Please note: applications that are not completely filled out or that are missing required documentation will be returned.

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 The Schrafft s City Center 529 Main Street, Suite 301 Boston, MA Or you may fax the application and supporting materials to For help with this application, please call HDAP at Please note: applications that are not completely filled out or that are missing required documentation will be returned. REMEMBER TO: Attach proof of Massachusetts residence Attach proof of your current income from all sources Attach a copy of your completed MassHealth paper application, the Results page of your Massachusetts Health Connector online application, or a MassHealth/Health Connector determination letter from within the past 12 months Include a copy of your health insurance card(s) Completely fill out Sections 1, 2, 3, 5, 6, and 8 of your HDAP/CHII application Have your provider fill out Section 4 of your HDAP/CHII application CHII APPLICANTS ONLY: Fill out Section 7 of your HDAP/CHII application and attach a recent health insurance premium/bill/employee premium deduction letter Last Revised: May 9, 2017

2 Name: HDAP ID # Pg 1 Massachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form Mailing Address: Community Research Initiative of New England/HDAP The Schrafft s City Center, 529 Main Street, Suite 301, Boston, MA Phone : Fax : 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 (required for coding purposes only): 4. HDAP ID # : 5. Date of birth (MM/DD/YYYY): / / 6. Social Security #: Residential street address (no PO boxes): Apt/Unit no: City: County: State: ZIP: 8. Mailing address: Same as residential address Other address: Apt/Unit no: City: County: State: ZIP: 8A. I would like all my HDAP/CHII mail sent to my case manager (see Section 4). 9. Gender: Male 10. Sex at birth: 11. If Transgender: Female Male Female Male-to-Female (MTF) 12. Number of legal dependents: Transgender Unknown Unknown Female-to-Male (FTM) Unknown

3 Name: HDAP ID # Pg 2 SECTION 1 APPLICANT INFORMATION (continued) 13. Marital status: Single Married Separated Divorced Widowed 14. Country where you were born: Preferred spoken language: 15. Race (select all that apply): 16. Ethnicity (select one): American Indian or Alaskan Native Asian. If Asian: 15A. Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Black/African American Native Hawaiian or Pacific Islander. If Native Hawaiian or Pacific Islander: 15B. Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander White Hispanic/Latino. If Hispanic/Latino: 16A. Mexican, Mexican American, or Chicano(a) Puerto Rican Cuban Other Hispanic, Latino(a), or Spanish origin n-hispanic/latino CONSENT TO CONTACT 17. Phone numbers: Home phone number: ( ) May we leave a confidential message on your voic or answering machine? If yes, initial here: Cell phone number: ( ) May we leave a confidential message on your voic or answering machine? If yes, initial here: Please do not contact me by phone. Contact my case manager only (see Section 4). 18. May we contact you by ? If yes, initial here: 19. May we contact you by text message? If yes, initial here: address:

4 Name: HDAP ID # Pg 3 SECTION 2 - INCOME INFORMATION 20. Current annual income (gross): $ 21. Do you receive income from any of these sources? (select all that apply): Retirement/pension Veteran s pension Interest/dividends Rental income Other income, specify: Salary Unemployment benefits Social Security (SSI, SSDI, SSA) Worker s compensation Private disability (short- or long-term) 22. Did you file a federal or state income tax return for last year? If YES, was it: Single Married filing jointly Married filing separately Other: 23. Are you currently working? Full-time (35 or more hours/week) Part-time (less than 35 hours/week) t working SECTION 3 OPTIONAL ALTERNATE CONTACT AND SIGNATURE PLEASE COMPLETE SECTION 3 ONLY IF YOU WANT TO DESIGNATE AN ALTERNATE CONTACT. 24. You have the option 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: / /

5 Name: HDAP ID # Pg 4 SECTION 4 - PROVIDER INFORMATION This section should be filled out by your health care provider(s). 25. Case manager information: Name: Institution: Street address: City: State: ZIP: Phone: ( ) Ext. Fax: ( ) address: Preferred form of contact: 26. Clinician information: Name: Phone Facility: Department: Street address: City: State: ZIP: Phone: ( ) Ext. address: 27. Is the patient currently taking any antiretroviral drugs for HIV/AIDS? 28. If not, has the patient ever taken any antiretroviral drugs for HIV/AIDS? REQUIRED FIELD PLEASE DO NOT LEAVE BLANK 29. Patient s clinical status: HIV+, not AIDS HIV+, AIDS status unknown 30. Patient s mode of exposure: Men who have sex with men (MSM) Injection drug users (IDU) Heterosexual contact Perinatal transmission CDC-defined AIDS Hemophilia/Coagulation disorder Other blood, blood products, tissue Other risk Undetermined/Unknown 31. Patient s most recent lab results: CD4 Date of last test: / / Viral load Date of last test: / / 32. Has the patient ever had a CD4 count equal to or below 200? Don t know 33. Does the patient currently have hepatitis C infection? Don t know 34. Clinician signature: (MD, DO, PA, NP, RN) Medical license # Date: / /

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7 Name: HDAP ID # Pg 6 SECTION 5 PHARMACY INFORMATION Please be sure to provide full address and contact information. 35. Pharmacy information: Pharmacy name: Pharmacy store #: Street address: City: _ Suite #: State: ZIP: Phone: ( ) Fax: ( ) If your health insurance plan requires you to use a mail order pharmacy or specialty pharmacy for some or all of your medications, please contact HDAP staff at SECTION 6 INSURANCE COVERAGE/CO-PAY COVERAGE 36. What type(s) of health insurance/prescription coverage do you have? (select all that apply): health insurance/prescription coverage MassHealth (Medicaid) MassHealth Limited Health Safety Net (HSN) If known: Full Partial ConnectorCare Name of plan: Mass Insurance Connection (MIC) One Care 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 Indian Health Services (IHS) Private Insurance Employer/Group Name of plan: Private Insurance Individual/n-group 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. 37. Type of prescription co-pay/co-insurance (choose one and indicate amount/percentage): Maximum dollar amount per prescription (co-pay) $ OR Percentage per prescription (co-insurance) %

8 Name: HDAP ID # Pg 7 SECTION 7 CHII INFORMATION PLEASE COMPLETE SECTION 7 ONLY IF YOU WOULD LIKE HDAP/CHII TO PAY YOUR MONTHLY HEALTH INSURANCE. ATTACH A RECENT PREMIUM/BILL OR EMPLOYER PREMIUM/PAYROLL DEDUCTION LETTER. 38. Have you had health insurance coverage within the last 60 days? 39A. I would like the CHII program to cover the cost of my monthly premium/bill for: Private (non-group) insurance Small group or self-employed health insurance MassHealth ConnectorCare Medicare Part D COBRA Employee premium deduction Other, specify: 39B. If you are currently working, does your employer offer health insurance? If YES, and you are currently not enrolled in your employer plan, please submit a copy of the summary of insurance benefits provided by your employer/human resources department. If you would like HDAP/CHII to pay for your monthly health insurance premium bill and you receive coverage through the Massachusetts Health Connector, please include with your HDAP application a copy of your federal tax return and all related forms and attachments for the most recent tax year. SECTION 8 CERTIFICATION STATEMENT (ALL APPLICANTS MUST SIGN) 40. I certify that I have read (or have had read to me) the information on this application, the Grievance Procedure, the Client Agreement Statement, and the Consent to Contact section, 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 (REQUIRED): Date: / / (Applicant or Parent/Guardian) Please note: applications that are not completely filled out or that are missing required documentation will be returned.