New Jersey Department of Health

AIDS Drug Distribution Program (ADDP) /

Health Insurance Continuation Program (HICP)	CERTIFICATION BY PHYSICIAN
If you need assistance completing this form, call toll free 1‑800-353-3232.
SECTION I ‑ TO BE COMPLETED BY APPLICANT

Please complete the requested information in Section I. Forward to your physician for

completion of Section II. Ask your physician to return the completed form to you.
Name

Social Security Number

Street Address

Date of Birth

City, State, Zip Code

PERMISSION FOR RELEASE OF INFORMATION

I hereby give permission to my physician to release the requested information to the New Jersey Department of Health for the purpose of determining my eligibility to participate in the AIDS Drug Distribution Program (ADDP) or Health Insurance Continuation Program (HICP).
Signature of Applicant	Date

SECTION II ‑ TO BE COMPLETED BY PHYSICIAN

The individual named above has applied to the New Jersey Department of Health for participation in the AIDS Drug Distribution Program or Health Insurance Continuation Program. Please provide the following information regarding the above applicant. Return this completed Certification form to the applicant to submit along with the completed Application.
1.	Is the applicant HIV+ (lab confirmed)?	Yes	No
2.	Does the applicant meet CDC criteria for AIDS?	Yes	No
3.	Date of the most recent T Helper (CD4+) lymphocyte count test (if test not done use "00/00"; if unknown use "99/99"):
/
Month
Year
a. Absolute CD4+ lymphocyte count for the above test:	cells/mm3
4.	Date of the most recent viral load test (if test not done use "00/00"' if unknown use "99/99"):
/
Month
Year
a. Viral load:	Results
5.	HIV Risk Factor(s) – please check appropriate category(ies):	Male who has sex with male(s)
Injecting drug user
Hemophilia/coagulation disorders
Heterosexual contact
Perinatal transmission
Undetermined/unknown, risk not reported or identified
Receipt of transfusion of blood, blood components or tissue
Other, specify:
CERTIFICATION

I hereby certify that the above-named applicant has a medical necessity to obtain FDA-approved AIDS/HIV-related drugs.
Name of Physician (Print)

License Number and State

Street Address

Telephone Number

City, State, Zip Code

Signature

Date

DHAS-37

MAR 13	Applicant: Forward this completed Certification to ADDP/HICP along with your completed Application.

DHAS-37, Certification by Physician

DHAS-37, Certification by Physician, ADDP, HICP, AIDS, AIDS Drug Distribution Program, HIV, STD and TB Services, medication, Health Insurance Continuation Program

EWhite

2001-03-12

NJDOH