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  • Ny Doh-3608 2008

Get Ny Doh-3608 2008-2025

Physician Signature MUST BE ACTUAL SIGNATURE DATE ON THE BACK OF THIS FORM PLEASE PROVIDE THE INFORMATION REQUESTED. IF YOU HAVE ANY QUESTIONS ABOUT MEDICAL ELIGIBILITY PLEASE CONTACT OUR TOLL FREE HOTLINE 1-800-542-2437. WHEN COMPLETED PLEASE RETURN TO EMPIRE STATION P. O. BOX 2052 ALBANY NY 12220-0052 DOH-3608 11/08 Page 1 of 2 MEDICAL INFORMATION Please Answer All Questions Patient s Name DOB SECTION I - DISEASE STAGING Is the applicant HIV in.

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DOH-2794 Questions & Answers

Get answers to your most pressing questions about US Legal Forms API.

Contact support

For questions regarding your ADAP and ADAP Plus coverage, call 1-800-542-2437 or 1-844-682-4058.

Dental and Vision Plans: Dental plans can be covered only if a client is already enrolled in OA-HIPP for a health insurance plan. Vision insurance can also be paid but only if included as part of a combined health or dental plan.

Applicants apply to the program, providing proof of residency and income. A Medical Application signed by a licensed medical professional is required, verifying HIV status. A treatment plan by a physician must also be submitted for Home Care applicants.

The AIDS Drug Assistance Program (ADAP) is a statewide, federally funded prescription medication program for low-income people living with HIV. This program provides access to medications to eligible uninsured clients or by purchase of health insurance that includes coverage for HIV medications.

Eligibility Criteria Medical: HIV-infection or at risk of acquiring HIV infection consistent with the guidelines for Pre-Exposure Prophylaxis. Residency: New York State (U.S. citizenship is not required.) Financial: Financial eligibility is based on 500% of the Federal Poverty Level (FPL).

For questions regarding your ADAP and ADAP Plus coverage, call 1-800-542-2437 or 1-844-682-4058.

Required Documentation Income Verification (one or more of the following): Three (3) current paycheck stubs. Three (3) current bank statements. SSI or SSDI letter.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232