The Adap Colorado form is a critical document used to renew enrollment in the Colorado AIDS Drug Assistance Program (ADAP). This program provides essential services, including Medication Assistance and Health Insurance Assistance, to individuals living with HIV. Completing this form is necessary to maintain access to these vital resources and ensure continued eligibility for support.
The Adap Colorado form is a crucial document for individuals seeking to renew their enrollment in the Colorado AIDS Drug Assistance Program (ADAP). This program offers essential services, including medication assistance, health insurance assistance, and a bridging program to help those affected by HIV/AIDS. Completing this form is mandatory, even if your enrollment has lapsed. It collects vital information about your personal details, medical history, and financial status, which are necessary for determining your eligibility for continued support. Federal legislation mandates that the Colorado Department of Public Health and Environment (CDPHE) review client eligibility biannually. Failing to submit this form may jeopardize your access to medication and insurance assistance. The form also prompts you to disclose any recent changes in your living situation or health status that might affect your eligibility. Overall, it serves as a comprehensive tool to ensure that those in need receive the necessary resources to manage their health effectively.
Colorado AIDS Drug Assistance Program
Recertification Form
Use this form to renew your enrollment with the Colorado AIDS Drug Assistance Program (ADAP), which includes Medication Assistance, Health Insurance Assistance, and Bridging the Gap, Colorado. Use this form even if your enrollment has expired. Please complete all of the information requested on this form. Federal legislation requires the Colorado Department of Public Health and Environment (CDPHE) to review client eligibility twice a year. This form is not optional. If you do not return this form, you may lose your medication and/or insurance assistance from CDPHE and your regional AIDS Service Organization. This form is intended to inform us of any changes that may affect your eligibility for Ryan White funded Services.
1. Full Legal Name (Last):
(First):
(MI):
Has this changed in the last 6 months?
☐Y ☐ N
2.What is your date of birth? _______/________/____________ (MM/DD/YYYY)
3.What is your Ethnicity? ☐ Hispanic/ Latino(a) ☐ Non‐Hispanic ☐ Unknown ☐ Prefer Not To Answer
4.What is your Race? Check all that apply
☐ White
☐ Black or African/ African American
☐ Native American/Pacific Islander
☐ American Indian or Alaska Native
☐ Asian
☐ Unknown
☐ Prefer Not to Answer
5.What is your preferred language? ☐ English ☐ Spanish ☐ French ☐ Other _______________________
6.What is your gender?
☐Male ☐ Female ☐ Transgender, male to female ☐Transgender, female to male
7. Check if any of the following were true for you at any time in the past six months:
☐I became homeless
☐I moved into an institution (hospice, nursing home, etc.)
☐I moved into temporary housing
☐I was out of the state for more than 2 months
8. What is your current residential address?
May we contact you at this address?
Street Address (PO Boxes will NOT be accepted)
☐ Y
☐ N
City
County
COLORADO
ZIP Code
You must attach proof that you live at this address.
Please see the instructions for the kind of proof ADAP will accept.
9. What is your current mailing address?
Street Address (PO Boxes will be accepted, but not outside Colorado)
☐ Y ☐ N
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10. At what phone numbers can we reach you during daytime hours?
Phone Number (
)
☐ Home
☐ Work
☐ Cell Phone
May we leave a message on this phone? ☐ Y
☐N
11. Is there anyone that our staff may call if your mail is returned to us (or your phone number does not
work)? ☐ Y
Name:
Phone Number: (
Does this person know that you are HIV positive? ☐ Y ☐N
12. Do you have a case manager/social worker at an AIDS Service Organization or Medical Clinic? ☐ Y ☐N If yes, list them below:
Name
___
Agency/ Clinic ______________________________________
If you do not currently have one, would you like ADAP to make a referral to a case manager or social worker?
☐Y ☐N
13. What is your current relationship status?
☐Single ☐ Married ☐Divorced ☐Legally Separated ☐Other __________________
For ADAP purposes, "married" refers to legally recognized marriages in Colorado.
This information affects your income eligibility for ADAP.
14. How many children do you have living with you? ______ How many other children do you have that don’t
live with you for whom you provide 50% or more of their monthly support? ______
15 If you are female, are you pregnant? ☐ Y ☐N ☐ Not Applicable If yes, when are you due to deliver?___________(Month)
16. What is your Social Security Number (if you have one)? __________‐________‐______________
MEDICAL INFORMATION
17.Who currently writes your HIV medication prescriptions?
18.When was your last visit with your HIV doctor? Month_________ Year________
19. Have you ever been told by your doctor or a laboratory that you have AIDS?
☐ Not Sure
20. Have you ever been told that you have Hepatitis C?
21. In the past six months, have you had labs drawn to check your CD4 count?
22. In the past six months, have you had labs drawn to check your viral load?
☐N ☐ Not Sure
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Your CD4 counts and viral load results are reported directly to CDPHE by your laboratory. Federal legislation requires that these laboratory results be reported to the US Health Resources and Services Administration (HRSA). However, these numbers will NOT be linked to your name in this report to HRSA. We will submit this information to HRSA using a unique and anonymous ID number only. If you are new to Colorado, or if an in‐ state lab has not reported your CD4 and Viral Load to CDPHE, we will contact you to request written laboratory reports of these numbers.
HOUSEHOLD INCOME, ACCESS TO HEALTH INSURANCE, AND OTHER PUBLIC ASSISTANCE
23.
Did you apply for or receive Medicaid in the last 6 months?
If yes, when? ____/_____
Status of application: ☐ Approved ☐ Denied ☐ I am still awaiting decision about my Medicaid eligibility
24.
Did you apply for medical disability in the last 6 months?
Status of application: ☐ Approved ☐ Denied ☐ I am still awaiting decision about my disability status
25. Are you eligible for Medicare?
If yes, which Parts are you enrolled in?
☐PART A Effective Date ____/_____☐PART B Effective Date ____/____ ☐PART D Effective date ____/____
If you became Medicare‐eligible, you must submit an additional “Bridging The Gap, Colorado” application.
26. Are you enrolled/ enrolling in the Cover Colorado High Risk Insurance Plan?
Are you enrolled/ enrolling in the GettingUSCovered Colorado Pre‐existing Insurance Plan?
27. Which of the following best describes your employment status?
☐ Unemployed for more than 6 months
☐ Recently unemployed as of ______/_______/________
☐ Retired/Disabled
☐ Applying for Disability
☐ Self‐employed
☐ Other: ______________________________________
☐Employed by _____________________________________ and working _______ hours per week
28.
If employed, did you start this job within the last 6 months? ☐ Y ☐N ☐I am not employed
29.
Are you eligible for health insurance though your employer, spouse, or some other individual?
If yes, when did you become eligible? ____/_____ (mm/yyyy)
30.If you are eligible for health insurance (through your employer, spouse, or other individual) are you enrolled in it?
☐N/A ‐ I am not eligible for health insurance
☐Yes, I am enrolled
☐No, because it does not cover the services I need
☐No, because I'm afraid my employer would find out I'm HIV positive
☐No, because it's too expensive
☐No, because of a pre‐existing condition limitation
☐No, for another reason (explain) _____________
________________________________________
If you or your spouse are employed, and you are NOT already receiving assistance from ADAP for the costs
of health insurance, you will need to have your employer complete the
“Employer Insurance Information Form” on page 6 and attach it to your recertification form. A copy of this form must be filled out for each family member who is currently employed.
If you answered that you were worried your employer would find out about your HIV status, you will be
contacted by ADAP staff to discuss an alternative.
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31.Please use the tables below to describe the total monthly income for your household. Please provide your gross income (before deductions) rather than your net income. You will need to attach proof of all income listed in this table, whether earned by you or another member of your household. See the instructions for the types of proof that ADAP will accept.
Only include household members who contribute income to your household. Include income from your legally married spouse (question 13) and income earned by your children (question 14). Do NOT include other people living in your household unless you are under 18, in which case you need to list your parent or legal guardian’s income. Attach additional sheets if you have more than 4 people receiving income in your household.
Did you or your spouse work this month or expect to work next month? ☐ Y ☐ N
Include temporary and seasonal work and income from self‐employment. If you have no household income ($0)
from employment or from any other source, fill out “Statement of Support” on page 7.
Name of Worker
Start date
Is this work
Monthly Amount
Employer Name
temporary or
(you, spouse ,dependent, etc.)
(or continuing)
(average)
seasonal?
$
Did you, your spouse, or any dependent receive income from any of these other sources? ☐ Y ☐ N If yes, check all that apply and fill out this table:
□ Unemployment benefits
□ SSDI (Supplemental Security Disability Insurance)
□ Veterans benefits
□ Short/Long‐term disability
□ AND (Aid to the Needy Disabled)
□ Retirement/Pension
□ SSI (Supplemental Security Income) □ TANF (Temporary Aid to Needy Families)
□ Taxable trust income
□ Worker’s compensation
□ Interest/Investment Income
□ Alimony paid to you
□ Other (please describe): _________________________________________
THIS CHECK COMES TO:
Type of Benefit or Income from list above (for example, “SSI”)
(me, my spouse, my child, etc.)
(Gross Amount)
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ADAP Certification and Authorization of Release of Information
I certify that the information provided in this application is complete and accurate, to the best of my knowledge.
I understand that my failure to be accurate and complete may prevent or delay a determination of eligibility to receive assistance from ADAP.
I understand that, for the purposes of determining my eligibility for ADAP, the CDPHE, its contractors and subcontractors may request further documentation to verify my HIV positive serostatus, my Colorado residency, and my financial, employment or insurance information as necessary.
I authorize my prescribing physician, case manager, other departments and programs of the State of Colorado, and other information sources to release information necessary to complete the application process, to verify the accuracy of any information provided in this application, and to verify my ongoing eligibility for ADAP. I further authorize the CDPHE to utilize data from public health records to verify that I am living with HIV.
I authorize the CDPHE to release information to my physicians, case manager, treatment centers, and other healthcare providers to facilitate provision of ADAP services.
I understand and agree to submit periodic information regarding my continued eligibility for ADAP, including proof of income, proof of residency, health insurance coverage, and general updates on forms provided by the CDPHE. I understand that changes in my situation will be evaluated to determine my continued eligibility for ADAP. I will be notified in writing if I am to be discontinued from ADAP.
I agree to notify, or have my case manager notify, the CDPHE of any circumstances affecting my participation in, or eligibility for, ADAP. I agree to notify the CDPHE within thirty (30) days if I change my address or other preferred contact information. I further authorize the CDPHE to contact the persons listed as “Emergency Contact” on this form if the CDPHE’s attempts to contact me have been unsuccessful.
I understand that I am to recertify for ADAP twice per year in a timely manner at my birth month and six months after my birth month.
I understand that my ADAP eligibility will terminate if:
-I do not cooperate with efforts to verify information in this application, or
-I do not comply with the activities needed to identify/verify potential sources of alternative coverage, or
-I fail to seek other forms of coverage, as instructed by the CDPHE, for which I may be eligible, or
-The CDPHE becomes aware of material misrepresentation, withheld information, or documented fraud, or
-Qualifying medication is no longer being prescribed to me.
I understand that the CDPHE reserves the right at any time and without notice to modify the ADAP application form.
I understand that my assistance through all CDPHE programs is contingent on state and federal funding. This funding is limited and may expire at any time without extended or alternative funds being available.
I understand that completing this application does not ensure that I will qualify for this program.
I understand that my name, address and any other personal identifying information provided in this application will be available to the CDPHE and its contractors and subcontractors, and that this information will not be disclosed to anyone else, except as required or permitted by law.
I understand that I have a right to ask for a full hearing if I feel that a decision on my eligibility was unfair or incorrect of if I believe CDPHE staff or contractors discriminated against me based on my age, race, ethnicity, sex, gender identity, disability, religion, nationality, or sexual orientation.
I understand that pursuant to the Colorado Governmental Immunity Act, C.R.S. § 24‐10‐101 et seq., the CDPHE is not liable for damages for any injury arising out of my participation in ADAP.
I understand that I may revoke this authorization at any time in writing.
However, the release shall remain valid until such time as I inform the ADAP, in writing, of my wish to terminate services through the program, or until such time as I no longer qualify for these services, whichever occurs first, except to the extent that action has been taken in reliance on this authorization.
A copy of this authorization has the same effect as the original.
_____________________________
___________________________________________
__________
Applicant Name (Please Print)
Signature of Applicant or Parent/Guardian
Date
Return this application to: CDPHE Care and Treatment Program
ADAP-3800, 4300 Cherry Creek Drive South, Denver, CO 80246
Fax: 303-691-7736 Phone: 303-692-2716
Employer Insurance Information Form
APPLICANT: This form is required if you or your spouse are employed and you have said that you are not eligible for or enrolled in health insurance. This may be because your employer does not offer health insurance, you are not eligible for specific reasons, or the insurance does not cover needed services. A copy of this form must be provided for every family member that is currently employed.
EMPLOYER: Please complete this form, have an authorized representative sign it, and return the form to the employee. This information will need to be provided every six months.
EMPLOYEE NAME:
EMPLOYER (Business Name)
To be completed by the EMPLOYER:
1. Do you offer a health insurance plan to any of your employees?
□ Yes □ No
If NO, skip to the signature portion of this form
If YES, to whom was the health insurance offered, and was it accepted?
If not eligible, explain if this person could become eligible in the
□ Not eligible
future, and when (e.g., becomes full time).
Employee
□ Offered, but not accepted
□ Offered and accepted
Potential eligibility date: ___/____/_______
Spouse
future, and when (e.g., employee becomes full time).
Name(s):
_____________
Dependent(s)
If not eligible, explain if dependents could become eligible in the
2. What is the date for your company’s next open enrollment period? ____/_____/_____
When does coverage begin after open enrollment? _____/______/______
COMMENTS: ______________________________________________________________________________
Please attach a copy of your employee benefits summary or other plan information, if available.
EMPLOYER REPRESENTATIVE
TITLE:
PHONE:
COMPLETING THIS FORM:
EMPLOYER’S AUTHORIZED SIGNATURE
DATE:
EMPLOYER: Please return this form to the employee along with explanation of benefits
STATEMENT OF SUPPORT FOR ____________________________ (NAME OF APPLICANT)
COMPLETE THIS FORM ONLY IF YOU CANNOT PROVIDE PROOF OF RESIDENCY IN YOUR NAME
OR YOU REPORT $0 HOUSEHOLD INCOME
SECTION 1 – IF SOMEONE ELSE PROVIDES YOU WITH SUPPORT, HAVE HIM/HER FILL OUT THIS PART OF THE FORM AND HAVE HIM/HER SIGN IN SECTION 3. THIS PERSON MUST PROVIDE PROOF
THAT THEY RESIDE AT THE ADDRESS LISTED.
Name of person providing support:
______________________________________
What is your relationship to the applicant?
Legally married in the State of Colorado
Domestic partner/civil union/partner
His/her parent (biological or adoptive)
His/her child (biological or adoptive)
Other relative (brother, sister, aunt, uncle, brother‐in‐law, mother‐in‐law, etc.)
Other (friend, neighbor, etc.)
Type of support provided for free or minor charge (check all that apply):
Lodging
Food
Telephone
Other (describe): ___________________
For what part of the past 12 months did the applicant live in your household? _____________
On your most recent U.S. Tax Return, did you claim the applicant as a dependent?
Yes
No
Have not filed a U.S. Tax Return
Please provide current contact information so we can contact you to verify any information.
Mailing Address: _________________________________
___________________________________________________
Daytime Phone (____) ____ ‐ ________
SECTION 2 – IF YOU HAVE $0 OF HOUSEHOLD INCOME AND ARE NOT RECEIVING SUPPORT FROM ANY OTHER INDIVIDUAL, COMPLETE THIS PART OF THE FORM AND SIGN IN SECTION 3.
Explain how you cover the costs of the following: Housing/shelter ___________________________
___________________________
Food ___________________________
Transportation ___________________________
Telephone ___________________________
Utilities ___________________________
Other
(cigarettes, etc.) ___________________________
If you are living off of savings, please provide a bank statement or describe why such documentation is not available (for example, your savings is in the form of cash or a reloadable credit card):
____________________________________
SECTION 3 – LEGALLY BINDING SIGNATURE
By signing below, I assert that the contents of this form are complete and accurate, to the best of my knowledge. I acknowledge that intentional misrepresentations in this form may constitute an attempt to defraud the State of Colorado, which could result in severe criminal and civil penalties. I authorize the State of Colorado to contact me
and to conduct other research necessary to verify the accuracy of the statements made on this form.
______________________________
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Support Provider Signature
Applicant Signature
The Colorado AIDS Drug Assistance Program (ADAP) Recertification Form is an essential document for individuals seeking to renew their enrollment in the program. Along with this form, several other documents are often required to ensure that applicants receive the necessary assistance. Below is a list of these forms and documents, along with a brief description of each.
Each of these documents plays a vital role in the application process for the ADAP program. Ensuring that all necessary paperwork is completed and submitted accurately can significantly impact the assistance you receive. If you have any questions about these forms or the application process, reaching out to a case manager or ADAP representative can provide clarity and support.
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Completing the Adap Colorado form is an essential step for individuals seeking to renew their enrollment in the Colorado AIDS Drug Assistance Program. It is important to ensure that all sections are filled out accurately and completely, as this information directly impacts your eligibility for assistance. Following the steps below will help you navigate the form effectively.
Once you have completed the form, review it carefully to ensure all information is accurate and all necessary documentation is attached. Submit the form to the address provided at the end, or you may choose to fax it if that is more convenient. Remember, staying on top of this process is crucial for maintaining your assistance.
The Colorado AIDS Drug Assistance Program (ADAP) Recertification Form shares similarities with the Medicaid Recertification Form. Both documents require individuals to provide personal information, including their full legal name, date of birth, and current residential address. They also ask for updates on health status and any changes in circumstances that may affect eligibility for assistance. Additionally, both forms necessitate proof of income and residency, ensuring that applicants meet the necessary criteria for continued support.
Another comparable document is the Social Security Disability Insurance (SSDI) Application. Like the ADAP form, the SSDI application requires detailed personal information, including medical history and current living situation. Both forms aim to assess eligibility for assistance based on financial and medical needs. They also emphasize the importance of providing accurate information and may require supporting documentation to verify claims, ensuring that applicants receive the benefits they qualify for.
In the ever-evolving landscape of financial support and credit access, a variety of application forms play crucial roles, akin to the Business Credit Application form utilized by enterprises seeking financial resources. Just as businesses must meticulously outline their financial situations and histories to lenders, individuals navigating health and social assistance programs similarly provide detailed personal information to secure vital support. For those aiming to streamline their process of obtaining necessary business credit, resources such as OnlineLawDocs.com can be invaluable in ensuring that all essential forms and documents are accurately prepared and submitted.
The Supplemental Nutrition Assistance Program (SNAP) Application is also similar to the ADAP form. Both documents require applicants to disclose household income and expenses, as well as information about family members. They aim to determine eligibility for government assistance programs designed to support individuals in need. The SNAP application, like the ADAP form, includes questions about changes in circumstances that could impact eligibility, ensuring that assistance is appropriately allocated based on current needs.
Furthermore, the Temporary Assistance for Needy Families (TANF) Application bears resemblance to the ADAP form. Both forms require personal details, income verification, and updates on household composition. They are designed to assess eligibility for financial assistance programs aimed at supporting low-income families. The TANF application, similar to the ADAP form, also includes questions about employment status and any changes that may affect ongoing eligibility for assistance.
Lastly, the Health Insurance Marketplace Application aligns with the ADAP Recertification Form in its focus on health coverage. Both documents require applicants to provide information about their current health insurance status and any changes in income or household composition. They aim to determine eligibility for health-related assistance programs, ensuring that individuals have access to necessary medical care. The Marketplace application, like the ADAP form, emphasizes the importance of updating information regularly to maintain eligibility for coverage and support.
The ADAP Colorado form is designed for individuals seeking to renew their enrollment in the Colorado AIDS Drug Assistance Program. This program provides critical support, including medication assistance, health insurance assistance, and bridging services for individuals living with HIV. Completing this form is mandatory, even if previous enrollment has expired. The Colorado Department of Public Health and Environment (CDPHE) requires this information to assess client eligibility, which is reviewed twice a year as mandated by federal legislation.
The form requires a variety of personal information to determine eligibility. Key sections include:
Completing all sections accurately is crucial for maintaining eligibility for assistance.
Failure to submit the ADAP Colorado form may result in the loss of medication and/or insurance assistance. The CDPHE relies on this information to ensure that clients remain eligible for services. If the form is not returned, clients risk being discontinued from the program, which could lead to significant challenges in accessing necessary health care and medications.
Clients are required to recertify their eligibility for the ADAP program twice a year. This process should be completed in the month of your birthday and six months thereafter. Timely recertification is essential to ensure uninterrupted access to assistance. It is important to keep track of these dates and submit the required information promptly.
If there are any changes in your situation—such as changes in income, residency, or health status—it is imperative to notify the CDPHE as soon as possible. The form includes a section for reporting changes, and timely updates are necessary to maintain eligibility for assistance. Clients are encouraged to communicate any significant life changes that could affect their participation in the program.
When filling out the Adap Colorado form, it is essential to follow specific guidelines to ensure your application is processed smoothly. Here are ten things to do and avoid:
By adhering to these guidelines, you can help facilitate the review process and maintain your eligibility for the Colorado AIDS Drug Assistance Program.