New Jersey Department of Health
AIDS Drug Distribution Program (ADDP) and
Health Insurance Premium Payment (HIPP)
PO Box 722
Trenton, NJ 08625-0722
INSTRUCTIONS FOR COMPLETING
THE APPLICATION FOR PARTICIPATION IN THE ADDP AND/OR HIPP PROGRAM
Before
you begin completing the application form, please take a few minutes to review these specific instructions. While many of the questions
are self-explanatory, some require additional clarification to be completed correctly. If you need assistance completing this application, call toll
free 1-877-613-4533 for ADDP.
SECTION
I - APPLICANT I
NFORMATION
Enter yo
ur principal place of residence.
Seasonal or temporary residence in New Jersey, of whatever duration, does not constitute residency.
Include proof of residence, proof of residency include:
•
Motor Vehicle records (e.g., valid Driver's License)
•
Lease or mortgage
•
Landlord's records and rent receipts
•
Public utility records and receipts (electric, gas, phone bill)
•
Records of social agencies, public or private
•
Employment records
•
Social Security records
•
Post Office records
•
Photo ID from county
•
If you are homeless, have case manager/social
worker provide support documentation on facility
letterhead
You may pr
ovide your Social Security number on Page 2 of the application. Although optional, the SSN will help us better coordinate your
benefits and speed up processing your application. Providing your Social Security number will also verify eligibility by matching tax files at
the New Jersey Division of Taxation, and to identify other prescription coverage by searching health insurance records.
DOMESTI
C STATUS:
Check “separated” if:
(1) You and your spouse/partner live apart AND if you do not have access to, or receive support from, your spouse’s/partner’s income;
(2) Your spouse/partner has been confined to a long-term care or psychiatric institution for at least 30 days prior to this application.
If you check “separated,” you must complete Section III
SECTION
V – COMMUNICAT
ION
The Certi
fication and Authorization must be dated and signed (or marked) by you, your spouse/partner (if married/civil union).
CONTACT PE
RSON:
Provide the name of someone we may contact in the event that we are unable to reach you. Please indicate if your contact person is aware
of your HIV status.
PREPARER I
NFORMATION:
Anyone other than the applicant who prepares the form must provide their name and telephone number, in case questions should arise
concerning the application.
CASE MANAGE
R INFORMATION:
It is recommended that all applicants have or consult a case manager determined by county of residence. You may contact your county
board of social services or call the Division of HIV, STD and TB Services for a list of funded facilities in your area. ----
SECTION
VI – INCOME DET
AILS
HOUSEHOL
D UNIT:
In calculating the number of people in the household, include:
(1) Yourself, spouse/partner (if married/civil union), AND
(2) All persons whom you claim as a dependent OR all persons who claim you, the applicant, as their dependent.
Enter yo
ur TOTAL HOUSEHOLD INCOME, by category, for the past 12 months. Enter your income. If you are married or a member of a
civil union, enter your income PLUS your spouse's/partner’s income. If you are dependent on others, also enter their total income.
Fill in ALL of the blanks. List gross figures unless otherwise indicated. If your income for any category is zero, write "0" in that space.
If you (a
nd/or your spouse/partner, if married/civil union) have no income, supply a letter of support from the person(s) who provides your
support. The letter must specifically state if the person(s) providing your support claims you as a dependent for income tax purposes.
If you an
d/or your spouse/partner have Medicare Part B premiums deducted monthly from your Social Security check, multiply this amount
by 12 (annual amount) and enter it under "Sources of Income." Most individuals who are permanently disabled or over 65 have Medicare
Part B deducted from their Social Security check.
DHAS-27
JAN 24
Page 1 of 11
Examples of income that also must be reported:
•
Business Income (Net)
•
Realized Capital Gains
•
Inheritance
•
Death Benefits Received (Net)
•
Royalties
If you need current income limits, call ADDP at 1-877-613-4533 or the Department of Health at 1 (800) 353-3232 or go to:
https://www.nj.gov/health/hivstdtb/hiv-aids/medications.shtml
If you or any member of your household filed a Federal, State and/or City Income Tax Return last year, a copy of each completed and signed
tax return, including any and all attached schedules, must accompany your application.
If you ha
ve applied for Social Security Disability benefits, forward a copy of your Notification of Social Security Disability Entitlement, once
received.
SECTION VI
I – HEALTH INSU
RANCE DETAILS
Check al
l that apply regarding your health insurance coverage. If you have "Private Health Insurance" through any source, provide the policy
number(s) as well as name and address of the insurance carrier(s). If this coverage is provided by an employer (current or previous) or union,
enter the name and address of the employer or union. "Private Health Insurance" includes the health insurance provided by private insurance
carriers such as Blue Cross/Blue Shield, Aetna, etc.
You must include a legible photocopy of the front and back of your insurance card(s) and prescription card(s).
CERTIFICATION BY P
HYSICIAN (Form DHSTS-37)
Complete the
requested information in Section I and forward to your physician for completion of Section II. Make sure that all requested
information has been clearly entered. Ask your physician to return the completed form to you. Return the completed certification along with
your completed application to ADDP.
Before y
ou begin completing the application form, please take a few minutes to review these specific instructions. While many of the questions
are self-explanatory, some require additional clarification to be completed correctly. If you need assistance completing this application, call
toll free 1-877-613-4533 for ADDP.
BEFORE YOU MAIL YOUR APPLICATION:
REVIEW THIS CHECKLIST AND MAKE SURE THAT ALL OF THE FOLLOWING ITEMS ARE MAILED WITH
YOUR COMPLETED APPLICATION.
IMPORTANT: Send copies of any requested documents. Do not send original documents as they WILL
NOT be returned.
Proof of residency
Verification of income (current pay stubs, unemployment records, etc.)
Most recent signed Federal, State and/or City Income Tax Returns, including any and all attached schedules or,
if no income tax return filed, submit most recent W-2 form(s), 1099 form(s), etc.
If you receive Social Security Disability benefits, please include the Notice of Award letter.
Copies of the FRONT and BACK of all health insurance/prescription cards
Certification by Physician form (DHSTS-37) (completed and signed)
If applying for assistance with employer sponsored insurance, also include also include current health
insurance premium billing notice that includes premium identification, number, premium, amounts,
payments due date, and where to send payments.
If you are a COBRA applicant, please include a copy of the completed COBRA election form and/or
current COBRA billing invoice.
DHAS-27
JAN 24
Page 2 of 11
New Jersey Department of Health
AIDS Drug Distribution Program (ADDP)
PO Box 722
Trenton, NJ 08625-0722
APPLICATION FOR PARTICIPATION IN THE
AIDS DRUG DISTRIBUTION PROGRAM AND/OR
HEALTH INSURANCE CONTINUATION PROGRAM
Please print clearly and answer all questions. Review the attached instructions before you begin.
If you need assistance completing this
application, call toll free 1-877-613-4533 for ADDP. Mail the completed application to the ADDP/HIPP Program at the address given
above or
fax to 609-588-7037. Send copies of any requested documents. Do NOT send original documents as they WILL NOT be returned.
SECTION I - APPLICANT INFORMATION
Residential Address (If homeless leave blank)
Apt. Number
City, State, Zip Code
County
Mailing Address (if different)
City, State, Zip Code
Whose mailing address are you using:
Self Medical Case Manager Other___________________________________
Residency
a. Is the address above your principal place of residence? Yes No
NOTE: Proof of residency MUST accompany this application. See Instructions.
NO HOME ADDRESS DECLARATION – If you do not have a residential address, you may have a case manager/social worker provide
support documentation on facility letterhead.
APPLICATIONS ARE ACCEPTED ONLY AT THE FOLLOWING ADDRESS:
ADDP
PO Box 722
Trenton, NJ 08625-0722
or fax to: 609-588-7037
If you want more information on the AIDS Drug Distribution Program (ADDP)
please go to our websites at:
For ADDP: http://nj.gov/health/aids/freemeds.shtml
IT IS THE CLIENT’S RESPONSIBIITY TO REPORT ANY CHANGES IN
CIRCUMSTANCES THAT WOULD IMPACT ELIGIBILITY FOR ADDP.
DHAS-27
JAN 24
Page 3 of 11
SECTION II - HOUSEHOLD
Directions:
First, provide your birthdate, gender, and marital status. Once Completed, describe other household members. You must do this for all the adults and
children under age 21 living in your household. Leave unneeded household member sections blank. The applicant must be HIV+.
If you plan on filing federal income taxes next year: Enter anyone who is filing jointly with you and anyone you intend to claim as your tax dependent,
even if that person does not want health coverage or does not live with you. If you will be claimed as a tax dependent by someone else, enter the tax
filer and any other dependents the tax filer intends to claim. This information is required to determine your correct household size.
If you DO NOT plan on filing federal income taxes next year:
Enter all the adults who live in your household and all the children under 21 who live in your household or are away at school full-time.
If you want assistance with NJ Marketplace (Get Covered NJ) insurance, you must file a FEDERAL Income tax return. Also, married couples must file
jointly.
If you have more than 2 household members, please See Addendum DHSTS-27b
Household Member 1:
Is this the Applicant? Yes No
Relationship to Applicant: Parent Grandparent Spouse Child Sibling
Applicant Other: _______________________
Last Name:
First Name: MI:
Date of Birth
/ /
Month Day Year
Are you legally present? Yes No
Undocumented status will not impact your ADDP eligibility.
This is to help you get Health Insurance
Social Security Number: _________________________
Please include the Social Security Number (SSN) for anyone applying for benefits.
Although you are not required to provide a SSN at this time, however, providing your SSN will speed up the application process.
Marital Status:
Single Married Widowed
Divorced Civil Union/ Domestic Partner
Separated (You will need to Verify this information Section III)
Gender:
Male Female
Transgendered Male to Female
Transgendered Female to Male
If Pregnant:
No. of babies expected:
Due Date: / /
Month Day Year
Gender at Birth: Male Female
Household Member 2:
Is this the Applicant? Yes No
Relationship to Applicant: Parent Grandparent Spouse Child Sibling
Other: __________________
Last Name:
First Name: MI:
Date of Birth
/ /
Month Day Year
Are you legally present? Yes No
Undocumented status will not impact your ADDP eligibility.
This is to help you get Health Insurance
Social Sec
urity Number: _________________________
Please include the Social Security Number (SSN) for anyone applying for benefits.
Although you are not required to provide a SSN at this time, however, providing your SSN will speed up the application process.
Marital Status:
Single Married Widowed
Divorced Civil Union/ Domestic Partner
Separated
(You will need to Verify this information in Section III)
Gender:
Male Female
Transgendered Male to Female
Transgendered Female to Male
If Pregnant:
No. of babies expected:
Due Date: / /
Month Day Year
Gender at Birth: Male Female
SECTION III – ATTESTATION OF SEPERATION
Fill out this section if applicant was previously in a Marriage/ Civil Union/ Domestic Partnership but is not currently.
I, ______________________________________, attest to the truthfulness of the following:
(Print Name of Applicant)
a. That my spouse and I are separated and no longer reside together.
b. I receive no support or monies from my spouse.
c. That my spouse and I do not mingle or join our funds in any way including the filing of joint federal or state income tax returns.
Signature of Applicant
Date
DHAS-27
JAN 24
Page 4 of 11
SECTION IV – DEMOGRAPHICS OF APPLICANT
Ethnicity, race, gender identity and sexual orientation questions are optional, but this information helps the DHSTS improve service to all people
using this program. We use this information to make sure everyone gets fair access to services. We won’t share your information with any government
or private entity. We must protect the privacy of your information. Your responses are only accessible to program staff and claims processors.
Providing this information won’t impact eligibility and it can’t be used to discriminate against you or deny you services.
Please identify your race (Check all that apply):
White Black or African American Asian American Indian or Alaska Native Native Hawaiian Pacific Islander
Please select your ethnicity:
Non- Hispanic
Hispanic/ Latino(a)
If Hispanic/Latino(a), please specify (Check all that apply):
Puerto Rican Mexican, Mexican American, Chicano
Cuban Other Hispanic Origin ____________________
Are you a Veteran? Yes No
Are you being released from an Institution/Hospital? Yes No
Is your CD4 count less than 200? Yes No
Are you being released from prison? Yes No
Signature of Applicant
Date
SECTION V – COMMUNICATION
Applicant Contact Information:
Home Phone: Cell Phone: Work Phone:
Please put a check mark next to your preferred contact number
Email:
a. May ADDP/HIPP staff leave a detailed voice mail message on (Check all that apply)?
Home Phone Cell Phone Work Phone
b. May ADDP/HIPP staff send text messages?
Yes No
c. May ADDP/HIPP staff contact via Email?
Yes No
Case Manager Information:
Check here if you have a Medical Case Manager
Check here if you give ADDP and HIPP permission to communicate with your Medical Case Manager and leave messages.
Case Manager Last Name:
First Name:
MI:
Work Phone: Cell Phone: Email:
Do you have an alternate contact and may ADDP/HIPP staff leave a message? Yes No
Alternate Contact Last Name:
First Name:
MI:
Work Phone: Cell Phone: Email:
Relationship to Alternate Contact: Parent Grandparent Spouse Child Sibling Friend Doctor
Other: __________________
All communication details are in effect until you notify ADDP of any changes
DHAS-27
JAN 24
Page 5 of 11
SECTION VI – INCOME DETAILS
If you have more than 2 household members, please See Addendum DHSTS-27b
Household Member 1:
Name: ____________________________
Do you have Work Income? Yes No
Check here if you are medically UNABLE to work.
If you are medically UNABLE to work, how long have you been medically unable to work?
Less than Six Months Less than Twelve Months More than Twelve Months
Employment Type: Work for Employer Business Owner Self Employed Other ____________________________
Have you had change in your employment status in the last 6 months: Yes No
If Yes, Why?: Change of Job Stopped working Hours Reduction Other:____________________________
Work Type: Full time (35 or more hours per week) Seasonal ____________________________
Part time (less than 35 hours per week)
(Indicate Months if Seasonal e.g.(1,2,3 means Jan, Feb, March & so on))
Does Employer Provide Health Insurance? Yes No
Frequency of Paycheck Weekly Every Two Weeks/ Bi-Weekly Twice per Month Once per Month
Other Income:
Income Type M
onthly Income Amount
Alimony received $
Cash support from friends OR family $
Rental Income (money you receive) $
Interest & dividends $
Net farming/fishing $
Pension or annuity $
Retirement accounts $
Social Security Disability benefits $
State disability $
Unemployment $
Other:
$
$
$
$
Allowable deductions:
Payment Type Month
ly Payment Amount
Alimony paid out $
Student Loan Interest deductions $
Tuition and Fees $
Health Saving Account Deduction $
Educator Expenses $
Moving Expenses $
IRA Deduction $
Other Deduction:
$
$
$
$
Please check this box if you plan to file a federal income tax return NEXT YEAR: Yes No
(You can still apply for this form even if you don't file income tax return)
Will you file jointly with your Spouse? Yes No
If Yes, please enter spouse's name:
Will you claim any dependents on your tax return? Yes No
If Yes, please add the name of your dependents:
(Dependents should be listed as household members)
Did you and/or any member of your
household file a Federal, State or City Income Tax return last year? Yes No
Were you listed as a dependent on a family member’s Federal, State or City Income Tax return last year?
If YES t
o either question, submit copies of each signed return, including any and all schedules, with this application.
Yes No
Yes No
DHAS-27
JAN 24
Page 6 of 11
Household
Member 2:
Name: ____________________________
Do you have Work Income? Yes No
Check here if you are medically UNABLE to work.
If you are medically UNABLE to work, how long have you been medically unable to work?
Less than Six Months Less than Twelve Months More than Twelve Months
Employment Type: Work for Employer Business Owner Self Employed Other ____________________________
Have you had change in your employment status in the last 6 months: Yes No
If Yes, Why?: Change of Job Stopped working Hours Reduction Other:____________________________
Work Type: Full time (35 or more hours per week) Seasonal ____________________________
Part time (less than 35 hours per week)
(Indicate Months if Seasonal e.g.(1,2,3 means Jan, Feb, March & so on))
Does Employer Provide Health Insurance? Yes No
Frequency of Paycheck Weekly Every Two Weeks/ Bi-Weekly Twice per Month Once per Month
Other Income:
Income Ty
pe Monthly Income Amount
Alimony received $
Cash support from friends OR family $
Rental Income (money you receive) $
Interest & dividends $
Net farming/fishing $
Pension or annuity $
Retirement accounts $
Social Security Disability benefits $
State disability $
Unemployment $
Other:
$
$
$
$
Allowable deductions:
Payment Typ
e Monthly Payment Amount
Alimony paid out $
Student Loan Interest deductions $
Tuition and Fees $
Health Saving Account Deduction $
Educator Expenses $
Moving Expenses $
IRA Deduction $
Other Deduct
ion:
$
$
$
$
Please check this box if you plan to file a federal income tax return NEXT YEAR: Yes No
(You can still apply for this form even if you don't file income tax return)
Will you file jointly with your Spouse? Yes No
If Yes, please enter spouse's name:
Will you claim any dependents on your tax return? Yes No
If Yes, please add the name of your dependents:
(Dependents should be listed as household members)
Did you and/or any member of y
our household file a Federal, State or City Income Tax return last year? Yes No
Were you listed as a dependent on a family member’s Federal, State or City Income Tax return last year?
If YE
S to either question, submit copies of each signed return, including any and all schedules, with this application.
Yes No
DHAS-27
JAN 24
Page 7 of 11
SECTION VII – HEALTH INSURANCE DETAILS
Do you currently have any type of health insurance?
Yes No
If yes, is your Insurance Policy through:
Self Former Employer (COBRA)
Union Current Employer
Employer or Union Providing Insurance Coverage:
(a)
Name:
(b)
Address:
(c)
City, State, Zip:
(d)
Contact Person:
(d) Telephone Number:
A dedicated pharmacy is required even if not utilized.
If yes, check all types that you currently have:
CHIP Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
COBRA ** Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Employer Contributed Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Marketplace Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Medicaid Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Medicare A/B Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Medicare D Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Private Insurance* Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Other: Start Date: / /
Month Day Year
Start Date: / /
Month Day Year
Expiration date: / /
Month Day Year
Expiration date: / /
Month Day Year
Are you applying for or have already applied for health insurance? Yes No
If Yes, is the current status, Pending Approved or Denied?
Medicaid Application Date: / /
Month Day Year
Status:
Medicare
Application Date: / /
Month Day Year
Status:
Health Insurance Reform Act
(Marketplace/Exchange)
Application Dat
e: / /
Month Day Year
Status:
Private*/ Off Market Application Date: / /
Month Day Year
Status:
* Private Insurance Definition: **COBRA Definition:
Plans provided by the private insurance ( industry; COBRA stands for Consolidated Omnibus Budget Reconciliation Act.The law generally as a benefit
applies to all group health plans maintained by private-sector employers with 20 or more (e.g. Horizon
Blue Cross Blue employees and sponsored by most state and local governments. If elected, COBRA Shield, Aetna,
Amerihealth, etc.);Or though employer benefits.
; allows individuals to continue group health coverage that would otherwise be lost due to
certain specific events such as termination of employment. COBRA coverage extends from the date
of
the qualifying event for a limited period of time.
DHAS-27
JAN 24
Page 8 of 11
Select the types of coverage you are currently receiving:
Are you currently receiving Prescription Coverage? Yes No
Is there a cap on the annual amount your insurance provider will pay for medication? Yes No
Are you required to use a mail order pharmacy? Yes No
Insurance Carrier's name: ____________________________________________________________________________________
Policy/Group: ____________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone #: ____________________________________________________________________________________
Identify your relationship to the primary policy holder: Self Spouse/ Partner Child Other: _______________________
Primary policy holder's name: ____________________________________________________________________________________
Primary’s Phone # ____________________________________________________________________________________
Primary’s SSN: ____________________________________________________________________________________
Primary’s Address ____________________________________________________________________________________
Street Address
____________________________________________________________________________________
City State County Zip Code
Primary’s Phone # ____________________________________________________________________________________
Are you currently receiving Medical Coverage? Yes No
Insurance Carrier's name: ____________________________________________________________________________________
Policy/Group: ____________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone #: ____________________________________________________________________________________
Identify your relationship to the primary policy holder: Self Spouse/ Partner Child Other: _______________________
Primary policy holder's name: ____________________________________________________________________________________
Primary’s Phone # ____________________________________________________________________________________
Primary’s SSN: ____________________________________________________________________________________
Primary’s Address ____________________________________________________________________________________
Street Address
____________________________________________________________________________________
City State County Zip Code
Primary’s Phone # ____________________________________________________________________________________
Are you currently receiving Dental Coverage? Yes No
Insurance Carrier's name: ____________________________________________________________________________________
Policy/Group: ____________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone #: ____________________________________________________________________________________
Identify your relationship to the primary policy holder: Self Spouse/ Partner Child Other: _______________________
Primary policy holder's name: ____________________________________________________________________________________
Primary’s Phone # ____________________________________________________________________________________
Primary’s SSN: ____________________________________________________________________________________
Primary’s Address ____________________________________________________________________________________
Street Address
____________________________________________________________________________________
City State County Zip Code
Primary’s Phone # ____________________________________________________________________________________
DHAS-27
JAN 24
Page 9 of 11
Are you currently receiving Vision Coverage? Yes No
Insurance Carrier's name: ____________________________________________________________________________________
Policy/Group: ____________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone #: ____________________________________________________________________________________
Identify your relationship to the primary policy holder: Self Spouse/ Partner Child Other: _______________________
Primary policy holder's name: ____________________________________________________________________________________
Primary’s Phone # ____________________________________________________________________________________
Primary’s SSN: ____________________________________________________________________________________
Primary’s Address ____________________________________________________________________________________
Street Address
____________________________________________________________________________________
City State County Zip Code
Primary’s Phone # ____________________________________________________________________________________
SECTION VIII - ATTACHMENT DETAILS
According to the information provided on this application, the Applicant and/or Applicant's Spouse may be asked for the documents listed below,
as applicable.
An application will not be considered complete until all needed documentation is received.
Insurance Card(s)/Prescription Card(s) front and back
Proof of Home Address
Homeless declaration
Signed Income Tax returns including any and all schedules
Signed COBRA Election Form and paperwork
Medicare card
Notice from your insurance carrier regarding Medicare Part D
Pay Stubs
Unemployment Record
Licensed Medical Provider Certificate of Diagnosis
Statement of Support (
for no inc
ome)
Divorce Papers
Name Change
Other relevant documents
__________________
_______________________________________________________________
___
_________________________________________________________________________________
___
_________________________________________________________________________________
___
_________________________________________________________________________________
___
_________________________________________________________________________________
___
_________________________________________________________________________________
___
NOTE: You MUST include a photocopy of the FRONT and BACK of all your insurance card(s)/prescription card(s)
and any notice from your Insurance Company regarding Medicare Part D.
DHAS-27
JAN 24
Page 10 of 11
SECTION IX- CERTIFICATION AND AUTHORIZATION BY APPLICANT
By submitting this application,
a. I certify that the information above is true to the best of my knowledge.
b. I wi
ll notify (AIDS Drug Distribution Program)/(Health Insurance Premium Program) immediately if: (1) my income changes; (2) I
move out of New Jersey; (3) I have an address or telephone number change; (4) if I become eligible for Medicaid/Welfare/PAAD,
(5) there is any change in insurance premium or insurance carrier or (6) any other changes that would affect my eligibility to
participate in (AIDS Drug Distribution Program)/(Health Insurance Premium Program).
c. I a
uthorize the release of information necessary to determine my AIDS Drug Distribution Program and/or Health Insurance Premium
Program or other New Jersey programs eligibility from the records in possession of the Social Security Administration, Internal
Revenue Service and New Jersey Division of Taxation, employers, banks, insurance provider and others as the need arises.
d. I aut
horize my physician to release information concerning prescriptions which have been paid on my behalf by ADDP.
e. I hereby assign the State of New Jersey as my authorized representative to vigorously seek reimbursement of drug benefits to
which I may be entitled under any other plan of assistance or insurance, from any other liable third party or other government
assistance.
f. I under
stand that I will be responsible to refund any AIDS Drug Distribution Program and/or Health Insurance Premium Program
benefits which are determined to have been incorrectly paid on my behalf..
g. I under
stand that AIDS Drug Distribution Program and Health Insurance Premium Program reserve the right to limit enrollment
based upon the availability of funds.
I declare under penalty of perjury that I have examined all the information on this form,
and it is true and correct to the best of my knowledge.
Signature of Applicant
Date
Signature of Spouse/Partner (if income is comingled)
Date
Preparer:
If Anyone other than the applicant prepared the form, they must provide name and telephone number, in case questions should arise
concerning the application.
Name of Preparer
Phone
Signature of Preparer
Date
FOR ADDP STAFF
USE ONLY:
Date eligibility determined:
/ /
DHAS-27
JAN 24
Page 11 of 11
