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HIV/AIDS Care and Treatment Forms

CDPH 8522

Program Application (OA-HIPP)

CDPH 8533

Program Application (OA-PCIP)

CDPH 8534

Consent Form (OA-PCIP)

CDPH 8545

Instructions for Completion of the AIDS Medi-Cal Waiver Program Medi-Cal Provider Application

CDPH 8568

Client Report Form (OA-HIPP or OA-PCIP)

CDPH 8570

Financial Eligibility Form (OA-HIPP or OA-PCIP)

CDPH 8683

Diagnosis Form (OA-HIPP or OA-PCIP)

CDPH 8684

Support Verification  Form (OA-HIPP or OA-PCIP) - This form must be submitted by clients who receive full financial assistance from family, friends, and/or homeless shelters.

CDPH 8685

Consent Form (OA-HIPP)

CDPH 8686

Self-Employment  Form (OA-HIPP or OA-PCIP) - This form must be submitted by clients who are self-employed and are unable to provide pay stubs or tax records.

CDPH 8691

Public Assistance Screening Form (OA-HIPP or OA-PCIP)

CDPH 8692

ARIES User Registration Form

CDPH 8693 (SP)

ARIES Forma de Consentimiento de Compartir/No Compartir

CDPH 8693

ARIES Client Share/Non-Share Consent Form

CDPH 8698

Medicare Part D Premium Payment Program Application

CDPH 8720

Enrollment Worker Confidentiality Agreement (OA-HIPP or OA-PCIP) - This form must be submitted by each certified enrollment worker once every two years.

CDPH 8721

Identification Verification Form (OA-HIPP) - This form must be submitted by non-ADAP clients who do not have a valid California ID.

CDPH 8722

Partial Payment Agreement (OA-HIPP) - This form must be submitted by clients who have a monthly insurance premium that exceeds the OA-HIPP program threshold.

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Last modified on: 11/20/2013 9:59 AM