'Maryland AIDS Drug Assistance Program Maryland AIDS Drug Assistance Program - Plus Insurance Assistance Maryland AIDS Insurance Assistance Program

Transcription

1 MADAP - MADAP Plus MAIAP Combined Application 'Maryland AIDS Drug Assistance Program Maryland AIDS Drug Assistance Program - Plus Insurance Assistance Maryland AIDS Insurance Assistance Program Return Completed, Signed Applications to: AIDS Administration' 500 North Calvert Street, 5 th Floor' Baltimore, Maryland (410) ' ToU Free Fax (410) TTY - Maryland Relay Service MADAP, MADAP-Plus, and MAIAP are administered by the Maryland Department of Health and Mental Hygiene, AIDS Administration. Eligibility is based on income, assets, Maryland residence, and medical need. Instructions for completing this application: If you wish to receive benefits through MADAP, MADAP-Plus, or MAIAP you must complete the attached application and submit it with the appropriate documentation as requested on the form. All information provided is kept completely confldentlal. The application will be used to determine your eligibility for assistance in obtaining prescription medication and/or paying health insurance premiums. MADAP provides prescription drug coverage for medications used to treat HIV/AIDS. MADAP Plus and MAIAP provide assistance in paying certain health insurance premiums. You may be eligible for more than one program. You do not need to submit a separate application for each program. Carefully read the following infonnation to prevent delay in processing your application. If you have questions or need help completing the application, please call (410) or (toll-free). Our staff is available to assist you with this application or in finding other HIV/AIDS resources in your area. It takes 5-10 business days to process a complete application. You wi!! be notified by mail of your status. If any of the requested information is missing, you will be sent a letter requesting the needed information, or your application will be returned to you to complete. If you have partial prescription insurance coverage for your HIV/AlDS drugs, MADAP may be able to help pay whatever your insurance does not cover, However, your pharmacy must bhi your insurance company for the part of the drug cost for which the insurance is liable. Depending upon your income and/or assets, you may have a financial obligation. Funds collected from you are used to cover part of the costs of your participation in MADAP, MADAP-Plus, and/or MAIAP. Eligibility for these programs continues for a twelve-month period, and then you must reapply to the program. You will be sent another application in time for your coverage to continue without interruption. BEFORE YOU MAIL THIS APPLICATION, PLEASE CHECK THE FOLLOWING: o CJ o Have you completely answered all questions and SIGNED the application (if you are married, your spouse must also sign)? Did you provide proof of current Maryland residence? Old you attach copies of proof of income (copies of 1 month's recent pay stubs, current Social Security award letter, unemployment fetter, etc.)? Did you attach copies of proof of cash assets (checking or savings account statements, stocks or bonds, certificates of deposit, IRA's, mutua! funds, or other items with a cash surrender value)? Did you attach a copy of your health insurance card(s), if you have insurance? Is the medical section (part 6) completed and SIGNED by your health care provider? If any of the items above are missing you will be notified by mail. Any missing information must be mailed to our office within 30 days or we may not be able to process your application. DHMH, AIDS Admin, Revised 4/

2 MAOAP - MAOAP Plus MAIAP 500 North Calvert Street Fifth Floor Baltimore, Maryland Telephone: (410) Fax: (410) TolI.free TTY Maryland Relay Hours: Mon.-Fri. 8:30 a.m 4:30 p.m. (Closed on State Holidays) For Agency Use Only New: MMIS II: Initials: Recert: Eligibility s: Client 10: All information provided is kept completely CONFIDENTIAL PART 1 APPLICANT INFORMATION: Please enter ALL the information below and include proof of your current Maryland residency such as a copy of your Maryland driver's license, or a copy of a bill showing your name and current address, or a notarized statement that you live at the address on this application. If you want mail from sent to an address different from the one below, please attach the mailing information to this form. Please be sure to include your apartment or suite number, ifapplicable. Name: City, State, and Zip: Telephone: May we leave a message at this number? Race: 01=White 02=Black or African American 03=Asian 04=Native Hawaiian or Other Pacific Islander 05=American Indian or Alaska Native 06=Other Daytime: DYes UNo Evening: Yes No Ethnicity: Are you Hispanic, Latino/a, or of Spanish heritage? 01=yes 02=no of Birth: Are you a Citizen or Lawful Permanent Resident of the United States? 0 Yes 0 No (your immigration status will NOT affect your eligibility for MADAP or MADAP Plus.) Sex: Please give the number of natural or legally 01= male adopted children under 18 years of age 02= female living with you: If application is filed on behalf of a child under 18 years of age, please print the parent's or guardian's name below: Marital Status: 01=5in91e 02=Married 03=Separated 04=Divorcad 05=Widowed Employment Status: 01=Full-Time 02=Part-Time 03=Permanent Disability 04=Not Currently Employed/Other 05=Not Applicable (child) PART 2. INCOME/ASSET INFORMATION: For each source of income below, write how much each person in your household expects to receive in the next year (gross annual income). ENCLOSE COPIES OF PROOF OF ALL INCOME such as one month's pay stubs, entitlement (SSDf) award notice, most recently filed tax return or current W-2 form, or a letier from your employer stating your gross annual salary. Enclose copies of proof of income for spouse and/or dependent children if applicable. Please list the cash assets for eveyone in your household. and check the appropriate sources. Attach proof for each type of asset. such as copies of bank statements. certificates, or reports. Your Social Security Number: Spouse's Social Security Number: Spouse's Name: Yearly Income: Applicant: Spouse: Children: Source(s} of income: Social Security (SSI, SSDI) Pension. Retirement, Private Disabtlity Interest Income o Employment Income Rental Income Unemployment Benefits o Other Source of Income Assets: Applicant: Spouse: Children: Type of Asset: o Cash Checking Savings n Stocks, Bonds, etc. IRA, Annuity Fund Certificate of Deposit Other cash value asset 2 DHMH, AIDS, Admin, Revised

3 PART 3. HEALTH INSURANCE I NFORMATION: Please complete the following insurance information. If you have private health insurance you please provide a copy of both sides of your card(s). Ifyou pay 50% or more of the monthly premium(s) for your health insurance, please provide us with payment Information. If applicable, please provide copies of COBRA letters, monthly bills for health insurance premiums, etc. If you have Medicare, please provide a copy of your Medicare card. Do you have Medicaid or MPAP? 0 Yes No Do you have Medicare? LJ Yes No Do you have health insurance? DYes 0 No Do you pay 50% or more of the monthly premium? Yes 0 No Insurance Company Name: Insurance Company City, State, and Zip Code: 3roup Number: Plan Number: Member Number: Services Covered: Office Visits Hospital Emergency Room Dental Vision Prescriptions Where do you make your monthly health insurance premium payments (attach premium bill or COBRA letter, if applicable) Payable to: City, State, Zip: Employer: Monthly Premium Amount: Contact Person: PART 4. CASE MANAGER INFORMATION: Please complete the information below, jf applicable. If you do not have a case manager. and would like information on case management resources in your area, please call MADAP for more information. Case Manager/Agency ~ PART 5. CERTIFICATION: Read the following information, and if you agree, please sign your name and write the date. If you are married, your spouse must also sign and date this statement. If you have a legal guardian or someone acting as an attorney on your behalf, that person must also sign and write the date. I certify that the information provided on this form is true, correct, and complete. I understand that if I give any false information, withhold information, orfail to promptly report changes in income or residency, t will be breaking the law and can be prosecuted and/or have services discontinued. I understand that I, or my legal representative may be asked to provide proof of any information on this form or additional information as required by the AIDS Administration, Maryland Department of Health and Mental Hygiene (DHMH). I agree to the release of my medical, income/asset, and insurance information to the AIDS Administration-DHMH pertinent to determination of eligibllity and my participation in MADAP, MADAP Plus, or MAIAP. I agree to the release of my insurance information as necessary to process MADAP claims and/or MADAP Plus or MAIAP payments of health insurance premiums on my behalf. I give permission to the AIDS Administration-DHMH to contact my insurance company and/or my current or past employer to the extent necessary to verify insurance coverage and to make MADAP Plus or MAIAP payments of health insurance premiums on my behalf. I agree to the release of information to the State of Maryland, Division of Reimbursements, for the purpose of their collecting any necessary fees necessary for my partipatlon in MADAP, MADAP Plus, or MAIAP. I request that payment of authorized benefits be made on my behalf. I certify that a full explanation of services and participation fees has been given to me. I agree to pay the monthly participation fee if MADAP determines I have one. I understand that I may pay excess income or assets to DHMH in order to participate in MArAP, if I choose to do so. If I am denied eligibility for services covered by this application, I understand I will be notified in writing of the decision and the reason(s) for denial and will be given instructions as to how I may appeal the decision. If you have questions, you may call the MADAP Administrator at A photocopy of this authorization will be considered as effective and valid as the original. Signature of Applicant Spouse/Legal Guardian's Name (Printed Signature of Spouse/Legal Guardlan 3 DHMH, AIDS Admin, Revised 4110/2008

4 PART 6. MEDICAL INFORMATION: This section is to be COMPLETELY filled out by the health care practitioner providing HIV-related care for the person named in this application. This section should be returned to the patient so that it may accompany the rest of the application. Path:nt's Name 8I1(j Complete Mailing Address (Street, City, S7 &ZIP) Is this patient HIV Infected? Yes or 0 No Has this case been reported to the local Health Department? o Yes or No What Is the date and result of the last CD-4 test? What Is the date and result of the last viral load test? What Is the patient's CDC stage category? (Ai thru es) Results In your professional opinion, is there a substantial likelihood that within approximately three months this patient will be too ill to work because of HIV~related disease? (Information on ability to work is used to Yes 0 No determine the insurance premium program for which an applicant may qualify.) Are you prescribing or planning to prescribe at least one of the medications below for this patient? Yes No abacavir (Ziagen) clotrimazola (Lotrimin, Mycelex) foscarnet (Fos.cavir) metoclopramlde (Reglan) abacavir!amivudine (Epzicom) clolrimazole-betamethasone (Lotrisone gabapentin (Neurontin) metoprolol (generic only) abacavir z1dovudine lamivudine (Trizivir) Cream) ganciclovir (Cytovene) metronidazole (FlagY', Metryl, Protoslat) acyclovir (Zovirax, Acyclovir) dapsone gemfibrozil (generic only) miconazole (Monlstat) adefovir dipivoxil (Hepsera) darunavir (Prezista) glimepiride (Amaryl) mirtazapine (Remeron) albuterol (Provenlil, Ventolln HFA) daunorublc!n citrate I!po$ome gllplzide (Glucotrol) moiiftoxacin hydrochloride (Avelox, (DaunoXome) amantadine (Symmetrel) haloperidol (Haldol) Vigamox) delavirdine (Rescriptor) amikacin sulfate 0 hydralazine (generic only) nandrolone decanoate dldanosine (Videx, ddl) amitriptyline hydrochloride (Elavit) hydrochlorothiazide nelfinavir (Viraoept) dilliazem (genanc only) amlodipine (ge!1<'jric only) hydroxyzine (Atarax) nevirapine (Viramune) diphenoxylate-atrcplne (Lomotil, DI.Atro) amoxicillin (AmoxiI, Trimox, Wymox, imlquimod (Aldara Cream) nifedipine (generic only) Biomox) divalproex sodium (Depakote) indapamlde nilazoxanide (Alinla) amoxiculin-c!avulanata polassium doxazosln (generic only) indinavir (Crlxivan) nortriptyline (Pamelor, Aventy1) (Augmentin) doxycycline (Doryx, Vlbramycln, Periosta!) Insulin glargine (Lantus) nyslelin (MycoSlatln) amphotericin B (Funglsone) duloxetine hydrochloride (Cymbalta) Insulin flspro (Humalog) oct(9otide (Sandostalil1) atazanavir sulfate (Reyataz) efevirenz; (SusHva) insulin NPH (Humulin N, Novolln N) olanzaplne (Zyprexa) atenolol {genenc only) efavirenziemlridtabltenofovi r (Atripla) insulin regular (Humulin R, Novofin R) omega S acid ethyl esters (Lovaza) etorvastatin (Lipitor) emtricllabine (Emtrlva) Interferon alpha 2A (Roferon-A) ondansetron hydroch Ioride (Zofran) atovaquorte (Mepron, Malarone) emtricitabine-lenofovir OF (Truvada) Interferon alpha 28 ([ntron A) oseitamivir phosphate (Tamiflu) aztthromycin (Zithromax) enalapril - felodiplne (lexxel) ipratropium bromide (Atrovent HFA) oxandrolone (Oxandrlny beciomethasone (Ovar) enfuvirtide (Fuzeen)' isoniazid (Nydrazid, INH) oxymelholone (Anadrol SO) buprenorphine sublingual (Subutex) entecavir (8araclude) isoniazld rifampin (Rifamate) paromomycin (Humalin) buprenorphlnelnaloxone sublingual epoeun alpha (procm, Epogen)' Itraconazo!e (Sporano>:) paroxetine (Paxill (Suboxone) Errin (branded generic) keloconazole (Nizoral) peginterferon alfa 2a (Pegasys)' buproplon (We/lbutrin) erythromycin (E.Sase, ElY-Tab, E-Mycin, lamivudine (Epivir, atc) peginterferon ajta 2b (Peg lntron)' captopril (generic only) Eryc) lamotrlglne (Lamlctal) penicillin G benzathine (Bicillin LA) carbamazepine (Tegretol, & XR) escitalopram oxalate (Lexapro) lansoprazole (Prevac:d) pentamidine (Pentam. NebuPent) cetpodoxime proxetil (Vantin) ethambutol (Myambutol) leucovorin perphenazine (Trilafon) ceftriaxone sodium (Rocephin) etra\llrlne (fnlalence) levetiracetem (Keppra) Plan S (branded generic) cephalexin (Kellax, Keftab) famciclovlr (Famvlr) lisinoprll (generic only) polymyxin B-trimethoprim sulfate chlorothiazide fenofibrate micronized (Trlcor) (Polytrim) lithium carbonaie cidofovir (Visbde) fenotibric acid (Trillpix) pravastalin (Pravacholl ciprofloxacln (Cipm Ciloxan) fllgrastlm (Neupogan)* loperamlde (Imodium) primaquine phosphate (Primaquine) citalopram hydrobromide (Celexa) fluconazole (Diflucan) lopinavir ritonavir (Kaletra) prochlorperazine (Compazine) clarithromycin (Blaxin) fluoxatine (Prozac) maravlroc (Selzentry)" promethazi!1<'j hydrochloride (Phenergan) dindamycln (CleOein) fluphenazine (ProIiXln) medroxyprogesferone (generic only) propranolol (generic only) clonidine (generic only) fosamprenavir calcium (lexiva) megestrol acetate (Megace) pyrazinamide (Rifater) metformin He!. (Glucophage) Drugs marked by require Prior Authorization (approvai). Contacr MADAP at for more information. HiV EXPOSURE CATEGORY - (This information is kept completely confidential and will be used for statisticaf analysis only): n MSM D HemDphiliaicoagulatlon disorder C Transfusion recipient Injection drug user (IOU) Heterosexual contact Mother HIV+ (For child <12 years of age) IDU MSM Born in pattem II country NIR 0 Refusedl Didn'task HEALTH CARE PRACTITIONER INFORMATION (Physician, Nurse Practitioner, or Physician's Assistant); Name: Phone Number: License Number and Issulng Sta1e: City, State, and Zip: Signature and Da1e: 4 DHMH, AIDS Admin, Revised

5 Informed Consent for the Release andlor Exchange of Information It may be necessary for the Maryland Department of Health and Mental Hygiene to release or exchange certain information with your employer and/or insurance company in order to make health insurance premium payments on your behalf. If you wish to participate in the health insurance premium payment program offered by the Department, you must complete this form, sign it. and have it witnessed by an adult person who knows you. I, _---:-:--~--...,_-_ ' born ~ --::_:: o :_--, (Applicant's Name) (Applicant's of Birth) and residing at:-:-:-~: :-:-_--:::--~-._--:--::::--:-- (Applicant's Address, City, State, and Zip) Hereby give permission to the Maryland Department of Health and Mental Hygiene, 500 N. Calvert Street, Floor, Baltimore, Maryland to release andfor exchange information with my employer and/or insurance company named below for the express purpose of making health insurance premium payments on my behalf. Further, f give my permission to the employer and/or insurance company named below to release and/or exchange information with the Maryland Department of Health and Mental Hygiene for the express purpose of making health insurance premium payments on my behalf. Employer: Employer's Employer's Phone Number: Insurance Company: Insurance Company In~rnnceComp~yP~neNumb~ ~ I understand that I may revoke this authorization by notifying the Department of Health and Mental Hygiene in writing at any time, should I choose to do so. Applicant Signature: : Witness Signature: : Witness Name (Printed): ReJationship to Applicant: 5 DHMH, AIDS Admin, Revised