eligibility for, ADAP. I agree to notify the CDPHE within thirty (30) days if I change my address or other preferred contact information. I further authorize the CDPHE to contact the persons listed as “Emergency Contact” on this form if the CDPHE’s attempts to contact me have been unsuccessful.

I understand that I am to recertify for ADAP twice per year in a timely manner at my birth month and six months after my birth month.

I understand that my ADAP eligibility will terminate if:

-I do not cooperate with efforts to verify information in this application, or

-I do not comply with the activities needed to identify/verify potential sources of alternative coverage, or

-I fail to seek other forms of coverage, as instructed by the CDPHE, for which I may be eligible, or

-The CDPHE becomes aware of material misrepresentation, withheld information, or documented fraud, or

-Qualifying medication is no longer being prescribed to me.

I understand that the CDPHE reserves the right at any time and without notice to modify the ADAP application form.

I understand that my assistance through all CDPHE programs is contingent on state and federal funding. This funding is limited and may expire at any time without extended or alternative funds being available.

I understand that completing this application does not ensure that I will qualify for this program.

I understand that my name, address and any other personal identifying information provided in this application will be available to the CDPHE and its contractors and subcontractors, and that this information will not be disclosed to anyone else, except as required or permitted by law.

I understand that I have a right to ask for a full hearing if I feel that a decision on my eligibility was unfair or incorrect of if I believe CDPHE staff or contractors discriminated against me based on my age, race, ethnicity, sex, gender identity, disability, religion, nationality, or sexual orientation.

I understand that pursuant to the Colorado Governmental Immunity Act, C.R.S. § 24‐10‐101 et seq., the CDPHE is not liable for damages for any injury arising out of my participation in ADAP.

I understand that I may revoke this authorization at any time in writing.

However, the release shall remain valid until such time as I inform the ADAP, in writing, of my wish to terminate services through the program, or until such time as I no longer qualify for these services, whichever occurs first, except to the extent that action has been taken in reliance on this authorization.

A copy of this authorization has the same effect as the original.

_____________________________	___________________________________________	__________
Applicant Name (Please Print)	Signature of Applicant or Parent/Guardian	Date

Return this application to: CDPHE Care and Treatment Program

ADAP-3800, 4300 Cherry Creek Drive South, Denver, CO 80246

Fax: 303-691-7736 Phone: 303-692-2716

v03202012

Employer Insurance Information Form

APPLICANT: This form is required if you or your spouse are employed and you have said that you are not eligible for or enrolled in health insurance. This may be because your employer does not offer health insurance, you are not eligible for specific reasons, or the insurance does not cover needed services. A copy of this form must be provided for every family member that is currently employed.

EMPLOYER: Please complete this form, have an authorized representative sign it, and return the form to the employee. This information will need to be provided every six months.

EMPLOYEE NAME:

EMPLOYER (Business Name)

To be completed by the EMPLOYER:

	1. Do you offer a health insurance plan to any of your employees?			□ Yes □ No
	If NO, skip to the signature portion of this form
	If YES, to whom was the health insurance offered, and was it accepted?
			If not eligible, explain if this person could become eligible in the
		□ Not eligible	future, and when (e.g., becomes full time).
	Employee	□ Offered, but not accepted
		□ Offered and accepted
			Potential eligibility date: ___/____/_______
	Spouse		If not eligible, explain if this person could become eligible in the
		□ Not eligible	future, and when (e.g., employee becomes full time).
	Name(s):	□ Offered, but not accepted
		□ Offered and accepted
	_____________
			Potential eligibility date: ___/____/_______
	Dependent(s)		If not eligible, explain if dependents could become eligible in the
		□ Not eligible	future, and when (e.g., employee becomes full time).
	Name(s):
		□ Offered, but not accepted
	_____________
		□ Offered and accepted
	_____________
			Potential eligibility date: ___/____/_______
	2. What is the date for your company’s next open enrollment period? ____/_____/_____
		When does coverage begin after open enrollment? _____/______/______
COMMENTS: ______________________________________________________________________________

Please attach a copy of your employee benefits summary or other plan information, if available.

EMPLOYER REPRESENTATIVE	TITLE:	PHONE:
COMPLETING THIS FORM:
EMPLOYER’S AUTHORIZED SIGNATURE		DATE:

EMPLOYER: Please return this form to the employee along with explanation of benefits

v03202012