Form DOH-3608 "Uninsured Care Programs - Medical Eligibility Form" - New York

What Is Form DOH-3608?

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

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the New York State Department of 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 printable version of Form DOH-3608 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-3608 "Uninsured Care Programs - Medical Eligibility Form" - New York

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NEW YORK STATE DEPARTMENT OF HEALTH
AIDS Institute
Uninsured Care Programs
Empire Station, P.O. Box 2052
Uninsured Care Programs – Medical Eligibility Form
Albany, NY 12220-0052
SU MEDICO NECESITA ESTA FORMA
INSTRUCTIONS: This form must be completed by the attending clinician. The information will be used to determine the patient’s eligibility
to receive assistance through the Uninsured Care Programs. Questions related to medical eligibility should be directed to the New York
State Department of Health’s Uninsured Care Programs toll-free hotline at 1-800-542-2437 or 1-844-682-4058. When completed, mail
the form to: Empire Station, P.O. Box 2052, Albany, New York 12220-0052.
Uninsured Care Programs
AIDS Drug Assistance Program (ADAP-Medications)
ADAP Plus (Primary Care)
ADAP Plus Insurance Continuation (APIC)
HIV Home Care Program
Pre-exposure Prophylaxis Assistance Program (PrEP-AP)
Patient Information
Last Name _______________________________________ First Name ________________________________ M.I.______
Street Address________________________________________________________________________ Apt. No. _________
City________________________________________________________________ State___________ ZIP ____________
Date of Birth (Month/Day/Year) ________________________ Social Security Number _________________________________
Home Phone ( _____ ) ______________________________ Alternate Phone ( _____ ) _______________________________
Practitioner Information and Verification
Last Name _______________________________________ First Name ________________________________ M.I.______
NPI Number ______________________________________ NYS License Number ___________________________________
Hospital or Facility _________________________________ Medicaid Number _____________________________________
Address_____________________________________________________________________________________________
City________________________________________________________________ State___________ ZIP ____________
Office Phone ( _____ ) ______________________________
Name of Alternate Contact for Medical Follow-up________________________________________________________________
Alternate Contact Phone ( _____ ) ______________________ E-mail Address _______________________________________
On the back of this form, please provide the information requested. If you have any questions about medical eligibility, please contact our
toll-free hotline 1-800-542-2437 or 1-844-682-4058. When completed please return to:
EMPIRE STATION
P.O. BOX 2052
ALBANY, NY 12220-0052
DOH-3608 (3/18) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
AIDS Institute
Uninsured Care Programs
Empire Station, P.O. Box 2052
Uninsured Care Programs – Medical Eligibility Form
Albany, NY 12220-0052
SU MEDICO NECESITA ESTA FORMA
INSTRUCTIONS: This form must be completed by the attending clinician. The information will be used to determine the patient’s eligibility
to receive assistance through the Uninsured Care Programs. Questions related to medical eligibility should be directed to the New York
State Department of Health’s Uninsured Care Programs toll-free hotline at 1-800-542-2437 or 1-844-682-4058. When completed, mail
the form to: Empire Station, P.O. Box 2052, Albany, New York 12220-0052.
Uninsured Care Programs
AIDS Drug Assistance Program (ADAP-Medications)
ADAP Plus (Primary Care)
ADAP Plus Insurance Continuation (APIC)
HIV Home Care Program
Pre-exposure Prophylaxis Assistance Program (PrEP-AP)
Patient Information
Last Name _______________________________________ First Name ________________________________ M.I.______
Street Address________________________________________________________________________ Apt. No. _________
City________________________________________________________________ State___________ ZIP ____________
Date of Birth (Month/Day/Year) ________________________ Social Security Number _________________________________
Home Phone ( _____ ) ______________________________ Alternate Phone ( _____ ) _______________________________
Practitioner Information and Verification
Last Name _______________________________________ First Name ________________________________ M.I.______
NPI Number ______________________________________ NYS License Number ___________________________________
Hospital or Facility _________________________________ Medicaid Number _____________________________________
Address_____________________________________________________________________________________________
City________________________________________________________________ State___________ ZIP ____________
Office Phone ( _____ ) ______________________________
Name of Alternate Contact for Medical Follow-up________________________________________________________________
Alternate Contact Phone ( _____ ) ______________________ E-mail Address _______________________________________
On the back of this form, please provide the information requested. If you have any questions about medical eligibility, please contact our
toll-free hotline 1-800-542-2437 or 1-844-682-4058. When completed please return to:
EMPIRE STATION
P.O. BOX 2052
ALBANY, NY 12220-0052
DOH-3608 (3/18) Page 1 of 2
Medical Information Please Answer All Questions
Patient’s Name __________________________________________________ Date of Birth___________________________
1. Is the applicant HIV infected?
Yes
No
Date of First Positive Test _________________________________________
To be eligible for assistance under PrEP-AP, the patient must have a documented negative HIV test result and be at risk of acquiring
HIV infection.
2. Does the applicant now have or ever had:
Hepatitis A
Hepatitis B
Hepatitis C
3. Risk(s):
IVDU
Sexual Abuse/Assault
Sexual Contact with:
Transfusion/Blood Product
Health Care Setting
Male
Other
Mother to Child
Female
Unknown
Person with HIV/AIDS
IVDU Partner
Complete PrEP, ARV and Hepatitis C, prescribing and
monitoring guidelines are available at www.hivguidelines.org
Practitioner Verification
I verify that the information on this application is true to the best of my knowledge.
Practitioner’s Signature (Must be actual signature) _________________________________________ Date ________________
DOH-3608 (3/18) Page 2 of 2
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