Form Dhhs 3014 Adap PDF Details

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.

QuestionAnswer
Form NameForm Dhhs 3014 Adap
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names3014adap_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:

/($6(/($9(!!%/$1.,)$33/,&$17'2(6127+$9(21(

)"5$16*(1'(5,6&+26(1 !5(48,5(6$33/,&$1772&+226("5$16*(1'(5!8%&$7(*25<6(($

)6,$125$7,9($:$,,$125$&,@&6/$1'(5,6&+26(1 !5(48,5(6$33/,&$1772&+226($ $&(!8%&$7(*25<6(($

),63$1,& $7,12,6&+26(1 !5(48,5(6$33/,&$1772&+226($17+1,&,7<!8%&$7(*25<6(($

)7+($33/,&$17,6,1&$5&(5$7('&+(&.<(63529,'(7+(1$0(2)7+(&2817<-$,/$1'3529,'(7+(-$,/?6$''5(66,1%2;(6 $1'

**NOTE: P"tients inc"rcer"ted in st"te or feder"l prisons "re not eli(ible for ADAP.

)$33/,&$17 3$7,(173529,'(6$1$/7(51$7(0$,/,1*$''5(66>$//&255(6321'(1&(:,//%(6(17727+$7$''5(66

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 27699-1907

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

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Applic"nt’s Si(n"ture

Rel"tionship to P"tient

Current D"te ####

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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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