New Jersey Department of Health

AIDS Drug Distribution Program (ADDP)

PO Box 722

Trenton, NJ 08625-0722

CERTIFICATION BY PHARMACIST

If you need assistance completing this form, call toll free 1-877-613-4533.

SECTION I ‑ TO BE COMPLETED BY APPLICANT

You must make an agreement with a Medicaid/PAAD participating pharmacist to dispense

FDA-approved AIDS-related drugs on your behalf. Please complete the requested

information in Section I. Forward to your pharmacist for completion of Section II.

Ask your pharmacist to return the completed form to you.
Name of Applicant

Social Security Number

Address

Date of Birth

Signature of Applicant

Date
SECTION II ‑ TO BE COMPLETED BY PHARMACIST

The individual named above has applied to the New Jersey Department of Health for participation in the

AIDS Drug Distribution Program. Please provide the following information regarding the applicant.

Return this completed Certification form to the applicant to submit along with the completed Application.
Name of Pharmacy

Telephone Number

Street Address

City, State, Zip Code

CERTIFICATION

I agree to dispense FDA‑approved AIDS/HIV‑related drugs to the applicant named above and accept reimbursement from the New Jersey Department of Health as payment in full.
Name of Pharmacist (Print)

Telephone Number

Pharmacist License Number

Pharmacy Medicaid/PAAD Provider Number

Signature of Pharmacist

Date

Applicant: Forward this completed Certification to ADDP, along with your completed Application.

DHAS-38

JUL 12

DHAS-38, Certification by Pharmacist

DHAS-38, Certification by Pharmacist, ADDP, AIDS drug distribution program, AIDS, HIV, STD and TB Services

EWhite

2001-03-12

NJDOH