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Physician Signature MUST BE ACTUAL SIGNATURE 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 1-800-542-2437. WHEN COMPLETED PLEASE RETURN TO EMPIRE STATION P. O. BOX 2052 ALBANY NY 12220-0052 DOH-3608 11/08 Page 1 of 2 MEDICAL INFORMATION Please Answer All Questions Patient s Name DOB SECTION I - DISEASE STAGING Is the applicant HIV in.
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DOH-2794 FAQ
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Required Documentation Income Verification (one or more of the following): Three (3) current paycheck stubs. Three (3) current bank statements. SSI or SSDI letter.
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For questions regarding your ADAP and ADAP Plus coverage, call 1-800-542-2437 or 1-844-682-4058.
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Eligibility Criteria Medical: HIV-infection or at risk of acquiring HIV infection consistent with the guidelines for Pre-Exposure Prophylaxis. Residency: New York State (U.S. citizenship is not required.) Financial: Financial eligibility is based on 500% of the Federal Poverty Level (FPL).
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The AIDS Drug Assistance Program (ADAP) is a statewide, federally funded prescription medication program for low-income people living with HIV. This program provides access to medications to eligible uninsured clients or by purchase of health insurance that includes coverage for HIV medications.
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Applicants apply to the program, providing proof of residency and income. A Medical Application signed by a licensed medical professional is required, verifying HIV status. A treatment plan by a physician must also be submitted for Home Care applicants.
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Dental and Vision Plans: Dental plans can be covered only if a client is already enrolled in OA-HIPP for a health insurance plan. Vision insurance can also be paid but only if included as part of a combined health or dental plan.
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For questions regarding your ADAP and ADAP Plus coverage, call 1-800-542-2437 or 1-844-682-4058.
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