The Adap Colorado form is a vital document used to renew your enrollment in the Colorado AIDS Drug Assistance Program (ADAP). This program provides essential services such as medication assistance and health insurance support for individuals living with HIV. Completing this form is crucial to maintain your eligibility for these services, so be sure to fill it out by clicking the button below.
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 provides essential services, including Medication Assistance, Health Insurance Assistance, and Bridging the Gap, Colorado. Completing this form is mandatory, even if your enrollment has expired. It collects vital information to assess your eligibility for services funded by the Ryan White program. The form requires personal details such as your full legal name, date of birth, ethnicity, race, and preferred language. It also addresses changes in your living situation, health status, and household income. Additionally, the form inquires about your current health insurance status and any public assistance you may receive. Failure to submit this form may result in losing access to necessary medications and insurance support. Therefore, it is important to provide accurate and complete information, as the Colorado Department of Public Health and Environment (CDPHE) will review your eligibility twice a year, as mandated by federal law.
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
Filling out the Adap Colorado form is an important step in renewing your enrollment with the Colorado AIDS Drug Assistance Program. It’s essential to provide accurate information to ensure you continue receiving the assistance you need. Below are the steps to help you complete the form effectively.
Once you have completed the form, make sure to review your answers for accuracy. Then, return the application to the specified address or fax number. It's crucial to submit the form on time to maintain your eligibility for assistance.
The Adap Colorado form is used to renew your enrollment in the Colorado AIDS Drug Assistance Program (ADAP). This program provides assistance with medications, health insurance, and other related services for individuals living with HIV. Completing this form is essential, even if your enrollment has expired, as it helps ensure you continue to receive necessary support.
You must submit the Adap Colorado form twice a year. The Colorado Department of Public Health and Environment (CDPHE) requires this regular review to maintain your eligibility for the program. It’s crucial to submit the form on time to avoid any interruption in your medication or insurance assistance.
The form requests various details, including:
Be sure to complete all sections and provide any required documentation to support your application.
If you fail to submit the Adap Colorado form, you risk losing your medication and insurance assistance. The CDPHE and your regional AIDS Service Organization may discontinue your services if the form is not returned, which can significantly affect your access to necessary health care.
If you have questions while completing the Adap Colorado form, you can contact the CDPHE directly at 303-692-2716. They can provide guidance on how to fill out the form correctly and clarify any concerns you may have about the process.
Once you have completed the Adap Colorado form, return it to the following address:
CDPHE Care and Treatment Program ADAP-3800 4300 Cherry Creek Drive South Denver, CO 80246
You can also fax the completed form to 303-691-7736 if that is more convenient.
Incomplete Personal Information: Failing to provide all required personal details, such as full legal name, date of birth, and current address, can lead to delays in processing.
Missing Proof of Residency: Not attaching the necessary documentation to verify your current residential address may result in rejection of the application.
Incorrect Social Security Number: Entering an incorrect Social Security Number can cause complications in verifying eligibility.
Not Updating Changes: Failing to report changes in your living situation, such as homelessness or moving, may affect your eligibility.
Inaccurate Income Reporting: Providing incorrect income figures or failing to include all household members contributing income can lead to eligibility issues.
Neglecting to Indicate Health Insurance Status: Not clearly stating your current health insurance status can complicate the assessment of your application.
Omitting Emergency Contact Information: Not providing an emergency contact can hinder communication if issues arise with your application.
Ignoring Recertification Requirements: Forgetting to recertify every six months can lead to loss of assistance.
Failure to Answer All Questions: Leaving questions unanswered may result in delays or denial of assistance.
Not Seeking Help: Hesitating to ask for assistance when unsure about how to fill out the form can lead to mistakes that affect eligibility.
The Colorado AIDS Drug Assistance Program (ADAP) Recertification Form is a key document for individuals seeking to renew their enrollment. Along with this form, there are several other documents that may be required or helpful in the process. Below is a list of these documents, along with a brief description of each.
These documents work together to ensure that your application for the ADAP program is complete and accurate. Providing the necessary information can help avoid delays in receiving the assistance you need.
The Colorado Medicaid Application Form is similar to the ADAP Colorado form in that both documents require personal information to assess eligibility for health-related assistance. Applicants must provide details such as their full name, date of birth, and income information. Like the ADAP form, the Medicaid application also asks about current living situations and any changes in circumstances that may affect eligibility. Both forms emphasize the importance of accuracy and require proof of residency and income to ensure that applicants receive the appropriate support.
The Ryan White Program Application shares similarities with the ADAP Colorado form, particularly in its focus on providing assistance to individuals living with HIV/AIDS. Both documents require applicants to disclose their medical history, including current treatment and medications. Additionally, both forms collect information about household income and insurance coverage, which are crucial for determining eligibility for the services offered. The Ryan White Program also emphasizes the need for regular updates on the applicant's status, similar to the recertification process outlined in the ADAP form.
The Health Insurance Marketplace Application is akin to the ADAP Colorado form in that it collects detailed personal and financial information to determine eligibility for health insurance options. Both forms require applicants to provide information about their household composition, income, and any existing health coverage. The Marketplace application also includes questions about changes in circumstances, which aligns with the ADAP's need for updated information to maintain eligibility for assistance. Both forms ultimately aim to ensure that individuals have access to necessary healthcare resources.
The Supplemental Nutrition Assistance Program (SNAP) Application has a similar structure to the ADAP Colorado form, as it requires personal and household information to assess eligibility for food assistance. Applicants must provide their income details, living situation, and household composition. Both forms emphasize the importance of submitting accurate information and may require documentation to verify claims. The SNAP application also includes questions about changes in circumstances, which mirrors the ADAP's focus on maintaining up-to-date information for ongoing assistance.
The Temporary Assistance for Needy Families (TANF) Application parallels the ADAP Colorado form in its goal of providing financial support to low-income families. Both documents require applicants to disclose personal information, income, and household details to determine eligibility. The TANF application also asks about employment status and any changes in circumstances, similar to the questions found in the ADAP form. Both programs aim to assist individuals in achieving stability and improving their quality of life.
The Social Security Disability Insurance (SSDI) Application is similar to the ADAP Colorado form in that it collects comprehensive information to evaluate eligibility for financial assistance due to disability. Both forms require applicants to provide personal details, medical history, and information about their living situation. The SSDI application also emphasizes the need for documentation to support claims, akin to the requirements outlined in the ADAP form. Both programs aim to provide necessary support to individuals facing significant health challenges.
The Women, Infants, and Children (WIC) Program Application shares similarities with the ADAP Colorado form, particularly in its focus on providing assistance to vulnerable populations. Both documents require personal and household information to assess eligibility for nutritional support. The WIC application also includes questions about income and family composition, mirroring the structure of the ADAP form. Both programs aim to improve the health and well-being of their respective target populations through tailored assistance.
The Low-Income Home Energy Assistance Program (LIHEAP) Application is akin to the ADAP Colorado form in that both documents collect personal and financial information to determine eligibility for assistance. Applicants must provide details about their household income, living situation, and any changes that may affect their eligibility. The LIHEAP application also emphasizes the importance of accuracy and may require documentation to verify claims, similar to the requirements outlined in the ADAP form. Both programs aim to alleviate financial burdens on low-income households.
The Housing Choice Voucher Program (Section 8) Application parallels the ADAP Colorado form in its focus on providing assistance to individuals in need of housing support. Both forms require personal information, income details, and household composition to assess eligibility. The Section 8 application also includes questions about changes in circumstances, which aligns with the ADAP's emphasis on maintaining updated information for ongoing assistance. Both programs aim to help individuals secure stable housing and improve their quality of life.
The Unemployment Insurance Application is similar to the ADAP Colorado form in that it requires detailed personal and financial information to determine eligibility for assistance during periods of unemployment. Applicants must disclose their employment history, income, and any changes in circumstances that may affect their eligibility. The Unemployment Insurance application emphasizes the importance of providing accurate information and may require documentation to support claims, akin to the requirements outlined in the ADAP form. Both programs aim to provide financial support during challenging times.
When filling out the Adap Colorado form, it is essential to approach the process thoughtfully. Here are some guidelines to follow:
Following these guidelines can make the process smoother and ensure that your application is processed efficiently. Remember, your health and well-being are the priority.
This is not true. The form is mandatory for individuals seeking to renew their enrollment in the Colorado AIDS Drug Assistance Program (ADAP). Failure to submit it may result in the loss of medication and insurance assistance.
In reality, existing participants must also complete the form to maintain their eligibility. Even if your enrollment has expired, it is essential to use this form for recertification.
This is incorrect. The information you provide is treated with strict confidentiality. It is used only for the purpose of determining eligibility for the program and is not disclosed to unauthorized individuals.
Proof of residency is a requirement. Applicants must attach documentation that verifies their current residential address to ensure compliance with program eligibility criteria.
This is misleading. Changes in your personal situation, such as income or housing status, can affect your eligibility. It is crucial to inform ADAP of any changes promptly.
On the contrary, medical information is necessary for determining your eligibility for specific services under the program. This includes details about your HIV status and any related medical treatments.
Timely submission is vital. The Colorado Department of Public Health and Environment (CDPHE) requires recertification twice a year. Delays may jeopardize your access to necessary assistance.
Filling out the Adap Colorado form is an important step for individuals seeking assistance through the Colorado AIDS Drug Assistance Program. Here are key takeaways to keep in mind:
By keeping these points in mind, you can navigate the application process more effectively and ensure that you receive the necessary support.