The DHHS 3014 ADAP Financial Eligibility Application is a critical document for individuals seeking assistance through the AIDS Drug Assistance Program (ADAP). This form is designed to determine eligibility based on financial criteria, ensuring that those who require support for managing HIV/AIDS can access the medications they need. The process involves a comprehensive assessment of both gross and net income, requiring applicants to report earnings and expenses accurately. Importantly, the form also delves into deductible medical expenses, a key factor in evaluating an applicant's financial situation. For families, the form prompts the disclosure of all countable family members' financial resources, emphasizing the collective assessment of eligibility. Instructions clearly underscore the importance of completing all fields to avoid delays, with specific notation that applications will be pended if incomplete. Additionally, it sets forth conditions around changes in financial and family circumstances, mandating prompt notification to maintain eligibility. The form also addresses the provision of information for annual net income calculations, further signifying the thorough nature of the eligibility determination process. This document not only serves as a gateway to vital medical support but also underscores the program's commitment to a fair and comprehensive review of an applicant's financial capacity to afford necessary medications without undue hardship.
| Question | Answer |
|---|---|
| Form Name | Form Dhhs 3014 Adap |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 3014adap_instru ctions dhhs 3014 adap form |
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INCOME FORMULAS:'57E<1B (R)J?>D9>E?EC<I5=@<?I54G17551B>5BC<9CD9>3?=56?BD85 =?>D8C256?B5D8541D5?61@@<931D9?>?BD85B5AE5CD5441D5?6 3?F5B175G89385F5B9C51B<95B *>5=@<?I=5>D (U)J,17551B>5BCE>5=@<?I541DD85D9=5?61@@<931D9?>?B6?B3?>C53ED9F541IC4EB9>7D85@B5F9?EC =?>D8C <9CD9>3?=56?B=?>D8C256?B51>416D5BD8541D5?61@@<931D9?>?BD85B5AE5CD5441D5?63?F5B175G89385F5B9C51B<95B Must report Gross and Net Income.
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Annual Net Income |
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3?@95C?69>CEB1>3531B4C for all countable family members. |
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All fields must be completed or application will be pended.
Purpose:"+,6)250,686('72&2//(&7@1$1&,$/,1)250$7,215(48,5(')25'(7(50,1$7,212)(/,*,%,/,7<1&('(7(50,1('(/,*,%,/,7<(;7(1'6 )251,1(0217+61(:)250,65(48,5(':+(1&+$1*(6,1&2817$%/()$0,/<0(0%(56$1' 25,1&20(2&&8552&(66,1*7,0(,65('8&(':+(17+,6 )250,6/(*,%/()5(48(67('$'',7,21$/,1)250$7,210867%(5(&(,9(':,7+,16,;0217+61&203/(7()2506:,//%(3(1'('
Instructions for Completin( Cert"in Items on this Form:
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**NOTE: P"tients inc"rcer"ted in st"te or feder"l prisons "re not eli(ible for ADAP.
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Count"ble F"mily Members$5(5(/$7('727+($33/,&$17%<%/22'0$55,$*(25$'237,21/,9(,17+(6$0(+286(+2/'$1'6+$5($@1$1&,$/ 5(63216,%,/,7<"+($33/,&$170867%(,1&/8'(',17+(&2817
Deductible Medic"l Expenses$5(7+26(3$,'25,1&855('%<$&2817$%/()$0,/<0(0%(5'85,1*7+(0217+635,25727+(($5/,(67'$7( 2)6(59,&(;3(16(63$,')25%<$127+(53$57<255(48(67(')25&29(5$*(%<$352*5$0&$1127%(86('$6'('8&7,216(',&$/(;3(16( '('8&7,2167+$7(;&((' 0867%('2&80(17(',1)8//
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M"il (do not F"x) this "pplic"tion "nd document"tion to:
DHHS, Division of Public He"lth, Purch"se of Medic"l C"re Services, 1907 M"il Service Center, R"lei(h, NC
TERMS AND CONDITIONS FOR APPLICANT — Must be signed and dated or the application ill be pended.
I"(ree to notify the interviewer within 30 d"ys "bout "ny ch"n(es,10<$''5(66@1$1&,$/5(6285&(6(;3(16(6)$0,/<6,78$7,2125+($/7+,1685$1&( &29(5$*(7+$70,*+7$))(&70<(/,*,%,/,7<)25(3$570(173$<0(17352*5$06&(57,)<7+$77+(,1)250$7,21+$9(3529,'(',6$758($1'&203/(7(67$7(0(17 2))$&76$&&25',1*720<%(67.12:/('*($1'%(/,()81'(567$1'7+$7,1)250$7,213529,'('0$<%(&+(&.('%<$67$7(5(9,(:(5$1'$*5((723529,'(7+( @1$1&,$/5(&25'65(48,5('72&$55<2877+,6,19(67,*$7,21$/6281'(567$1'7+$70<(03/2<(50$<%($6.('729(5,)<,1)250$7,21&21&(51,1*0<,1&20(
I"ssi(n insur"nce benefits to the Dep"rtment.$*5((725(3$<7+((3$570(17$1<021(<5(&(,9()520,1685$1&(25/,$%,/,7<6(77/(0(176)256(59,&(6 25$33/,$1&(6:+,&+7+((3$570(17385&+$6(')250(81'(567$1'7+$768&+3$<0(1766+28/'%(0$'(727+((3$570(17:,7+,1'$<62)7+('$7(7+$7 5(&(,9(7+(0$1'7+$77+($028173$,'727+((3$570(176+28/'127(;&(('7+($028177+((3$570(173$,'7+(3529,'(5)857+(5$*5((7+$7)$,/85(725(3$< $66,*1(',1685$1&(%(1(@76727+((3$570(17,6$5($621)25'(1,$/2))8785(6(59,&(5(48(676727+((3$570(17817,/68&+$028176+$9(%((15(3$,'
Iunderst"nd th"t my eli(ibility for Medic"id will be checked.+(5(%<$87+25,=($1'$*5((72$)5(((;&+$1*(2),1)250$7,21%(7:((17+(,9,6,21 2)(',&$/66,67$1&($1'7+((3$570(172)($/7+$1'80$1!(59,&(65(/$7,1*72@1$1&,$/,1)250$7,21$1'7+($028172)6(59,&(63529,'('%<(,7+(5 352*5$0
I hereby "uthorize the interviewer "nd service providers to rele"se to the Dep"rtment "nd its "ffili"te pro(r"ms7+(,1)250$7,213529,'('217+,6)250 $1'$/627+(0(',&$/5(&25'62)7+(3$7,(17:+,&+3(57$,1720(',&$/6(59,&(625$33/,$1&(6)25:+,&+5(,0%856(0(17,6%(,1*628*+7)5207+((3$570(17
I"lso "uthorize rele"se of this inform"tion to the county he"lth dep"rtment:+(5(7+(3$7,(175(6,'(6$1' 255(&(,9(66(59,&(6$/62$87+25,=(5(/($6( 2)7+(,1)250$7,21217+,6)25072$//+($/7+'(3$570(176$1'+263,7$/6,1257+$52/,1$"+(6(',6&/2685(66+$//%(0$'()25385326(62)'(7(50,1,1*7+( 3$7,(17?6(/,*,%,/,7<)25(3$570(173$<0(17352*5$06$1')25&21'8&7,1*352*5$0(9$/8$7,21
Ivolunt"rily (ive my consent to the terms of this rele"se. <&216(176+$//%(9$/,')25$3(5,2'2)21(<($5)857+(581'(567$1'7+$70$<5(92.(0< &216(17$7$1<7,0(!8&+5(92&$7,21'2(6127$))(&77+(9$/,',7<2)0<&216(17)25,1)250$7,21',6&/26('35,25727+(5(92&$7,21
Iunderst"nd th"t I m"y "ppe"l the deni"l of this fin"nci"l eli(ibility "pplic"tion.1)250$7,2121+2:72$33($/7+('(1,$/&$1%(2%7$,1('%<:5,7,1* 7285&+$6(2)(',&$/$5(!(59,&(6 $,/!(59,&((17(5 $/(,*+ 81'(567$1'7+$73$<0(17%<7+((3$570(17)25+($/7+&$5( 3529,'('720(,6'(3(1'(1783210(0((7,1*$//@1$1&,$/$1'0(',&$/5(48,5(0(1767,0(/<68%0,66,212)$87+25,=$7,215(48(676$1'&/$,06$1'7+( $9$,/$%,/,7<2))81'6
+(5(%<&(57,)<7+$7+$9(5($'257+(,17(59,(:(5+$65($'720(7+(7(506$1'&21',7,216'(6&5,%('$%29($1'7+$7$*5((72&203/<:,7+7+(0$/62&(57,)<7+$7+$9(%((1 3529,'('$123325781,7<72$6.7+(,17(59,(:(548(67,216$%2877+(6(7(506$1'&21',7,216$1'7+$781'(567$1'7+($16:(56:$6*,9(1
Applic"nt’s Si(n"ture
Rel"tionship to P"tient
Current D"te ####
&(57,)<7+$7+$9((;3/$,1('7+(7(506$1'&21',7,216&217$,1('$%29(727+($33/,&$17$1'+$9(:,71(66('+,6 +(56,*1$785(
Type or Print Interviewer’s N"me
Interviewer’s Si(n"ture
A(ency N"me
Street Address/P.O. Box
City/St"te/Zip Code
Current D"te ####
Phone
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&EB381C5?6#54931<1B5(5BF935C'5F95G