Skip to main content
CA.Gov State of California Logo
en EspaƱol Contact Us About News & Media Jobs/Careers
+ Increase Text Resize Reset to Default - Decrease
CDPH Site Logo
CDPH Site Logo
  • Text Size
      • + Increase Increase
      • - DecreaseDecrease
      • Reset to Default Reset to Default
  • I am looking for

      • Whatā€™s New

      • 2025 State of Public Health Testimony

      • CDPH New Look

      • H5N1 Bird Flu

      • Respiratory Virus Report

      • Tips for After an Earthquake

      • Wildfire Preparedness and Safety

      • CDPH 2025-26 Budget May Revision

      • Administrative

      • All Local Health Jurisdiction Letters ļ¼† Notices

      • Budget Highlights

      • Boards and Advisory Committees

      • Forms

      • Language Access Services Program

      • Local Health Services/Offices

      • Public Records Act Request

      • Proposed Regulations

      • Proposition 56 Fiscal Reporting

      • Diseases and Conditions

      • Cancer

      • COVID-19

      • Diabetes

      • Diseases and Conditions

      • Disease Reporting

      • Healthcare-Associated Infections

      • HIV/AIDS

      • Mpox

      • Problem Gambling

      • Respiratory Viruses

      • Sexually Transmitted Diseases

      • See More

      • Family Health

      • Breastfeeding

      • Genetic Disease Screening

      • Mental Health

      • Nutrition and Physical Activity

      • Pregnancy and Reproductive Health

      • Women, Infants and Children

      • Health and Safety

      • Climate Change and Health

      • Emergency Preparedness

      • Environmental Health

      • Health in all Policies

      • Workplace Health

      • Health Facilities

      • File a Complaint

      • California Health Facilities Information Database

      • Personal Health and Prevention

      • Behavioral Health

      • Cannabis (Marijuana)

      • Immunizations

      • Nutrition

      • Quit Smoking

      • Licensing, Certification and Other Credentials

      • Certificates, Licenses, Permits and Registrations

      • Health Care Facility Licenses

      • Health Care Professionals

      • Laboratory

      • Medical Professional Licenses

      • Medical Waste

      • Pet Importation and Exportation

      • Radiation and Nuclear

      • Registered Environmental Health Specialist

      • Vital Records

      • X-ray Machine Registration

  • I am a

      • Clinician / Healthcare Provider

      • Legislator / Legislative Staff

      • Media Representative

      • Researcher / Statistician

      • Person Interested In

      • Infant and Child Health

      • Menā€™s Health

      • Senior Health

      • Womenā€™s Health

      • Youth and Young Adult's Health

      • LGBT Health

  • Programs

      • Center for Healthy Communities

      • California Tobacco Control

      • Childhood Lead Poisoning Prevention

      • Chronic Disease Control

      • Chronic Disease Surveillance and Research

      • Emergency Preparedness

      • See More

      • Center for Preparedness and Response

      • Be Prepared California

      • Know and Understand Natural Disasters

      • Center for Family Health

      • Genetic Disease Screening Program

      • Maternal, Child and Adolescent Health

      • Women, Infants and Children

      • Center for Health Care Quality

      • Healthcare-Associated Infections Program

      • Licensing and Certification

      • Center for Health Statistics and Informatics

      • End of Life Option Act

      • Medical Marijuana Identification Card Program

      • Research and Analytics Branch

      • Vital Records

      • Center for Infectious Diseases

      • HIV/AIDS

      • Binational Border Health

      • Communicable Disease Control

      • Communicable Disease Emergency Response

      • Refugee Health

      • See More

      • Director / State Public Health Officer

      • Legislative and Governmental Affairs

      • Let's Talk Cannabis

      • Office of Health Equity

      • Office of Communications

      • See More

      • Center for Environmental Health

      • Division of Food and Drug Safety

      • Division of Radiation Safety and Environmental Management

      • See More

      • Center for Laboratory Sciences

      • Division of Environmental Health Laboratories

      • Infectious Diseases Laboratory Division

      • Laboratory Field Services

      • Office of State Public Health Laboratory Director

      • Operations Branch

      • See More

      • Other CDPH Offices

      • Privacy Office

      • Office of Regulations

      • See More
  • A-Z Index
Division (Office) of AIDS

Skip Navigation Linksoa_adap_forms
 

Top Menu
  • Center for Infectious Diseases
    • Division (Office) of AIDSCurrently selected
    • Division of Communicable Disease Control
      • CAIR
    • Office of Binational Border Health
    • Office of Infectious Disease Preparedness and Response
      • Pathways
    • Office of Refugee Health
Skip Navigation LinksCenter for Infectious Diseases > Division (Office) of AIDS > pages > oa_adap_forms
  • Home
  • Programs
  • Center for Infectious Diseases
  • Division (Office) of AIDS
  • HIV/AIDS ADAP Forms
Left Menu
  • Lists
  • Programs
    • California Conference of Local Health Officers
      • CCLHO Board and Committee Information
      • CCLHO Board of Directors
      • Chronic Disease And Injury Prevention
      • Communicable Disease Control And Prevention
      • Environmental Health
      • CCLHO Executive Committee
      • Health Information And Data
      • Semiannual Meetings
      • Small Jurisdiction Committee
      • Other CCLHO Meetings
      • CCLHO Board of Directors April 2017
      • About CCLHO
      • CCLHO Affiliates
      • CCLHO Board And Committee Chairs
      • CCLHO Strategic Map 2017-2020
      • CCLHO Organization
      • Chronic Disease Injury Prevention Agenda 1-5-2017
      • Chronic Disease Injury Prevention Agenda 2-15-2017
      • Chronic Disease Injury Prevention Agenda 3-2-2017
      • Health Officer Resources
    • Center for Environmental Health
      • Division of Food and Drug Safety
        • Manufactured Cannabis Safety Branch
          • Apply for a License
          • Complaint
        • Program Landing
        • Manufactured Cannabis Safety Branch
        • Food and Drug Laboratory Branch
        • FDLB Contact Us
        • FDLB Chemistry and Microbiology Client List
        • Abused Substances Analysis Section (ASAS)
        • Chemistry Section
        • Food and Drug Branch
        • FDB Certificates and Licenses
        • Forensic Alcohol Laboratory Program
        • Methadone Laboratory Regulatory Program
        • FARC
        • Helpful Hints
        • FAQs
        • Cannery Frequently Asked Questions
      • Division of Radiation Safety and Environmental Management
        • Radiologic Health Branch (RHB)
        • Radiologic Technology Certification Committee
        • RHB Laws and Regulations
        • RHB-Contact
        • RHB Job Opportunities
        • IN-LPRP
        • Radiation Emergencies
        • RHB - What's New
        • RHB - About Us
        • Recreational Health Program Contact Page
        • RHB - Radiation Safety Complaints
      • Certificates, Licenses, Permits and Registrations
      • Environmental Health Support Section
      • One Health
      • EHTER
      • Office of State Environmental Health Director
    • Center for Family Health
      • Division of Genetic Disease Screening
        • GDSP Mission
        • Genetic Disease Screening Program Publications
        • GDSP False Claims Act
        • Screening Information System (SIS)
        • GDSP Notice Of Information And Privacy Practices
        • GDSP Program and Services
        • Billing and Payment
        • Payment Portal FAQ
        • Current Year Budget Estimates
        • GDSPContactPage
        • Referral Centers
        • Your Future Together
        • Supporting Research
        • Education Resources for Individuals and Families
        • Education Resources for Healthcare Providers
      • Maternal, Child and Adolescent Health Division
        • Adolescent Family Life Program
          • Where We Are
          • Contact Us
          • Program Consultants and Contract Liaisons
          • Stories from the Adolescent Family Life Program
          • AFLP Request for Application 2023
          • AFLP RFA 2023 Addendum #1
          • AFLP RFA 2023 Addendum #2
          • AFLP RFA 2023 Addendum #3
          • AFLP RFA 2023 Questions and Answers
          • AFLP RFA 2023 Addendum-4
          • AFLP RFA 2023 Public Notice of Intent to Award
          • AFLP RFA 2023 Final Announcement of Awards
          • AFLP Program Implementation
          • AFLP Evaluation Program Outcomes
          • AFLP Program Evaluation
          • State Fiscal Year (SFY) 2024-2025 AFLP Budget Submission and Supplemental Forms Announcement
        • Adolescent Health
        • Adolescent Sexual Health Education Program
        • Black Infant Health Program
          • Where We Are: Local BIH Sites and Coordinators
          • Contact Us
          • Maternal and Infant Mortality/Morbidity
          • Health Equity
          • Outreach and Education Toolkit
          • Program Consultants and Contract Liaisons
          • Evaluation of the California Black Infant Health Program
          • Program Evaluation: Intermediate Outcomes Among Prenatal Group Model Participants
          • Program Evaluation: Services Received and Services Provided During Prenatal Group
          • Program Evaluation: Participant Participant and Staff Perceptions about the Program
          • SisterStory: Stories from Black Infant Health
          • Program Evaluation: Participants Served
          • Program Evaluation: Contextual Conditions that Supported the Implementation of the Prenatal Group Model
          • Group Model Components
          • Notice of Intent to Award: Updated Annual Allocations for the Black Infant Health Program for State Fiscal Years 2024/25 and 2025/26
        • Breastfeeding Initiative
          • Breastfeeding Sites and Local Coordinators
          • Guidelines and Resources
          • Guidelines and Resources for Clinics
          • Guidelines and Resources for Community Partners
          • Guidelines and Resources for Hospitals
          • Guidelines and Resources for Providers
          • Hospital Quality Improvement
          • Breastfeeding Laws
          • Breastfeeding Model Hospital Policy Recommendations
          • Lactation Accommodation
          • Lactation Accommodation: For Child Care Providers
          • Lactation Accommodation: For Community Partners
          • Lactation Accommodation: For Employers
          • Lactation Accommodation: For Parents
          • Breastfeeding
          • Data and Reports
          • In-Hospital Breastfeeding Initiation Data
          • Lactation Accommodation Laws for Workplace, Jails and School
          • Breastfeeding Awareness
        • California Home Visiting Program
          • Program Policies and Procedures
          • CHVP Sites and Local Coordinators
          • Contact Us
          • Data and Reports
          • Program Resources
          • Program Consultants and Contract Liaisons
          • HomeStory
          • California Statewide Home Visiting Needs Assessment
          • Evidence-Based Home Visiting Models in California
          • CHVP Memo #23-04: Notice of Award for MIECHV
          • CHVP Memo #23-05: Notice of Award for State General Fund
          • Request for Supplemental Information
          • State General Fund Innovation 2.0
          • Funding Alert for CHVP State General Fund Innovation for State Fiscal Year 2023 ā€“ 2028, 2023
          • Addendum #1 for CHVP State General Fund Innovation for State Fiscal Year 2023 ā€“ 2028, 2023
          • Questions and Answers for CHVP Request for Sā€‹upplā€‹ā€‹ementaā€‹l Information 2023
          • Interim Guidance Regarding Allowable Uses of CHVP State General Funding for Mental Health or Social Worker Consultation in Home Visiting
          • CHVP Policy and Procedure Feedback Request
          • Addendum 2 - CDPH/CHVP State General Fund Innovation 2.0 Request for Supplemental Information (RSI) for State Fiscal Year 2023 ā€“ 2028, 2023
        • California Personal Responsibility Education Program
          • CA PREP Request for Application 2018
          • CA PREP Questions and Answers for 2018 RFA
          • Contact Us
          • CAPREP-RFA-2021
          • CA PREP RFA 2021 Addendum #1
          • CA PREP Questions and Answers for 2021 RFA
          • CA PREP RFA 2021 Addendum #2
          • CA-PREP RFA 2021: Public Notice of Intent to Award
          • CA-PREP RFA 2021: Public Notice of Final Award
        • Comprehensive Perinatal Services Program
          • CPSP/MCAH Prenatal Programs in Your County
          • Contact Us
          • Provider Resource Document
          • New CPSP Provider Application and Process
        • Data Dashboards
        • Fetal and Infant Mortality Review
          • Local FIMR Coordinators
        • FLOURISH
        • Human Stem Cell Research
          • Human Stem Cell Research Advisory Committee
          • Human Stem Cell Research Reporting Forms
          • HSCR Advisory Committee Meetings
        • Information and Education
          • Local I&E Coordinators
          • I&E Request for Application 2019
          • Contact Us
        • Local Maternal, Child and Adolescent Health
          • Local MCAH Directors and Coordinators
          • Annual Reports
          • County Profiles
          • About Us
          • Contact Us
          • Transition of the Perinatal Services Coordinators (PSCs) Activities ā€” October 6, 2023
          • Comprehensive Perinatal Services Program (CPSP) Frequently Asked Questions (FAQs)
          • Release of Comprehensive Perinatal Services Program (CPSP) Frequently Asked Questions (FAQs)
        • Maternal and Infant Health Assessment
          • Methods
          • Questionnaires
          • Successes
          • Contact Us
          • MIHA Data and Reports
          • FAQs
          • Income loss, job loss and childcare problems early in the COVIDā€‘19 pandemic
          • Mental health during and after pregnancy early in the COVID-19 pandemic
          • Food Insecurity and Housing Instability Early in the COVID-19 Pandemic
          • COVID-19 impacts on pregnant people and families in California, 2020
          • MIHA Data Dashboards
          • MIHA Data Snapshots Dashboard
        • Nutrition and Physical Activity
          • Guidelines and Resources
          • Systems and Environmental Change
          • Emergency Preparedness: Infant and Young Child Feeding
          • MyPlate
          • Healthy Eating and Physical Activity as a Family
          • Folic Acid
          • California Infant Feeding Guide
          • Healthy Weight for Healthy Birth and Beyond
          • Physical Activity for Children
          • Choking Prevention for Young Children
          • Multiple Factors Affect Birthing Parentsā€™ Weight
          • Healthy Weight for Healthy Birth and Beyond Toolkit
          • Healthy Weight for Healthy Birth and Beyond Data Brief
          • Physical Activity as a Family
          • Healthy Eating as a Family
        • Perinatal Equity Initiative
          • Contact Us
          • Outreach and Education Toolkit
          • PEI Where We Are
          • Program Consultants and Contract Liaisons
          • PEI Community Advisory Board (CAB)
          • Perinatal Equity Initiative Public Awareness Campaigns
        • Preconception
        • Regional Perinatal Programs of California
          • Where We Are: Local RPPC Sites and Coordinators
          • Contact Us
          • RPPC Request for Application 2025
          • RPPC RFA 2025 Questions & Answers
          • Addendum 2 - RPPC Request for Application 2025
          • Addendum 1 - RPPC Request for Application 2025
          • RPPC RFA 2025: Public Notice of Intent to Award
          • RPPC RFA 2025: Final Announcement of Award
        • Sudden Infant Death Syndrome (SIDS) Program
          • Local SIDS Coordinators
          • Risk Reduction Resources
          • SIDS Advisory Council
          • SIDS Advisory Standing Rules
          • Safe Sleep Environments for Infants
          • SIDS Resources for Me and My Family
          • SIDS Protocols
          • Tool for First Responders
          • Preparing for SUID Home Visit
          • SIDS Program Mentors
          • Health Care Professionals
          • Contact-Us
          • MyStory: Stories from the California SIDS Program
          • SIDS Coordinator Mentors
          • SIDS Parent Support Group
          • Safe Sleep for Babies
          • SueƱo Seguro Para Los BebĆ©s
          • SIDS/SUID Advisory Council Members
      • Women, Infants and Children
        • Program Landing
        • Grocers
        • Local Agencies
        • Report Fraud & Abuse
        • Farmersā€™ Markets
        • WIC Foods
        • Research & Data
        • About WIC
        • Laws & Regulations
        • How Can I Get WIC?
        • Health Care Providers
        • Budget Estimate Archive
        • FederalFoodRequirementsandExamples
        • Breastfeeding Resources for Health Care Providers
        • Bulletin Regulations
        • 2021 Summer Benefit Increase
      • Hunger, Nutrition, and Health
    • Center for Health Care Quality
      • Healthcare Associated Infections
        • Program Landing
        • Me and My Family
        • Healthcare Providers
        • Annual HAI Reports
        • Public Health Partners
        • HAI Advisory Committee
        • ContactUs
        • M.Chimaera
        • ā€‹Antimicrobial Resistance (AR)
        • HAI Interactive Maps
        • Monitoring Adherence to Healthcare Practices that Prevent Infection
        • Healthcare-Associated Infections (HAI)
        • Healthcare Personnel Influenza Vaccination Reporting In CA Hospitals
        • HAI Advisory Committee Members List
        • CA Campaign To Prevent BSI in Hemodialysis Patients
        • 2-Day Basics IP Course
        • C. difficile (C. diff, CDI)
        • Central Line-associated Blood Stream Infection (CLABSI)
        • Methicillin-Resistant Staphylococcus aureus Bloodstream Infection (MRSA BSI)
        • Vancomycin Resistant Enterococci Bloodstream Infection (VRE BSI)
      • Licensing and Certification Program
        • CalHealthFind
          • ASPEN_STATE_2567
          • Complaint Investigation Process
          • Consumer Guide
          • Facility/Provider Types
          • Facility Compare
          • Facility Detail
          • Facility Detail Popup
          • Helpful Links
          • Search Result
          • State Enforcement Actions
          • STATE_PENALTY_1424
          • STATE_PENALTY_2567
          • ASPEN_FEDERAL_2567
          • Complaint
          • Survey Inspection Details
          • Medi-Cal Involuntary Terminations
        • Program Landing
        • Health Care Facilities
        • Patients, Residents, and Families
        • Stakeholders and Policy Makers
        • Health Care Professionals
        • All Facilities Letters
        • L&C All Facilities Letters 2006
        • L&C All Facility Letters 2007
        • L&C All Facility Letters 2008
        • Stakeholder Forum
        • Find and choose a nursing home
        • L&C All Facilities Letters 2009
        • L&C All Facilities Letters 2010
        • Field Operations Branch - District Offices
        • License Fee Reports
        • Quality Improvement Initiatives
        • L&C All Facilities Letters 2011
        • L&C All Facilities Letters 2012
      • testpage
      • Stakeholder Forum
      • SNFMobileApp
      • SNFData
      • SNFeducation
      • SNFsurveymodel
      • SNFresources
      • testnewdn
    • Center for Health Statistics and Informatics
      • California Marriage License, Registration and Ceremony Information
      • Vital Records
      • RAB - County Health Status Profiles
      • RAB Researchers and Statisticians
      • Vital Records Fees
      • Vital Records Important Infomation
      • Vital Records Obtaining Certified Copies of Death Records
      • Authorized Copy vs. Informational Copy
      • Assembly Bill (AB) 1733
      • Contact CDPH Vital Records
      • Vital Records Processing Times
      • Sworn Statement
      • Obtaining Vital Records From County Offices
      • Vital Records Issuance and Preservation Branch
      • California Marriage License General Information
      • Types of Marriage Licenses
      • Adoption Process
      • Marriage Officiant Frequently Asked Questions
      • County Registrars and Recorders
    • Center for Healthy Communities
      • Division of Chronic Disease and Injury Control
        • California Tobacco Control Branch
          • Tobacco Education and Research Oversight Committee
          • TEROC Meeting Information
          • TEROC Plan 2025
          • Education Materials
          • Tool Kits And Manuals
          • Media Campaign Information
          • Evaluation Plans
          • Cessation Services and Resources
          • Contact Information
          • CTCB Peer Reviewed Publications
          • Electronic Smoking Devices
          • Fact Sheets and Reports
          • Flavored Tobacco and Menthol
          • Welcome
          • Partners
          • News and Press Releases
          • Tobacco Taxation and Price
        • Chronic Disease Control Branch
          • Program Landing
          • Alzheimerā€™s Disease
          • Arthritis
          • Diabetes Prevention
          • Heart Disease Prevention
          • Preventive Medicine Public Health Residency Program
          • California Epidemiologic Investigation Service Fellowship Program
          • California Wellness Plan Implementation
          • California Stroke Registry-California Coverdell Program
          • Healthy Hearts California
          • Guidelines, Resources, and Evidence-Based Best Practices for Providers
          • About Us
          • California Alzheimerā€™s Disease Centers
          • CWPI Convenings
          • CWPI Resources
          • Alzheimerā€™s Disease Program
          • Alzheimers Disease Resources
          • AlzheimersDataStatisticsReports
          • Stroke
        • Chronic Disease Surveillance and Research Branch
          • Contact CDSRB
          • California Comprehensive Cancer Control Program
          • California Cancer Registry
          • About the CDSRB
          • About the CCR
          • Contact the CCR
          • California's Comprehensive Cancer Control Plan
          • PSE in Comprehensive Cancer Control
          • CDOC Contact Us
          • Cancer Survivorship Care Plans
          • CDOC's Big Win
          • Library of Surveillance Tutorials
          • CDOC Webinars and Presentations
          • CDOC main page
          • CDOC Executive Committee
          • California Parkinson's Disease Registry
          • CPDR FAQs
          • HIPAA FAQs
        • Injury and Violence Prevention
          • Injury and Violence Prevention Branch
          • Overdose Prevention Initiative
          • Domestic Violence/Intimate Partner Violence
          • Sexual Violence Prevention
          • Teen Dating Violence
          • Domestic Violence Prevention
          • Child Passenger Safety (CPS) In California
          • Essentials for Childhood
          • Cal-Enhanced
          • Crash Medical Outcomes Data Project
          • Naloxone Grant Program
          • Kids Plates
          • Pedestrian Safety (PedSafe) Program
          • Drowning Prevention: Toddler Pool and Spa Safety
          • Rape Prevention and Education Program
          • Domestic Violence Awareness Month
          • Sexual Assault Awareness Month
          • Naloxone Terms and Conditions
          • Your Pain is Real. So Are the Risks.
        • Nutrition and Physical Activity Branch
          • NEOPB Employment Opportunities
          • Research and Evaluation Section (RES)
          • Statewide Evaluation
          • Initiatives
          • Children and Youth
          • Prevention First
          • LHD Program Letters
          • Local Health Department Evaluation
          • Impact Outcome Evaluation
          • SNAP-Ed Guidance for Local Health Departments
          • Helpful Links
        • CDIC Leadership
      • Division of Environmental and Occupational Disease Control
        • Childhood Lead Poisoning Prevention Branch
          • Healthcare Provider Education
          • Lead Education Materials
          • Lead Related Construction
          • LRC Program Overview
          • Types of Certification
          • Testing Your Home for Lead
          • LRC Certification Process
          • LRC Traning
          • LRC State Certification Exam
          • Apply for Certification or Renewal
          • Hire a Lead Professional
          • Find a Lead Professional
          • Frequently Asked Questions
          • Health Care Providers
          • About the CLPPB
          • Report Results
          • Me and My Family
          • Lead Professionals
          • Provider Overview
          • Data
        • Environmental Health Investigations Branch
          • Community Participation & Education Section
          • Environmental Epidemiology Section
          • Exposure Assessment Section
          • Site Assessment Section
          • Contact EHIB
          • Environmental Justice
          • About EHIB
          • EHIB Programs
          • EHIB A to Z Index
          • EHIB Educational Materials
          • Data, Tools, and Research
          • Prescribed Fire
          • LHD-Prescribed-Fire
        • Environmental Health Laboratory Branch
          • Air Quality Section
          • Biochemistry Section
          • About the Environmental Health Laboratory
          • CDPH-Approved Cholinesterase Laboratories
          • Contact the Environmental Health Laboratory
        • Occupational Health Branch
          • About Occupational Health Branch
          • Occupational Health Branch Programs and Activities
          • Occupational Health Branch Publications & Videos
          • Data & Statistics
          • Contact OHB
          • What's New at the Occupational Health Branch
          • Newsletter
          • Work-Related Valley Fever (Coccidioidomycosis)
          • Occupational Health Watch February 2017
          • Occupational Health Watch March 2017
          • Occupational Health Watch January 2017
          • Occupational Health Watch April 2017: Spotlight on Skylight Falls for Workers Memorial Day
          • Occupational Health Watch November 2016
          • Occupational Health Watch October 2016
          • Occupational Health Watch September 2016
          • Occupational Health Watch July 2016: August Is Valley Fever Awareness Month
          • Occupational Health Watch June 2016
          • Occupational Health Watch May 2016
        • Continuing Education
        • Environmental Health Topics
        • Emergency Preparedness Team
        • Senior Health
      • Opioids
      • Substance and Addiction Prevention Branch
        • Cannabis
      • Environmental Health
      • Vaping Health Advisory
      • EVALI Weekly Public Report
      • About Us
      • Media Campaigns
      • Local Health Department Corner
      • Proposition 56 Fiscal Reporting
      • Office of School Health
      • About Us
      • 2023ā€“24 Program Accomplishments
      • School-Based Health Center
      • Office of School Health Hub
      • Guidance for School & Child Care Communicable Disease Mitigation
      • Epinephrine Standing Order Frequently Asked Questions
    • Center for Infectious DiseasesCurrently selected
      • Division (Office) of AIDS
        • HIV/AIDS Welcome Page
        • HIV/AIDS Program Overview
        • HIV Care Branch
        • HOPWA Program
        • OA Medi-Cal Waiver Program (MCWP)
        • Minority AIDS Initiative
        • OA ADAP Branch
        • HIV/AIDS Prevention Program
        • HIV/AIDS Surveillance Program
        • Office of AIDS Budget Process
        • LGBTQ+ Health
        • HIV Care Program
        • HIV/AIDS ADAP Contractors
        • HIV/AIDS ADAP Service Providers
        • HIV/AIDS ADAP Communications
        • HIV/AIDS ADAP Health Insurance Premium Payment Assistance
        • HIV/AIDS ADAP Forms
        • HIV/AIDS ADAP Resources
        • OA HIV Data Systems
        • SEP Certification Applications
      • Division of Communicable Disease Control
        • CalREDIE
        • CalREDIE Contact Us
        • CDER Contact Us
        • CDER Information for Health Professionals
        • CDER Resources
        • Chlamydia
        • Communicable Disease Emergency Response Program
        • DCDC Contact Us
        • DCDC Information for Local Health Departments
        • DCDC Resources
        • Gonorrhea
        • Hepatitis C
        • Infectious Diseases Branch
        • Interpreting Zika Virus Test Results
        • Pelvic Inflammatory Disease (PID)
        • Sexually Transmitted Diseases Control Branch
        • Syphilis
        • TBCBContactUs
        • Trichomoniasis
        • VRDL Guidelines for Specimen Collection and Submission for Pathologic Testing
      • Office of Binational Border Health
        • Office of Binational Border Health Publications
        • Office of Binational Border Health Advisory Group
        • About the Office of Binational Border Health
        • Contact the Office of Binational Border Health
        • Border Infectious Disease Surveillance
        • Infectious Disease Epidemiology
        • Binational Case Reporting
        • Binational Communication
        • Quarterly Binational Epidemiology Meetings
        • Border Region Respiratory Disease Surveillance
        • Border Infectious Disease Surveillance - Coccidioidomycosis
        • Border Infectious Disease Surveillance - Queso Fresco
        • Border Infectious Disease Surveillance - Mosquito-borne-diseases
        • Border Infectious Disease Surveillance - Rocky Mountain Spotted Fever
        • Border Infectious Disease Surveillance - Influenza and Other Respiratory Infections
        • Border Demographics
        • Border Obesity
        • Border Diabetes
        • Border Mental Health & Suicide
      • Office of Infectious Disease Preparedness and Response
        • Pathways
      • Office of Refugee Health
        • Refugee Health Clinics
        • Program Overview
        • Data & Statistics
        • Alameda County Resources
        • How to Request an Interpreter
        • Making a Medical Appointment
        • What is a Specialist
        • Complain About a Doctor
        • Health Emergency
        • Difference between Hospital and Clinic
        • Choose a Health Plan
        • Dental Care
        • Prescription Medication
        • Preventative Care
        • Health Screening
        • Immunizations
        • Contra Costa
        • Los Angeles
        • Orange
        • Sacramento
      • About the Deputy Director
      • AboutCID
    • Center for Laboratory Sciences
      • Division of Environmental Health Laboratories
        • Drinking Water and Radiation Laboratory
        • Environmental Health Laboratory
        • Food and Drug Laboratory
      • Infectious Diseases Laboratory
        • Infant Botulism Treatment and Prevention Program
        • Microbial Diseases Laboratory
        • Viral and Rickettsial Disease Laboratory
      • Operations
    • Director's Office
      • Let's Talk Cannabis
        • En EspanĢƒol
        • FAQ and Fact Sheet Printable Resources
        • Helpful Resources
        • Whatā€™s Legal
        • Parents and Mentors
        • Pregnant and Breastfeeding Women
        • Responsible Use
        • Youth
        • Community Toolkit
    • Emergency Preparedness Office
      • CDPH/EMSA Real-Time Mapping Application
      • Develop a Family Disaster Plan
      • Prepare an Emergency Supply Kit
      • Be Prepared California
      • Be Prepared Landing
      • Be Informed
      • Emergency and Evacuation Planning Guide for Schools
      • Tips for Communicating with Students During an Emergency
      • Know When and How to Shelter-in-Place for Schools
      • How to Help Students Cope and Deal with Stress
      • Pandemic Flu Checklist Homepage
      • Partners - Landing
    • Human Resources Division
      • Recruitment Events
      • Accounting
      • BusinessPros
      • BusinessPros
      • Community Safety
      • Consumer Goods
      • Entry Level
      • Environmental
      • IT
      • LabScience
      • Legal
      • Operations
      • PHDisease
      • Physician
      • ProgramAdmin
      • Public Relations
      • Regulatory Enforcement and Inspection
    • NBS
    • Office of Communications
      • CDPH Lifts Rock Crab Health Advisory in Portions of San Mateo County - South of Pillar Point
      • News Releases 2017
      • CDPH Launches Mobile Website for WIC Participants
      • CDPH Reports Widespread Flu Activity that is More Severe than Last Year
      • CDPH Fines San Francisco County Facility in Death of Resident
      • CDPH Fines Los Angeles County Facility in Death of Resident
      • Letā€™s Get Healthy California Announces Local Innovations to Improve Californiaā€™s Health
      • Dungeness Crab Health Advisory Lifted for Remainder of California Coast
      • CDPH Issues Penalties to 14 Hospitals
      • News Releases 2016
      • Influenza Cases Widespread in California
      • Dungeness Crab Health Advisory Lifted in Portions of Mendocino County ā€“ South of Ten Mile River
      • CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from San Luis Obispo County
      • Dungeness Crab Health Advisory Lifted in Portions of Sonoma, Mendocino, Humboldt Counties
      • CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel
      • CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from Monterey County
      • CDPH Awarded Grant to Expand Child Safety-Seat Use
      • CDPH Awarded Grant to Study Motor-Vehicle Crash Injuries
      • Holiday Travelers Reminded to Take Precautions to Prevent Zika
      • Local Transmission Confirmed in Ensenada, Mexico
    • Office of Compliance
      • Office of Compliance Contact Us Page
    • Office of Health Equity
      • Abortion
      • Office of Health Equity Advisory Committee
      • Health Equity Research and Statistics Section
      • OHE Advisory Committee Bios
      • About_OHE
      • Contact Us
      • CDEU
      • OHESpeaker Series
      • CRDP
      • Health in All Policies
      • Disparities
      • Men's Health
      • Women's Health
      • Climate & Health Profile Reports
      • CalBRACE Project - Climate Change & Health Equity
      • CCHEP - Climate Impacts of Racism
      • Climate & Health Vulnerability Indicators for CA
    • Office of Legislative and Governmental Affairs
      • Legislative Summaries
      • Legislative Newsletters
      • Contact Us
      • LegislativeReports
    • Office of Policy and Planning
      • California Equitable Recovery Initiative (CERI) Q&A
      • AB 1726 Asian and Pacific Islander Data Disaggregation Brief
      • State of Public Health Report
      • State of Public Health Report Resource Hub
      • Redirect Fusion to OPP
      • Transforming Behavioral Health
      • Partner and Community Engagement
      • Behavioral Health Services Act (BHSA): Population-Based Prevention Program Guide
      • Behavioral Health Transformation
      • BHSA Population-Based Prevention
      • BHSA Population-Based Prevention Program Framework
      • Appendix A
      • Appendix B
    • Office of Problem Gambling
      • Helplines & Support Groups
      • Types of Treatment Offered
      • Resources & Tools
      • Gambler Self Assessment
      • Youth Gambler Self-Assessment
      • Know a Problem Gambler?
      • CalGETS
      • CalGETS Phase II
      • Announcements, Events & Trainings
      • Reports
      • Advisory Group
      • About OPG
      • Provider-Directory
      • Tools and Resources
      • 3 Questions
      • If You Feel Alone
      • Calendar
      • What is Problem Gambling
      • Loved Ones and Youth
      • Hope for Gamblers
    • Office of Professional Development & Engagement
      • Contact OPDE
      • Internship Program
      • Interns Corner
      • Meet the Former Interns --Eric Neuhauser
      • Meet the Former Interns -Carmen San
      • Meet the Former Interns - Katey DeSanti
      • Meet the Former Interns - Ryan Skaggs
      • Meet the Former Interns - Yesenia Posadas
      • Volunteer Internship Program
      • Language Access Plan
      • Language Access Services Program
      • Cal-EIS Application Procedures
      • Cal-EIS Applicant Requirements
      • Cal-EIS Fellows
      • Cal-EIS FAQs
      • Cal-EIS Graduates
      • Preventive Medicine Residency Program FAQs
    • Office of the State Public Health Laboratory Director
      • Laboratory Central Services
        • California Laboratory Animal Use Approval Program
      • Laboratory Field Services
        • About Us
        • Contact Us
        • Job Opportunities
        • Regulatory Information
        • Complaints Program - Laboratory Field Services
        • Clinical Laboratory Technology Advisory Committee (CLTAC)
        • Clinical Laboratory Scientist Trainee License
        • Clinical Chemist Scientist Trainee License
        • Clinical Cytogeneticist Scientist Trainee License
        • Clinical Genetic Molecular Biologist Scientist Trainee License
        • Clinical Hematologist Scientist Trainee License
        • Clinical Histocompatibility Scientist Trainee License
        • Clinical Immunohematologist Scientist Trainee License
        • Clinical Microbiologist Scientist Trainee License
        • Clinical Toxicologist Scientist Trainee License
        • License Verification
        • Clinical Laboratory Professional Licensing
        • Renewal of Clinical Laboratory Personnel Licenses & Certificates
        • Changing Key Demographic Information
        • Phlebotomy Certificate
  • Recent

Office of aids

  • Home
  • +About OA
    • Mission Statement
    • Programs Overview
    • State Budget Information
    • Local Assistance Funding
    • OA Voice Monthly Newsletter
    • Conference Presentations
  • About HIV
  • +Looking for an HIV Test?
    • Order a free HIV self test ā€“ TakeMeHome
    • Get Tested - National HIV, STD, and Hepatitis Testing
  • +Looking for HIV Prevention Services?
    • Prevention Services
    • PrEP Assistance Program (PrEP-AP)
  • +HIV Positive? Next Steps: Care, Treatment & Paying for Insurance
    • Local Health Services
    • HIV Care and Housing Programs
    • AIDS Drug Assistance Program
  • +HIV Data and Data Systems
    • HIV Surveillance
    • HIV Data Systems
  • +Community
    • Celebrate Pride
    • California Planning Group
    • California STD/HIV Controllers Association
    • HIV and Women
    • LGBTQ+ Health
    • Transgender Health in California
    • Youth Community Health in California
  • HIV Laws
  • Request for Applications
  • Harm Reduction & Syringe Services Programs
  • Ending the Epidemics Strategic Plan

ADAP Client Application Forms

Client Application Forms

Review the list of Acceptaā€‹ble Supporting Documentation (Acceptable Supporting Documentation (Spanish)) for ADAP clients. The following lists contain forms that may be applicable to each client type, please note that not every form in the list will be required for each clientā€‹.

ā€‹General ADAP Formsā€‹ā€‹

ā€‹CDPH Form #ā€‹

ā€‹Form

ā€‹Last Revised

ā€‹Client Type
ā€‹CDPH 8ā€‹439
 ā€‹ADAP Application (PDF)ā€‹
 ā€‹August 2019
 ā€‹ADAP
ā€‹CDPH 8439 SP
 ā€‹ADAP Application (Spanish) (PDF)
 ā€‹August 2019
 ā€‹ADAP
ā€‹CDPH 8439 ZHS
 ā€‹ā€‹ADAP Application (Simplified Chinese) (PDF)
 ā€‹August 2019
 ā€‹ā€‹ADAP
ā€‹CDPH 8439 KO
 ā€‹ā€‹ADAP Application (Korean) (PDF)
 ā€‹August 2019
 ā€‹ā€‹ADAP
ā€‹CDPH 8439 TL
 ā€‹ā€‹ADAP Application (Tagalog) (PDF)
 ā€‹August 2019
 ā€‹ā€‹ADAP
ā€‹CDPH 8439ā€‹ VI
 ā€‹ā€‹ADAP Application (Vietnamese) (PDF)ā€‹
 ā€‹August 2019ā€‹
 ā€‹ā€‹ADAP
ā€‹CDPH 8456ā€‹
 ā€‹ADAP ā€‹Special Power of Attorney (PDF)
 ā€‹March 2019
 ā€‹ADAP

ā€‹CDPH 8456Aā€‹

ā€‹ADAP Revocation of Special Power of Attorney (PDF)

ā€‹July 2017

ā€‹ADAP
ā€‹CDPH 8685
 ā€‹ADAP Consent Form (PDF)
 ā€‹January 2025
 ā€‹ADAP

ā€‹CDPH 8685 SP

ā€‹ADAP Consent Form (Spanish) (PDF)

January 2025ā€‹

ā€‹ADAP
ā€‹CDPH 8685 ZHS
 ā€‹ADAP Consent Form (Simplified Chinese) (PDF)
 ā€‹September 2024
 ā€‹ā€‹ADAP
ā€‹CDPH 8685 KO
 ā€‹ADAP Consent Form (Korean) (PDF)
 ā€‹September 2024
 ā€‹ā€‹ADAP
ā€‹CDPH 8685 TL
 ā€‹ADAP Consent Form (Tagalog) (PDF)
 ā€‹September 2024
 ā€‹ā€‹ADAP
ā€‹CDPH 8685ā€‹ VI
 ā€‹ADAP Consent Form (Vietnamese) (PDF)
 ā€‹September 2024ā€‹
 ā€‹ā€‹ADAP

ā€‹CDPH 8723

ā€‹ADAP/PrEP-AP Client Attestation Form (PDF)

ā€‹May 2023

ā€‹ā€‹ā€‹ADAP/PrEP-AP

ā€‹CDPH 8723 SP

ā€‹ADAP/PrEP-AP Client Attestation Form (Spanish) (PDF)

ā€‹May 2023

ā€‹ā€‹ā€‹ADAP/PrEP-AP
ā€‹ā€‹CDPH 8723 ZHS
 ā€‹ADAP/PrEP-AP Client Attestation Form (Simplified Chinese) (PDF)
 ā€‹May 2023
 ā€‹ā€‹ADAP/PrEP-AP
ā€‹ā€‹CDPH 8723 KO
 ADAP/PrEP-AP Client Attestation Form (Korean) (PDF)
 ā€‹May 2023
 ADAP/PrEP-AP
ā€‹ā€‹CDPH 8723 TL
 ā€‹ADAP/PrEP-AP Client Attestation Form (Tagalog) (PDF)ā€‹
 ā€‹May 2023
 ADAP/PrEP-AP
ā€‹ā€‹CDPH 8723 VIā€‹
 ā€‹ADAP/PrEP-AP Client Attestation Form (Vietnamese) (PDF)
 ā€‹May 2023
 ā€‹ā€‹ADAP/PrEP-APā€‹
ā€‹CDPH 8747ā€‹
 ā€‹ā€‹Certification of Justice-Involved Client Eligibilityā€‹ (PDF)ā€‹
 ā€‹November 2020ā€‹
 ā€‹ADAP
ā€‹CDPH 9117
 ā€‹ā€‹ā€‹Enrollment Worker Phone Enrollment Attestationā€‹ (PDF)
 ā€‹April 2022
 ā€‹ā€‹ADAP/PrEP-AP
ā€‹CDPH 8542
 ā€‹Grievance Form (PDF)
 ā€‹February 2022
 ā€‹ADAP/PrEP-AP
ā€‹CDPH 8542 SP
 ā€‹Grievance Form (Spanish) (PDF)
 ā€‹March 2018ā€‹
 ā€‹ADAP/PrEP-AP
CDPH 8542 ZHS
 ā€‹Grievance Form (Simplified Chinese) (PDF), available upon request
 November 2024
 ā€‹ADAP/PrEP-AP
ā€‹CDPH 8542 KO
 ā€‹ā€‹Grievance Form (Korean) (PDF), available upon request
 November 2024
 ā€‹ADAP/PrEP-AP
ā€‹CDPH 8542 TL
 ā€‹Grievance Form (Tagalog) (PDF), available upon request
 November 2024
 ā€‹ADAP/PrEP-AP
ā€‹CDPH 8542 VI
 ā€‹ā€‹Grievance Form (Vietnamese) (PDF), available upon request
 ā€‹November 2024
 ā€‹ADAP/PrEP-AP
 

Residency Documentationā€‹ā€‹

ā€‹CDPH Forā€‹m #

ā€‹Form

Last Revised

ā€‹Client Type

ā€‹CDPH 8727

ā€‹Residency Verification Affidavit (PDF)

ā€‹August 2023

ā€‹ā€‹ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8727 SPā€‹
 ā€‹ā€‹Residency Verification Affidavit (Spanish) (PDF)
 ā€‹ā€‹August 2023
 ā€‹ā€‹ā€‹ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8727 ZHS
 ā€‹Residency Verification Affidavit (Simplified Chinese) (PDF), available upon request
 ā€‹November 2023
 ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8727 KO
 ā€‹Residency Verification Affidavit (Korean) (PDF), available upon request
 ā€‹November 2023
 ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8727 TL
 ā€‹Residency Verification Affidavit (Tagalog) (PDF), available upon request
 ā€‹November 2023
 ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8727 VI
 ā€‹Residency Verification Affidavit (Vietnamese) (PDF), available upon request
 ā€‹November 2023ā€‹
 ā€‹ADAPā€‹/PrEP-AP


Identity Documentation

ā€‹CDPā€‹H ā€‹Form #

ā€‹Form

ā€‹Last Revised

ā€‹ā€‹Client Type

ā€‹CDPH 8442

ā€‹Provider Verification of Identity (PDF)

ā€‹April 2020

ā€‹ā€‹ā€‹ADAPā€‹/PrEP-AP


Clinical Documentation

ā€‹ā€‹ā€‹CDPHā€‹ Form #ā€‹

ā€‹Form

ā€‹Last Revised

ā€‹ā€‹Client Type
ā€‹ā€‹CDPH 8440ā€‹ā€‹
 ADAP Diagnosiā€‹s Formā€‹ (PDF)
 ā€‹October 2024
 ā€‹ADAPā€‹

ā€‹

Income Documentation

ā€‹ā€‹CDPH Form #

ā€‹Form

ā€‹Last Revised

ā€‹ā€‹Client Type

ā€‹CDPH 84ā€‹41

ā€‹ADAP/PrEP-AP Income Verification Affidavit (PDF)

ā€‹August 2022

ā€‹ā€‹ā€‹ADAPā€‹/PrEP-AP

ā€‹CDPH 84ā€‹41 SP

ā€‹ADAP/PrEP-AP Income Verification Affidavit (Spanish) (PDF)

ā€‹August 2022

ā€‹ā€‹ā€‹ADAPā€‹/PrEP-AP
ā€‹CDPH 84ā€‹41 ZHS
 ā€‹ADAP/PrEP-AP Income Verification Affidavit (Simplified Chinese) (PDF)ā€‹
 ā€‹ā€‹August 2022
 ā€‹ADAPā€‹/PrEP-AP
ā€‹CDPH 84ā€‹41 KO
 ā€‹ADAP/PrEP-AP Income Verification Affidavit (Korean) (PDF)
 ā€‹ā€‹August 2022
 ā€‹ADAPā€‹/PrEP-AP
ā€‹CDPH 84ā€‹41 TL
 ā€‹ADAP/PrEP-AP Income Verification Affidavit (Tagalog) (PDF)
 ā€‹ā€‹August 2022
 ā€‹ADAPā€‹/PrEP-AP
ā€‹CDPH 84ā€‹41 VI
 ADAP/PrEP-AP Income Verification Affidavit (Vietnamese) (PDF)ā€‹
 ā€‹ā€‹August 2022
 ā€‹ADAPā€‹/PrEP-AP

ā€‹CDPH 8726

ā€‹ADAP/PrEP-AP Self-Employment Affidavit (PDF)

ā€‹October 2024

ā€‹ā€‹ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8726 SPā€‹
 ā€‹ADAP/PrEP-AP Self-Employment Affidavit (Spanish) (PDF)
 ā€‹August 2022
 ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8726 ZHS
 ā€‹ā€‹ADAP/PrEP-AP Self-Emplā€‹ā€‹oyment Affidavit (Simplified Chinese) (PDF)ā€‹
 ā€‹ā€‹August 2024
 ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8726 KO
 ā€‹ā€‹ADAP/PrEP-AP Self-Employment Affidavit (Korean) (PDF)ā€‹
 ā€‹ā€‹August 2024
 ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8726 TL
 ADAP/PrEP-AP Self-Employment Affidavit (Tagalog) (PDF)ā€‹
 ā€‹ā€‹August 2024
 ā€‹ADAPā€‹/PrEP-AP
ā€‹ā€‹CDPH 8726 VI
 ADAP/PrEP-AP Self-Employment Affidavit (Vietnamese) (PDF)ā€‹
 ā€‹ā€‹August 2024ā€‹
 ā€‹ADAPā€‹/PrEP-AP


Eligibility Exception Request and Temporary Access Period Forms

ā€‹ā€‹CDPH Fā€‹orm #

ā€‹Form

ā€‹Last Revised

ā€‹ā€‹Client Type

ā€‹CDPH 8729

ā€‹ADAP Eligibility Exception Request (EER) (PDF)

ā€‹April 2024

ā€‹ADAP

ā€‹CDPH 8724ā€‹

ā€‹ADAP Medi-Cal Eligibility Exception Request (MEER) (PDF)

ā€‹April 2024

ā€‹ADAP

ā€‹CDPH 8728

ā€‹ADAP Temporary Access Period (TAP) (PDF)

ā€‹January 2022

ā€‹ADAP
ā€‹CDPH 8728 SP
 ā€‹ADAP Temporary Access Period (TAP) (Spanish)ā€‹ (PDF)
 ā€‹ā€‹January 2022
 ā€‹ADAP
ā€‹CDPH 8728 ZHS
 ā€‹ADAP Temporary Access Period (TAP) (Simplified Chinese) (PDF)
 ā€‹July 2024
 ā€‹ADAP
ā€‹CDPH 8728 KO
 ā€‹ADAP Temporary Access Period (TAP) (Korean) (PDF)
 ā€‹ā€‹July 2024
 ā€‹ADAP
ā€‹CDPH 8728 TL
 ā€‹ADAP Temporary Access Period (TAP) (Tagalog) (PDF)
 ā€‹ā€‹July 2024
 ā€‹ADAP
ā€‹CDPH 8728 VI
 ā€‹ADAP Temporary Access Period (TAP) (Vietnamese) (PDF)
 ā€‹ā€‹July 2024ā€‹
 ā€‹ADAP


Insurance Assistance Program Forms

ā€‹CDPH Fā€‹orm #

ā€‹Form

ā€‹Last Revised

ā€‹ā€‹Client Type

ā€‹CDPH 8738

ā€‹ADAP Acknowledgement of Policies and Responsibilities (PDF)

ā€‹February 2022

ā€‹OA-HIPP

ā€‹CDPH 8737ā€‹

ā€‹ADAP Health Insurance Assistance ā€“ Family Plan Consent Form (PDF)

ā€‹February 2024

ā€‹OA-HIPP

ā€‹CDPH 8722

ā€‹ADAP Partial Payment Agreement (PDF)

ā€‹January 2025

ā€‹OA-HIPP/EB-HIPP/MPPP

ā€‹CDPH 8722 SP

ADAP Partial Payment Agreement (Spanish) (PDF)ā€‹

ā€‹January 2025

ā€‹OA-HIPP/EB-HIPP/MPPP
ā€‹ā€‹CDPH 8722 ZHS
 ā€‹ADAP Partial Payment Agreement (Simplified Chinese) (PDF), available upon request
 ā€‹January 2025
 ā€‹ā€‹OA-HIPP/EB-HIPP/MPPP
ā€‹ā€‹CDPH 8722 KO
 ā€‹ADAP Partial Payment Agreement (Korean) (PDF), available upon request
 ā€‹January 2025
 ā€‹ā€‹OA-HIPP/EB-HIPP/MPPP
ā€‹ā€‹CDPH 8722 TL
 ā€‹ADAP Partial Payment Agreement (Tagalog) (PDF), available upon request
 ā€‹January 2025
 ā€‹ā€‹OA-HIPP/EB-HIPP/MPPP
ā€‹ā€‹CDPH 8722 VIā€‹
 ā€‹ADAP Partial Payment Agreement (Vietnamese) (PDF), available upon request
 ā€‹January 2025ā€‹
 ā€‹ā€‹OA-HIPP/EB-HIPP/MPPPā€‹
ā€‹ā€‹CDPH 8443
 ā€‹Medical Out-Of-Pocket (MOOP) Claim Form (PDF)
 ā€‹March 2022
 ā€‹OA-HIPP/EB-HIPP/MPPP
ā€‹CDPH 8443 SP
 ā€‹Medical Out-ā€‹Of-Pocket (MOOP) Claim Form (Spanish) (PDF)ā€‹
 ā€‹March 2022
 ā€‹OA-HIPP/EB-HIPP/MPPPā€‹
ā€‹CDPH 8443 ZHS
ā€‹Medical Out-Of-Pocket (MOOP) Claim Form (Simplified Chinese) (PDF), available upon request
ā€‹March 2022
ā€‹ā€‹OA-HIPP/EB-HIPP/MPPPā€‹
ā€‹CDPH 8443 KO
ā€‹Medical Out-Of-Pocket (MOOP) Claim Form (Korean) (PDF), available upon request
ā€‹March 2022
ā€‹ā€‹OA-HIPP/EB-HIPP/MPPPā€‹
ā€‹CDPH 8443 TL
ā€‹Medical Out-Of-Pocket (MOOP) Claim Form (Tagalog) (PDF), available upon request
ā€‹March 2022
ā€‹ā€‹OA-HIPP/EB-HIPP/MPPPā€‹
ā€‹CDPH 8443 VI
ā€‹Medical Out-Of-Pocket (MOOP) Claim Form (Vietnamese) (PDF)ā€‹, available upon requestā€‹
ā€‹March 2022ā€‹
ā€‹ā€‹OA-HIPP/EB-HIPP/MPPPā€‹
ā€‹N/A
 ā€‹OA-HIPP Client Responsibilities (PDF)
 ā€‹September 2024
 ā€‹ā€‹ā€‹OA-HIPP
ā€‹ā€‹N/A
 ā€‹OA-HIPP Client Responsibilities (Spanish) (PDF)
 ā€‹September 2024
 ā€‹ā€‹ā€‹OA-HIPP
ā€‹ā€‹N/A
 ā€‹OA-HIPP Client Responsibilities  (Simplified Chinese) (PDF)
 ā€‹September 2024
 ā€‹ā€‹ā€‹OA-HIPP
ā€‹ā€‹N/A
 ā€‹OA-HIPP Client Responsibilities (Korean) (PDF)
 ā€‹September 2024
 ā€‹ā€‹ā€‹OA-HIPP
ā€‹ā€‹N/A
 ā€‹OA-HIPP Client Responsibilities (Tagalog) (PDF)
 ā€‹September 2024
 ā€‹ā€‹ā€‹OA-HIPP
ā€‹ā€‹N/A
 ā€‹OA-HIPP Client Responsibilities (Vietnamese) (PDF)ā€‹
 ā€‹September 2024ā€‹
 ā€‹ā€‹ā€‹OA-HIPP

Additional ADAP Forms

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

CDPH 8444 (PDF) ā€“ Client Handout Form

CDPH 8730 (PDF) - Confidential Fax Submissionā€‹

CDPH 8731 (PDF) - New Enrollment Worker Training Request Form

CDPH 9114 (PDF) - PrEP-AP Pharmacy User Training Requestā€‹
ā€‹ā€‹

Page Last Updated : June 24, 2025
PHAB
For General Public Information
  • (916) 558-1784
  • Contact Us
  • Web Accessibility Certification
  • Download PDF Viewer
  • Feedback
  • Jobs/Careers
  • Privacy Policy
  • Sitemap
  • Use Policy
Useful Links
  • Visit Governor's Website
  • State Agency Directory
  • CA Health & Human Services
  • Centers for Disease Control and Prevention
Visit CDPH on Instagram for the latest updates and health tips. Follow CDPH on Facebook to stay informed and connected. Explore professional updates and news from CDPH on LinkedIn. Watch health-related videos and get updates from CDPH on YouTube. Stay up to date with tweets and announcements from CDPH on X. Get the latest information and stay informed with CDPH on Bluesky. Connect and engage with CDPH on Threads to get the latest updates.