Colorado Public Health Intervention Program Application & Recertification Form Use this form to apply, or RECERTIFY for the Public Health Intervention Program (PHIP). This program is intended to support with prescription costs and medical expenses related to Pre-exposure Prophylaxis (PrEP), It allows participating providers and pharmacies to bill the program directly and electronically for any eligible services they provide our clients. Please complete all of the information requested on this form. IT IS IMPORTANT THAT YOU UNDERSTAND THAT THIS PROGRAM IS UNDER DEVELOPMENT. THE MEDICAL BENEFIT IS NOT IN PLACE AT MOST PROVIDERS AT THIS TIME.

(First):

1. Full Legal Name (Last):

(Middle Initial): Name I Prefer to be Called:

2. What is your date of birth? _______/________/____________ (MM/DD/YYYY) 3. a) Current Gender: ☐ Male ☐ Female ☐ Transgender, Male to Female ☐ Transgender, Female to Male b) Gender at Birth ☐Male ☐Female ☐ Other:_________________________ 4. Ethnicity ☐Non-Hispanic/Latino ☐ Hispanic/Latino (please specify):

☐Mexican ☐Puerto Rican ☐ Cuban ☐Other Hispanic 5. Race (check all that apply): ☐ Asian (please specify): ☐ White ☐ Black ☐American Indian/Alaskan Native ☐ Other ________________________

☐ Asian Indian ☐Chinese ☐Filipino ☐ Korean

☐Japanese

☐Vietnamese ☐Other

☐ Native Hawaiian/ Pacific Islander (please specify): ☐Native Hawaiian

☐Guamanian

☐Samoan

6. What is your preferred language? ☐ English ☐ Spanish ☐ French ☐ Other ____________________ May we contact you at this address? 7. Mailing Address (PO Boxes are permissible if no local delivery) ☐Y ☐ N

City

Colorado

ZIP Code:

County

By signing below, I attest that the address provided above is my current address. I understand the State of Colorado may request additional information to check on the accuracy of this information: X________________________________________

Date: _______________________________ May we leave a message?

8. At what phone numbers can we reach you during daytime hours? Phone Number (

)

☐ Home ☐ Cell Phone

Phone Number (

)

☐ Home ☐ Cell Phone

☐Y ☐Y

☐N ☐N

9. Email Address: _______________________________________________ ☐Y

10. Is there anyone that our staff may call if we are unable to reach you? Name: Page 1

Phone Number: (

☐N

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PrEP (pre-exposure prophylaxis) Screening Questions: The answers to these questions will be used to determine whether the PHIP will be able to provide financial assistance for the applicant to access services. Are you currently taking PrEP to lower your risk of becoming infected with HIV? ☐Y ☐N Are you currently living with HIV?

☐Y

☐N

Are you having sex with only one partner who has tested HIV negative in the past 3 months? Are you currently having sex with someone who is living with HIV? ☐ Y

☐Y

☐N

☐N

Which of the following have you done in the PAST SIX MONTHS? Check ALL that apply. Please be honest; PHIP is designed to assist people with very high HIV risk, so failure to disclose higher risk activities may exclude you from receiving PHIP financial assistance.  Had condomless anal or vaginal sex with a man who had sex with other men  Been diagnosed with a sexually transmitted infection  Injected drugs and used needles, syringes, or other drug preparation equipment that had already been used by another person  Been in a methadone or other medication-based drug treatment program  Had condomless anal or vaginal sex with someone who injects drugs  Exchanged sex for something of value 12. At which clinic are you currently receiving your HIV or STD prevention services? If you aren’t currently receiving such services, write “NONE”. 13. What is the name of your doctor or nurse practitioner? 14. Which of the following best describes your employment status? ☐ Unemployed for more than 60 days ☐ Recently unemployed (less than 60 days) ☐ Retired/Disabled

☐ Self-employed

☐ Other: __________________________________

☐ Employed, working MORE than 32 hours a week ☐ Employed, working LESS than 32 hours a week 15. Does your employer offer health insurance? ☐ Yes, I am enrolled ☐ Yes, but I have not enrolled. REASON: ________________________ ☐ My employer does not offer insurance coverage 16. What type of health insurance do you currently have?  Private (either through employer or the Marketplace) ☐ Medicaid

☐ Medicare ☐ I do not currently have any health insurance

If you do not have health insurance, how interested are you in enrolling when it becomes available? O O O O O O O O O Not interested Neutral/Not Sure Very interested How much money would you be willing to spend each month to have health insurance? $ ___________________

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17. Please use the table below to provide your best estimate of your GROSS monthly income. You will need to provide proof of one paystub for verification. Include income from your legally married spouse and income earned by your children. Do NOT include other people living in your household. If you are under 18, please list your parent or legal guardian’s income. Use the table below to report any income you or your spouse receive 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 8. Sources of income other than employment include: 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, or Alimony paid to you. Call the SDAP HelpDesk at (303) 692-2716. Name of Worker (You, spouse, dependent, etc.)

Employer Name

Start date (or continuing)

Is this work temporary or seasonal?

Monthly Gross Amount (estimate)

☐Y ☐N

$

☐Y ☐N

$

☐Y ☐N

$

☐Y ☐N

$

Participation in PrEP Retention Program Colorado Department of Public Health and Environment provides a wide range of services designed to support ongoing access to PrEP. The PHIP program provides financial assistance, but we also know there will be other types of assistance needed, like finding a prescriber, getting reminders to fill prescriptions, and counseling about relationship issues that may come up when you are on PrEP. As part of your enrollment in PHIP, you will be contacted about these additional services and will have a chance to sign up for services that meet your needs. At a minimum, each PHIP enrollee must agree to brief quarterly check-ins about their experiences and needs around PrEP, which may take place by email, text, or traditional mail.

Would you like to receive future recertification reminders electronically? ☐ Y ☐ N If you checked yes, please go to www.safeplussound.org to set a reminder to recertify eleven (11) months from today. You will still get your assistance card in the mail, but instead of receiving a paper application mailing every year, you will receive a text or email reminder. Staff use only: Does this client need referral for any of the following? ____Referral to PrEP Physician Page 3

____Insurance screening and support

____Enrollment in QHP v11302015

PHIP Certification and Authorization of Release of Information 

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I understand that Preexposure Prophylaxis (PrEP) or Post exposure Prophylaxis (PEP) taken to avoid HIV infection is not 100% effective. I understand that I cannot hold CDPHE or any of my other providers responsible should I still become infected with the HIV virus or other Sexually Transmitted Diseases. 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 the Public Health Intervention Program (PHIP) I understand that, for the purposes of determining my eligibility for PHIP, the CDPHE, its contractors and subcontractors may request further documentation to verify my Colorado residency, and my financial, employment or insurance information as necessary. I authorize my prescribing physician, PrEP support agency, 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 PHIP. I authorize the CDPHE to release information to my physicians, PrEP Support staff, treatment centers, and other healthcare providers to facilitate provision of PHIP services. I understand and agree to submit periodic information regarding my continued eligibility for Colorado PHIP, including proof or attestation 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 PHIP I agree to notify the CDPHE of any circumstances affecting my participation in, or eligibility for, PHIP. 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 “a contact” on this form if the CDPHE’s attempts to contact me have been unsuccessful. I understand that I am to recertify for PHIP yearly in a timely manner at my birth month. I understand that my PHIP 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, or PrEP supportive services 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 fail to maintain minimum level of involvement in other PrEP support services. I understand that the CDPHE reserves the right at any time and without notice to modify the PHIP application form. I understand that my assistance through all CDPHE programs is contingent on state 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, PrEP claim history, and any other personal health information provided while I am applying for or enrolled in PHIP 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 PHIP. I understand that I may revoke this authorization at any time in writing. PLEASE REMEMBER TO However, the release shall remain valid until such time as I inform the PHIP, in NOTIFY SDAP IF writing, of my wish to terminate services through the program, or until such ANYTHING IN THIS time as I no longer qualify for these services, whichever occurs first, except to APPLICATION CHANGES 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 PHIP-3800, 4300 Cherry Creek Drive South, Denver, CO 80246 Fax: 303-691-7736 Phone: 303-692-2716 Page 4

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