Form CDPH8729 "Eligibility Exception Request (Eer) - Aids Drug Assistance Program (Adap)" - California

What Is Form CDPH8729?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8729 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8729 "Eligibility Exception Request (Eer) - Aids Drug Assistance Program (Adap)" - California

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State of California
California Department of Public Health
Health and Human Services Agency
AIDS DRUG ASSISTANCE PROGRAM (ADAP)
ELIGIBILITY EXCEPTION REQUEST (EER)
INSTRUCTIONS:
This form is used by a certified ADAP enrollment worker to request extended eligibility
for an ADAP client who is on a 30-day Temporary Access Period (TAP) and is unable to
obtain and submit required ADAP eligibility supporting documentation within the 30-day
TAP timeframe. This form should be used prior to the expiration of a client’s 30-day
TAP. Please complete all sections then submit to ADAP, along with any supporting or
follow-up documentation, by fax at (844) 421-8008 or by encrypted email to
CDPHMedAssistFax@cdph.ca.gov. Completed forms are processed in 1 business day.
ADAP CLIENT INFORMATION:
(Current Date)
(ADAP ID Number)
(Client First Name)
(Client Last Name)
(Date of Birth)
(Social Security Number, if applicable)
ADAP ENROLLMENT WORKER INFORMATION:
(Enrollment Worker First Name)
(Enrollment Worker Last Name)
(Enrollment Worker ID Number)
(Enrollment Site Name and Number)
(Phone Number)
(Fax Number)
(Enrollment Worker Email Address)
CDPH 8729 (06/17)
Page 1 of 2
State of California
California Department of Public Health
Health and Human Services Agency
AIDS DRUG ASSISTANCE PROGRAM (ADAP)
ELIGIBILITY EXCEPTION REQUEST (EER)
INSTRUCTIONS:
This form is used by a certified ADAP enrollment worker to request extended eligibility
for an ADAP client who is on a 30-day Temporary Access Period (TAP) and is unable to
obtain and submit required ADAP eligibility supporting documentation within the 30-day
TAP timeframe. This form should be used prior to the expiration of a client’s 30-day
TAP. Please complete all sections then submit to ADAP, along with any supporting or
follow-up documentation, by fax at (844) 421-8008 or by encrypted email to
CDPHMedAssistFax@cdph.ca.gov. Completed forms are processed in 1 business day.
ADAP CLIENT INFORMATION:
(Current Date)
(ADAP ID Number)
(Client First Name)
(Client Last Name)
(Date of Birth)
(Social Security Number, if applicable)
ADAP ENROLLMENT WORKER INFORMATION:
(Enrollment Worker First Name)
(Enrollment Worker Last Name)
(Enrollment Worker ID Number)
(Enrollment Site Name and Number)
(Phone Number)
(Fax Number)
(Enrollment Worker Email Address)
CDPH 8729 (06/17)
Page 1 of 2
REASON FOR ELIGIBILITY EXCEPTION:
Missing or incomplete identification document(s)
Missing or incomplete residency document(s)
Missing or incomplete diagnosis document(s)
Missing or incomplete income document(s)
Other (please explain):
QUESTIONS or COMMENTS:
Please contact the ADAP call center at (844) 421-7050
Monday through Friday, 8 a.m. — 5 p.m. (excluding holidays).
CDPH 8729 (06/17)
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