Massachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form

Transcription

1 Massachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form Please print clearly and answer all questions. Review the attached instructions before you begin. Mail the completed application and supporting documentation to: Community Research Initiative of New England/HDAP 38 Chauncy Street, Suite 500 Boston, MA Or you may fax the application and supporting materials to For help with this application, please call HDAP at SECTION 1 APPLICANT INFORMATION 1. First Name: MI: Last Name: 2. Name of legal guardian (if applicant is a minor): 3. Mother s first name: 4. HDAP ID # : 5. Date of Birth (MM/DD/YYYY): / / 6. Social Security #: Residential street address: City: County: State: ZIP: 8. Mailing address: Same as residential address Address: City: County: State: ZIP: 8a. If you would like all of your mail sent to your case manager instead of to your mailing address, please check here: 9. Phone Numbers: Home phone number: ( ) May we leave a message on your voic or answering machine? Yes No Work/cell phone number: ( ) May we leave a message on your voic or answering machine? Yes No 10. address:

2 Massachusetts HDAP/CHII Application Form Name: HDAP ID # Pg Gender: M F Transgender Unknown 12. If Female, Pregnancy Status: No Yes Unknown 13. If Transgender: Male-to-Female (MTF) Female-to-Male (FTM) Unknown 14. Number of legal dependents: 15. Marital Status: Single Married Separated Divorced 16. Country where you were born: Preferred spoken language: 17. Race (select all that apply): American Indian or Alaskan Native Asian Black/African American Native Hawaiian or other Pacific Islander White Unknown 18. Ethnicity (select one): Hispanic/Latino Non-Hispanic/Latino Unknown 19. Additional racial or ethnic groups (select all that apply): Brazilian Cape Verdean Haitian Portugese Eastern European Southeast Asian Sub-Saharan African Other, specify: SECTION 2 - INCOME INFORMATION 20. Current annual income: $ 21. Do you receive income from any of these sources? (select all that apply): Salary Unemployment benefits Social Security (SSI, SSDI, SSA) Worker s compensation Private disability (short- or long-term) Retirement/pension Veteran s pension Interest/dividends Rental income Other income, specify: 22. Did you file a federal or state income tax return for last year? Yes No 23. Are you currently working? Full-time (35 or more hours/week) Part-time (less than 35 hours/week) Not working 24. If you are currently working, does your employer offer health insurance? Yes No

3 Massachusetts HDAP/CHII Application Form Name: HDAP ID # Pg Case Manager Information: SECTION 3 - PROVIDER INFORMATION This section should be filled out by your provider(s). Name: Institution: Address: City: State: ZIP: Phone: ( ) Ext. Fax: ( ) address: Preferred form of contact: Phone 26. Clinician Information: Name: Facility: Department: Street address: City: State: ZIP: Phone: ( ) Ext. address: 27. Is the patient currently taking any antiretroviral drugs for HIV/AIDS? Yes No 28. If not, has the patient ever taken any antiretroviral drugs for HIV/AIDS? Yes No 29. Patient s clinical status: HIV+, not AIDS HIV+, AIDS status unknown CDC-defined AIDS Unknown 30. Patient s mode of exposure (select all that apply): Men who have sex with men Heterosexual contact Injection drug use Perinatal transmission 31. Patient s most recent lab results: Hemophilia/coagulation disorder Through blood, blood products, tissue Other risk Undetermined/unknown CD4 Date of Last Test: / / Viral Load Date of Last Test: / / 32. Has the patient ever had a CD4 count 200? Yes No Don t know 33. Clinician Signature: Medical License # Date: / /

4 Massachusetts HDAP/CHII Application Form Name: HDAP ID # Pg Pharmacy Information: SECTION 4 PHARMACY INFORMATION Pharmacy Name: Pharmacy Store #: Street Address: City: State: ZIP: Phone: ( ) Fax: ( ) SECTION 5 INSURANCE COVERAGE / CO-PAY COVERAGE 35. What type(s) of health insurance / prescription coverage do you have? (select all that apply): No health insurance / prescription coverage MassHealth (Medicaid) Health Safety Net Commonwealth Care Name of plan: Mass Insurance Connection (MIC) Medicare Part A (hospital insurance) Medicare Part B (medical insurance) Medicare Part C (Medicare Advantage) Medicare Part D (prescription insurance) Name of plan: Veterans Administration (VA) coverage Private Insurance Name of plan: You must include a copy of a completed MassHealth application (or a MassHealth determination letter from within the past 12 months) with your HDAP application. Please include a copy of your insurance card(s) /prescription card(s), front and back, with your application. 36. Type of prescription co-pay (choose one and indicate amount/percentage): OR Maximum dollar amount per prescription $ Percentage per prescription SECTION 6 CHII INFORMATION 37. Have you had health insurance coverage within the last 60 days? Yes No 38. I would like the CHII program to cover the cost of my monthly premium for: Private (non-group) insurance Small Group or Self-Employed health insurance MassHealth premium Commonwealth Care premium COBRA Employee premium deduction Other, specify:

5 Massachusetts HDAP/CHII Application Form Name: HDAP ID # Pg 5 SECTION 7 ALTERNATE CONTACT AND SIGNATURE 39. You may choose to have another individual (i.e. a family member or friend) speak to HDAP staff about your HDAP/CHII enrollment or insurance status at any time you are not available. If you would like to designate someone other than yourself to communicate with HDAP staff, please sign the following statement. I authorize HDAP staff to speak with the following individual on my behalf about coordination of my HDAP enrollment and coverage: Name of alternate contact: Relationship to client: Client signature: Date: / / SECTION 8 CERTIFICATION STATEMENT 40. I certify that I have read (or have had read to me) the information on this application, the Grievance Procedure, and the Client Agreement Statement, and that I understand my rights and responsibilities. I also certify that I am a Massachusetts resident and that the information on this application and any attachments is correct and complete. If I deliberately misrepresent information on this application, I may be required to repay benefits provided to me and I may be prosecuted under applicable state and federal statutes. Signature (applicant or parent/guardian): Date: / / To attach proof of Massachusetts residence? DID YOU REMEMBER? To attach proof of your current income from all sources? To attach a copy of your completed MassHealth application or MassHealth denial letter from within the past 12 months? To include a copy of your health insurance card(s)? To completely fill out sections 1, 2, 4, 5, 7, 8 of your HDAP/CHII application? To have your provider fill out section 3 of your HDAP/CHII application? CHII applicants only: To fill out section 6 of your HDAP/CHII application and attach a recent health insurance premium statement?