​Pre-Exposure Prophylaxis Assistance Program (PrEP-AP)

Acceptable Supporting Documentation

Introduction

• Adult Client – these clients are 18 years or older and include insured clients, uninsured clients, and clients with Medicare, TRICARE, or Medi-Cal with a Share of Cost. To be eligible, they must, reside in California, be HIV negative, have an income less than 600% of the poverty level, and not be eligible for full coverage Medi-Cal.
• Minor Client – these clients are 12-17 years old as defined in Section 6926 of the Family Code. To be eligible, they must reside in California and be HIV negative.
• Adult Client with Confidentiality Concerns – these clients are 18 years or older and are insured but have confidentiality concerns with using health insurance they have through a parent, spouse, or registered domestic partner. To be eligible, they must reside in California and be HIV negative.

​Required Supporting E​​ligibility Documentation/Form	​Adult Client	​Minor Client	​Adult Client with Confidentiality Concerns
​Identity​	​	​	​​​
​California Residency	​	​	​
​HIV Negative Status	​	​	​
​Income	​	​	​
​Proof of Medi-Cal Ineligibility	​	​	​
​ADAP/PrEP-AP Consent Form	​	​	​
​PrEP-AP Client Attestation	​	​	​
​Request for Services Form	​	​ (Minor Specific)	​ (Confidentiality Client Specific)
​Confidentiality Concerns Enrollment Worker Affidavit	​	​	​

​One item from each section is required unless otherwise indicated. Additional documents may be needed to determine eligibility.

Proof of Identity*

• Driver's License
  
• State or local ID card (e.g., DMV issued ID, Municipal ID, student ID, or an ID from the Department of Corrections (CAL-ID))
• U.S. Passport
• Permanent Residence Card
• Employment authorization card
• Military ID card
• Photo ID issued by a foreign government (e.g., voter registration card, passport, or consulate ID card)
• Birth certificate (only if client does not have one of the ID's listed above)
• Provider Verification of Identity form (PDF)
  
• Request for Services form (PDF) (for use with minors only)**
  

Proof of Residency*

NOTE: Proof of residency is not required for minor clients.

These documents must be dated within 90 days, be in the client’s name, and include the client’s residential address:

• California rent or mortgage receipt
• Current utility bill with the service address listed in California (a cell phone bill is not acceptable)
• Employment paycheck stub
  

HIV Negative Status

Must be dated within 6 months of PrEP-AP application.

• HIV negative lab result (lab results must be a printout from a lab, a medical record from a provider or rapid HIV Test stating the client’s name, test result, and test date)
  
• Copy of Patient Assistance Program approval letter (uninsured clients only)
• Patient Assistance Program Application signed by a PrEP-AP Network Provider (uninsured clients only)
• PrEP-AP Provider Referral Form (PDF) signed by a PrEP-AP Network Provider (uninsured clients only)

Proof of Income

NOTE: Proof of income is not required for minor clients or clients with confidentiality concerns.

Income documentation for all household members is required.

• Household members include:
• An applicant,
• An applicant's spouse or registered domestic partner (RDP), and
• Any tax dependents of the applicant, spouse, or RDP.
• Preferred income documents for establishing Modified Adjusted Gross Income (MAGI) include:
• Federal tax returns (current and previous year only) and
• State tax returns (current and previous year only).
  

In addition to state and federal tax returns, IRS Form 2555 Foreign Earned Income must be submitted if applicable. If a federal or state tax return is not available to establish MAGI, then applicants may submit gross income documentation for all household members.

MAGI Documents

• Filed Federal or State tax return with W-2, 1099 or Schedule C (PrEP-AP will not accept a tax return without a W- 2, 1099 or Schedule C unless the return is signed or accompanied by proof of electronic submission)
  
• Form SSA-1099 Social Security Benefit Statement may be accepted without additional accompanying documents for clients with Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).

Gross Income Documents

• Employment Income
  
• Three consecutive months; of current paystubs, or
• One paystub showing Year-To-Date (YTD) earnings that includes at least three months of income, and the employment start date, and/or
  
• Payment/ weekly summaries or bank statements documenting three current consecutive months of income from clients who work for companies (i.e., Uber, Lyft, etc.) as independent contractors (self-employed). Payment/weekly summaries must clearly show the payment transactions are from the company the client works for and contain:
  
• The person's first and last name and company name
• Dates covered and the gross income from profit/ loss
• Employer statement (must be on company letterhead, signed by the employer and dated within 45 days of PrEP-AP application, and include, name of employer or company, name and title of person writing the letter, employer or company address and phone number, date of the letter, start date and if applicable, the end date of the employee's employment or pay and the two following statement: "I certify that [first and last name of person employed or receiving income: is/was an employee of [name of company]. [employee's name]'s gross income for this pay period is/was $[Enter Amount] and frequency of pay is [weekly, every two weeks, twice a month, or monthly]. This letter does not guarantee employment or wages." and "The information provided above is true and correct to the best of my knowledge.")
• Self-employment Profit and Loss Statement or Ledger documentation (the most recent quarterly or year-to-date profit and loss statement, or a self-employed ledger.) (Form must include the client's first and last name, company name, dates covered and the net income form profit/loss.)
• Self-Employment Affidavit (PDF) form (earnings for the past 3 months to present). This form can be used if clients are unable to obtain payment/weekly summaries from the company (i.e., Uber and Lyft) they work for as independent contractors (self-employed).
• Income Verification Affidavit (PDF) form (completed by the individual providing income support other than the applicant's spouse/RDP) (dated within one month). This form can be used if clients are seasonal workers (i.e., farmers, actors) who work during certain times of the year and are ineligible for Medi-Cal.
  
• Disability and Worker's Compensation Income
  
• Private disability award letter (dated within one year)
  
• State Disability Insurance (SDI) award letter (dated within one year)
• Social Security award letters (includes SDI) (dated within one year)*
  
• Bank statement showing direct deposit of SDI benefits.  Statement must be dated within 90 days and clearly identify the deposit/income source (e.g., US Treasury, SSA)
• 1099 or W2 for proof of disability income
• Worker’s Compensation Award Letter (dated within one year)
• Screenshots of online disability and worker’s compensation accounts; must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days
• Screenshots of a bank account will be accepted for disability and workers’ compensation income and must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days​
  
• Unemployment Income
  
• Bank statement showing direct deposit of Unemployment Insurance (UI). Statement must be dated within 90 days and clearly identify the deposit/income source (e.g., US Treasury, SSA)
• UI award letter (dated within one year)​
• Screenshots of online unemployment accounts; must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days
• Screenshots of a bank account will be accepted for unemployment income and must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days​
• Social Security Income
• Social Security award letters (includes Supplemental Security Income (SSI)) (dated within one year)
• Bank statement showing direct deposit of SSI benefits.  Statement must be dated within 90 days and clearly identify the deposit/income source (e.g., US Treasury, SSA)
• Bank statement clearly stating date, retirement/insurance name, deposit amount, and name of client (dated within one month)
• Social Security Retirement Benefit award letter (dated within one year)
• Screenshots of online social security accounts; must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days
• Screenshots of a bank account will be accepted for social security income and must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days​
• Pension/Retirement Income
  
• Retirement/Pension award letter or three consecutive or monthly benefit statements, pay slips, or pay stubs (dated within one year)
• Monthly retirement statement clearly stating date, retirement/insurance name, deposit amount, and name of client (dated within one month)
• 1099 or W2 for proof of retirement income
• Screenshots of online retirement accounts; must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days
• Screenshots of a bank account will be accepted for retirement income and must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days​
• Veterans Administration Income
  
• VA award letter (dated within one year)
  
• Screenshots of a bank account will be accepted for Veteran’s Administration (VA) deposits and must include the following requirements:
• Name of client, type of account, deposit amount, dated within 30 days​
• Additional Income Sources
  
• Spousal support court documentation
  
• Investment income documentation (e.g., statement or portfolio summary dated within one month)
  
• Rental income documentation (e.g., a signed rental agreement dated within the last year or three current bank statements showing rental income deposits)
  

Proof of Medi-Cal Ineligibility*

NOTE: proof of Medi-Cal ineligibility is not required for minor clients or clients with confidentiality concerns

PrEP-AP applicants must provide proof that they are ineligible for Medi-Cal as described below.​

​Proof of MAGI Medi-Cal ineligibility (provide one of the following):

• Income documentation showing household income at or above 138% of the Federal Poverty Level
• ID documentation (see above for a list of examples), showing client is aged 65 or older (not applicable to undocumented clients 65 and older)
• NOA of Medi-Cal denial or termination will be reviewed and may be accepted on a case-by-case basis. NOA must be current and include a termination date. Unacceptable denial/termination reasons:
• Failure to comply
• Client lives in a facility (such as a long-term care, convalescent home, mental health facility, or jail
• Withdrawal of application
• Loss of contact/unable to locate
• Denied reason of “Other.”
  

*Note: Individuals 19 years of age or older with income below 138% of the FPL regardless of immigration status qualify for MAGI Medi-Cal.

Proof of Non-MAGI Medi-Cal ineligibility (provide one of the following):

• Denial Letter for non-MAGI Medi-Cal, SSI or SSDI (dated within one year)
• Proof of employment (dated within thirty days)
• Unemployment Insurance award letter (dated within one year)