Office of AIDS Forms

CDPH 8439 (PDF) - AIDS Drug Assistance Program Enrollment Application

CDPH 8439 SP (PDF) - AIDS Drug Assistance Program Enrollment Application

CDPH 8440 (PDF) - Diagnosis Form

CDPH 8441 (PDF) - Income Verification Affidavit

CDPH 8441 SP (PDF) - Income Verification Affidavit (Spanish Version)

CDPH 8442 (PDF) - Provider Verification of Identity

CDPH 8443 (PDF) - Insurance Premium Payment Assistance Medical Out-of-Pocket Claim Form

CDPH 8443 SP (PDF) - Insurance Premium Payment Assistance Medical Out-of-Pocket Claim Form (Spanish Version)

CDPH 8444 (PDF) - Important Information Regarding Your Prescription Coverage

CDPH 8444 SP (PDF) - Important Information Regarding Your Prescription Coverage

CDPH 8456 (PDF) - Special Power of Attorney

CDPH 8456 A (PDF) - Revocation of Special Power of Attorney

CDPH 8459 (PDF) - Report of Request and Decision for HIV, HEP B, and/or HEP C Testing

CDPH 8479 (PDF) - Report of Potential HIV Exposure to Law Enforcement Employees

CDPH 8485 (PDF) - Confidential Report of Court-Ordered HIV Testing

CDPH 8532 (PDF) - Request for HIV/AIDS Summary Data

CDPH 8542 (PDF) - Medication and Insurance Assistance Programs Grievance Form

CDPH 8542 SP (PDF) - Medication and Insurance Assistance Programs Grievance Form (Spanish Version)

CDPH 8685 (PDF) - AIDS Drug Assistance Program Consent Form

CDPH 8685 SP (PDF) - AIDS Drug Assistance Program Consent Form (Spanish Version)

CDPH 8689 (PDF) - Agreement by Employee/Contractor to Comply with Confidentiality Requirements

CDPH 8718 (PDF) - Local Health Jurisdiction Local Evaluation Online (LEO) Data File Request Form

CDPH 8719 (PDF) - Request for HIV Prevention Program Reports

CDPH 8720 (PDF) - Agreement by Employee/Contractor to Comply with Confidentiality Requirements

CDPH 8722 (PDF) - Partial Payment Agreement ADAP OA-HIPP Program

CDPH 8722 SP (PDF) - Partial Payment Agreement ADAP OA-HIPP Program

CDPH 8723 (PDF) - AIDS Drug Assistance Program (ADAP) Client Attestation

CDPH 8723 SP (PDF) - AIDS Drug Assistance Program (ADAP) Client Attestation (Spanish Version)

CDPH 8724 (PDF) - AIDS Drug Assistance Program (ADAP) Medi-Cal Eligibility Exception Request (MEER)

CDPH 8726 (PDF) - Self Employment Affidavit

CDPH 8726 SP (PDF) - Self Employment Affidavit (Spanish Version)

CDPH 8727 (PDF) - Residency Verification Affidavit

CDPH 8727 SP (PDF) - Residency Verification Affidavit (Spanish Version)

CDPH 8728 (PDF) - AIDS Drug Assistance Program (ADAP) Temporary Access Period (TAP) Request

CDPH 8728 SP (PDF) - AIDS Drug Assistance Program (ADAP) Temporary Access Period (TAP) Request (Spanish Version)

CDPH 8729 (PDF) - AIDS Drug Assistance Program (ADAP) Eligibility Exception Request (EER)

CDPH 8730 (PDF) - Confidential Fax Submission

CDPH 8731 (PDF) - AIDS Drug Assistance Program New Enrollment Worker Training Request

CDPH 8732 (PDF) - OA-HIPP Client Responsibilities​

CDPH 8732 SP (PDF) - OA-HIPP Client Responsibilities (Spanish Version)

CDPH 8733 (PDF) - Pre-Exposure Prophylaxis Assistance Program Consent Form

CDPH 8733 SP (PDF) - Pre-Exposure Prophylaxis Assistance Program Consent Form (Spanish Version)

CDPH 8736 (PDF) - Pre-Exposure Prophylaxis Assistance (PrEP-AP) Medi-Cal Eligibility Request (MEER)

CDPH 8737 (PDF) - AIDS Drug Assistance Program Health Insurance Assistance Family Plan Consent Form

CDPH 8738 (PDF) - Acknowledgement of Policies and Responsibilities Health Insurance Premium Payment (HIPP) Program Family Plan

CDPH 8739 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Provider Referral (Uninsured)

CDPH 8740 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Temporary Access Period (TAP) Request

CDPH 8740 SP (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Temporary Access Period (TAP) Request (Spanish Version)

​CDPH 8741 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Provider Referral (Insured)

CDPH 8742 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Provider Referral (Kaiser Only)

CDPH 8745 (PDF) - Request for Services-Minors

CDPH 8745 SP (PDF) - Request for Services-Minors (Spanish Version)

CDPH 8746 (PDF) - Request for Services – Confidentiality Concerns

CDPH 8746 SP (PDF) - Request for Services-Confidentiality Concerns (Spanish Version) 

CDPH 8747 (PDF) - Certification of Justice Involved Client Eligibility

CDPH 9117 (PDF) - Enrollment Worker Attestation

CDPH 9122 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP​) Confidentiality Concern Enrollment Worker Verification Affidavit

CDPH 9123 (PDF) -​​ Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Provider​ Referral Form