In the realm of healthcare access for the uninsured, particularly for individuals living with HIV/AIDS, the New York State Department of Health Uninsured Care Programs have been a cornerstone. These programs, including the AIDS Drug Assistance Program (ADAP), ADAP Plus (Primary Care), the HIV Home Care Program, and ADAP Plus Insurance Continuation (APIC), are designed to bridge the gap for those who lack health insurance. Central to these efforts is the DOH 3608 form, a Medical Eligibility Form that must be completed by a physician. This critical document works in tandem with the Uninsured Care Programs Eligibility Application (DOH-2794) to assess a patient's eligibility for receiving assistance. Detailing patient and physician information, disease staging, history, and treatment recommendations, the form ensures that comprehensive data supports each application. By requiring evidence such as CD4+ count, viral load, and a history of opportunistic infections or conditions, the form facilitates a targeted approach to care. Moreover, it captures data on the mode of HIV transmission and treatment history, underscoring the tailored support provided through these programs. Physicians play a pivotal role in this process, verifying the accuracy of the information provided, which is then used to determine a patient's eligibility for vital health care support. Through the DOH 3608 form, the New York State Department of Health underscores its commitment to addressing the healthcare needs of HIV-positive individuals, highlighting an organized, compassionate approach to healthcare access.
| Question | Answer |
|---|---|
| Form Name | Doh 3608 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | New_York, cd4, avium, medical eligibility form |
NEW YORK STATE DEPARTMENT OF HEALTH
UNINSURED CARE PROGRAMS
Empire Station, PO BOX 2052
Albany, NY 12220 |
Uninsured Care Programs - Medical Eligibility Form |
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SU MEDICO NECESITA ESTA FORMA
Uninsured Care Programs:
•AIDS DRUG ASSISTANCE PROGRAM (ADAP)
•ADAP PLUS (PRIMARY CARE)
•HIV HOME CARE PROGRAM
•ADAP PLUS INSURANCE CONTINUATION (APIC)
The Medical Eligibility Form must be completed by a physician and should be submitted in conjunction with the Uninsured Care Programs Eligibility Application
MEDICAL ELIGIBILITY: Patients applying for the Uninsured Care Programs must be HIV positive. 1.) PATIENT INFORMATION (Please print or type)
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New York |
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2.) |
PHYSICIAN INFORMATION and VERIFICATION (Please print or type) |
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Hospital or Facility |
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Alternate Contact for |
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Medical Follow Up
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Physician Verification: |
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I verify that the information on this application is true to the best of my knowledge. |
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Physician Signature |
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(MUST BE ACTUAL SIGNATURE) |
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(DATE) |
ON THE BACK OF THIS FORM, PLEASE PROVIDE THE INFORMATION REQUESTED. IF YOU HAVE ANY QUESTIONS ABOUT MEDICAL ELIGIBILITY PLEASE CONTACT OUR TOLL FREE HOTLINE
WHEN COMPLETED PLEASE RETURN TO:
EMPIRE STATION
P.O. BOX 2052
ALBANY, NY
MEDICAL INFORMATION
Please Answer All Questions
Patient’s Name |
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DOB |
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SECTION I - DISEASE STAGING |
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1.) |
Is the applicant HIV infected? |
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] Yes |
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] No |
Year of First Positive Test |
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2.) |
What is this applicant's most recent CD4+ (T4) count? |
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What is lowest CD4+ (T4) count? |
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4.) |
Lymphocyte % |
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% |
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Viral Load (absolute value) |
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Date of Test |
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PLEASE ENCLOSE A COPY OF THE LAB (CD4+ and/or Viral Load) REPORT |
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Does the applicant have |
[ ] Yes [ |
] No |
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Date of Diagnosis |
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Location at time of AIDS diagnosis (State and County) |
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SECTION II - DISEASE HISTORY |
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1.) |
Does the applicant now have or ever had: |
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] Malignancies |
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] AIDS Dementia/PML |
[ ] Mycobacterium Avium Complex |
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] Wasting Syndrome |
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] Syphilis |
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] PCP |
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] Hepatitis: [ ] A [ ] B [ |
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] E |
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2.) |
Tuberculosis: [ ] No Evidence of TB |
[ ] Unknown |
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Evidence of TB and: |
or |
Evidence of TB but: |
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[ ] Active, receiving treatment |
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] Inactive, prophylaxis |
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] Active, no treatment |
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[ ] Inactive, no prophylaxis |
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] Active, treatment unknown |
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] Inactive, treated |
3.) |
Mode of HIV transmission (check all that apply): |
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] IVDU |
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] Sexual Abuse/Assault |
[ ] Sexual contact with: |
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] Transfusion/Blood Product |
[ ] Health Care Setting |
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] Male |
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] Other |
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] Maternal |
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] Female |
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] Unknown |
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[ ] Person with HIV/AIDS |
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] IVDU |
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SECTION III - TREATMENT HISTORY |
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Has a comprehensive HIV evaluation been conducted? |
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] Yes |
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] No |
2.) |
Has |
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] Yes |
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] No |
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Has PCP prophylaxis been recommended? |
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] Yes |
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] No |
4.) |
Has the applicant had these immunizations: Influenza |
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] Yes |
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] No |
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Hepatitis B Vaccine |
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] Yes |
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] No |
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Pneumovax |
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] Yes |
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] No |
5.) |
Is the applicant participating in clinical trials for the treatment of HIV? |
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] Yes |
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] No |