CONFIDENTIAL

New Jersey Department of Health

Division of HIV, STD AND TB Services

HIV Home Care Program

APPLICATION FOR ELIGIBILITY

Please PRINT clearly. Answer all questions. See instructions for specific items.

INITIAL APPLICATION	RENEWAL APPLICATION	CLIENT ID #

SECTION I ‑ APPLICANT INFORMATION
1. Name of Applicant (Last)	(First)	(MI)

2. Sex (M/F)

3. Birth Date
/	/
4. Street Address

5. Social Security Number

6. City	State	Zip Code

7. County

8. How long have you lived at this address?	9. Is this your principal place of residence?

Yes No	10. Telephone Number (Incl. Area Code)

( )
Years	Months
11. Have you been tested positive for HIV?

Yes No	12. Have you been diagnosed with AIDS?

Yes No	13. Date of Application
If Yes, what is the date of the test?

(Use 99/99 if month or year is unknown)	If Yes, what is the date of the test?

(Use 99/99 if month or year is unknown)
/	/
Month / Day / Year
/
/
Month / Year	Month / Year
SECTION II ‑ CURRENT INSURANCE COVERAGES/BENEFITS
14. Have you applied for, or are you enrolled in, Supplemental Security Income (SSI) benefits?
Yes No
If Yes, please check the status of your enrollment:
Status:	SSI Application in Process	Date Sent:	/	/
SSI Approved	Date Enrolled:	/	/
SSI Denied	Date Denied:	/	/
Appealing for SSI	Date Appealed:	/	/
Reapplying for SSI	Date Reapplied:	/	/
Reason Denied:
15. Have you applied for, or are you enrolled in, Social Security Disability (SSD) benefits?
Yes No
If Yes, please check the status of your enrollment:
Status:	SSD Application in Process	Date Sent:	/	/
SSD Approved	Date Enrolled:	/	/
SSD Denied	Date Denied:	/	/
Appealing for SSD	Date Appealed:	/	/
Reapplying for SSD	Date Reapplied:	/	/
Reason Denied:

CONFIDENTIAL

APPLICATION FOR ELIGIBILITY

(Continued)

CLIENT ID #

16. Have you applied for, or are you enrolled in, the AIDS Community Care Alternatives Program (ACCAP)?
Yes No
a. If Yes, please check the status of your enrollment:
Status:	Application in Process	Date Sent:	/	/
ACCAP Approved	Date Enrolled:	/	/
ACCAP Denied	Date Denied:	/	/
If denied, please check the reason denied:
Not Medically Eligible
Not Financially Eligible
Not Medically/Financially Eligible
Not Eligible for ACCAP
Other (Specify):
a. If Yes, ID Number:
a. If Yes, will the HIV Home Care Program be supplementing ACCAP?
Yes No
17. Have you applied for, or are you enrolled in, Jersey Care?
Yes No
If Yes, please check the status of your enrollment:
Status:	Application in Process	Date Sent:	/	/
Jersey Care Approved	Date Enrolled:	/	/
Jersey Care Denied	Date Denied:	/	/
18. Do you have State Medicaid?
Yes No
If Yes, please provide the following information:
ID Number:
Name of Program:
Effective Date:	/	/
19. Do you have Medicare A (Hospital Insurance)?
Yes No
If Yes, please provide the following information:
ID Number:
Name of Program:
Effective Date:	/	/

CONFIDENTIAL

APPLICATION FOR ELIGIBILITY

(Continued)

CLIENT ID #

20. Do you have Medicare B (Medical Insurance)?
Yes No
If Yes, please provide the following information:
ID Number:
Name of Program:
Effective Date:	/	/
21. Have you applied for, or are you enrolled in, other health insurance coverage?
Yes No
If Yes, please provide the following information:
Date Application Sent:	/	/
Date of Enrollment:	/	/
ID Number:
Name of Company, Employer, or Plan:
Address:
Type of Plan:	Major Medical
Supplement to Medicare
Other (Specify):
SECTION III ‑ HOUSEHOLD / INCOME INFORMATION
22. Number of persons living in household:	23. Gross Monthly Income for Household from ALL Sources	24. Specify the proof of income you are providing with this application:

$
25. List Household Members
Name
Relationship

CONFIDENTIAL

APPLICATION FOR ELIGIBILITY

(Continued)

CLIENT ID #

SECTION IV ‑ CERTIFICATION AND AUTHORIZATION
A.	I understand that I must be diagnosed as having AIDS or HIV infection and that the Program covers adults, adolescents and children. I authorize the release of medical records necessary to determine my eligibility.

B.	I will notify the Program immediately if my/our income rises above allowable limits, if I move from New Jersey or if I become eligible for reimbursement under other health insurance/payment mechanisms, including either institutional or community based Medicaid services.

C.	I authorize the release of information necessary to determine my eligibility from the records in possession of the Social Security Administration, the Internal Revenue Service, the New Jersey Division of Taxation, employers, banks and others as the need arises.

D.	I understand that I may be visited by representatives of the Program in order to determine my/our satisfaction with the services being provided for use in Program evaluation and planning.

E.	I certify that the information provided in this application is true and correct to the best of my knowledge.

F.	I understand that the Program is entitled to repayment for incorrectly provided benefits. I further understand that I will be held liable for the costs of any benefits which are determined to have been incorrectly provided based on fraudulent, incorrect, or incomplete information provided in this application.

G.	I further understand that home care services are based upon availability of funds.
Signature (or Mark) of Applicant	Date
Name of Witness (Print)
Signature of Witness	Date
Name of Preparer, if Other Than Applicant (Print)
Signature of Preparer	Date
Name of Person to Contact if Questions Arise	Telephone Number

IMPORTANT:

Detach and retain Instruction page. It contains important information regarding your Rights of Appeal should you be determined ineligible for participation in this program.

DAPC‑54

FEB 97 Page 4 of 4 Pages.

DHAS-8

JUL 12	Page 4 of 4 Pages.

DHAS-8, Application for Eligibility - HIV Home Care Program

DHAS-8, application for eligibility, HIV home care program, HIV, AIDS, HIV, STD and TB Services, DHAS

Elaine White

2003-12-09

ewhite

NJDOH