In order to be tax compliant, it's important for businesses to understand their obligations when it comes to federal and state taxes. For example, did you know that there is a form called Doh 3608 that must be filed in order to claim a sales or use tax exemption? This article explains what the Doh 3608 form is and how to file it correctly. If you're not sure whether you need to file this form or not, contact a tax professional for help. Filing the Doh 3608 incorrectly can result in fines and penalties, so it's best to be as informed as possible about your filing requirements.
| 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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(M.I.) |
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New York |
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Date of Birth |
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Telephone ( |
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(Home) |
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(Work) |
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(Ext.) |
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2.) |
PHYSICIAN INFORMATION and VERIFICATION (Please print or type) |
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DEA # |
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Name |
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NYS License # |
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Hospital or Facility |
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Medicaid # |
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Address |
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NPI # |
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Office Telephone Number ( |
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Ext. ______ |
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Alternate Contact for |
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Medical Follow Up
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(Telephone #) |
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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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/mm3 |
Date of Test |
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3.) |
What is lowest CD4+ (T4) count? |
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/mm3 |
Date of Test |
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4.) |
Lymphocyte % |
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% |
Date of Test |
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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 [ |
] C [ |
] 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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1.) |
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 |
3.) |
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 |