The Department of Health and Human Services (DHHS) released a new form, Form DHHS 3014 ADAP, to help state AIDS Drug Assistance Programs (ADAPs) better track and report the use of HIV drugs. The form is designed to collect data on HIV drug utilization patterns and trends. It will help DHHS understand the impact of HIV drugs on patients' health and identify any potential areas for improvement. States must submit the form by August 1, 2017.
Question | Answer |
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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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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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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