DOH Form 150-101 "HIV & Health Status Information Form - Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap)" - Washington

What Is DOH Form 150-101?

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

Form Details:

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

Download a printable version of DOH Form 150-101 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download DOH Form 150-101 "HIV & Health Status Information Form - Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap)" - Washington

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Pre-Exposure Prophylaxis Drug Assistance Program (PrEP DAP)
HIV & Health Status Information Form
HIV & HEALTH STATUS INFORMATION (HHSI)
HIV and health status must be confirmed in order to process your application. This section must be completed by you AND your
health care provider who is prescribing PrEP to you. Please submit this form to us with this application or ask your health care
provider to send it directly to us by mail or fax.
Call (800) 272-2437 if you have questions about this form.
Client Section – To be Completed by the Client –
Signature and Date R EQUI RED
Last Name
First Name
Applicant or Legal Guardian Signature
Date of Birth
Today’s Date
(do not leave blank)
(do not leave blank)
____ / ____ / ____
____ / ____ / ____
I authorize my health care provider to release the information on this form to the Washington State
Department of Health.
Required Health Care Provider Section – To be Completed by the Health Care Provider
Please answer the following questions about the patient:
(For HIV – test date, new applicants date must be within 14 days, for renewing participants date must be within 90 days)
Is your patient HIV-negative?
Yes
No
Date of the last HIV-negative test: ____ / ____ / ____
Please tell us which of the following eligibility risk factors apply to your patient:
Does your patient have sex with men?
Yes
No
In the last 12 months has your patient tested positive for chlamydia, gonorrhea or syphilis?
Yes
No
If Yes, tell us which one(s):
Chlamydia
Gonorrhea
Syphilis
In the last 12 months has your patient used methamphetamines (crystal, tina, crank, ice)?
Yes
No
In the last 12 months has your patient used poppers (alkyl or amyl nitrates)?
Yes
No
In the last 12 months, did your patient have sex without using a condom with anyone they did not consider to be a main/primary partner?
Yes
No
Is your patient in an ongoing sexual relationship with a partner who you know to be HIV-positive?
Yes
No
Is the patient’s partner on HIV medications?
Yes
No
Is the patient’s partner trying to get pregnant?
Yes
No
In the last 12 months, has your patient exchanged sex for things like money or drugs?
Yes
No
In the last 12 months, has your patient injected or shot up any drugs not prescribed by a health care provider?
Yes
No
Briefly share any information you would like PrEP DAP to consider when making the patients eligibility determination
By signing below, you:
• Declare that you are the health care provider for the patient named above
• Confirm that you have evidence of the patient’s HIV status and risk
• Understand and will follow current standards of care for PrEP
• Prescribed TRUVADA® to this patient
• Certify the information on this form is accurate and complete to the best of your knowledge.
Provider Signature: ____________________________________
Today’s Date: ____ / ____ / ____
(Do Not Leave Blank)
(Do Not Leave Blank)
Please provide us with information about your practice:
Provider Name:
Facility Name:
Facility Phone:
Provider/Facility Email:
Facility Full Address:
Mail or Fax this form to: PrEP DAP, PO BOX 47840, Olympia WA 98504 – FAX: 360-664-2216
DOH 150-101 November 2017
Client Name: ___________________________________________ PrEP DAP Client ID: __________________
For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY call 711).
Pre-Exposure Prophylaxis Drug Assistance Program (PrEP DAP)
HIV & Health Status Information Form
HIV & HEALTH STATUS INFORMATION (HHSI)
HIV and health status must be confirmed in order to process your application. This section must be completed by you AND your
health care provider who is prescribing PrEP to you. Please submit this form to us with this application or ask your health care
provider to send it directly to us by mail or fax.
Call (800) 272-2437 if you have questions about this form.
Client Section – To be Completed by the Client –
Signature and Date R EQUI RED
Last Name
First Name
Applicant or Legal Guardian Signature
Date of Birth
Today’s Date
(do not leave blank)
(do not leave blank)
____ / ____ / ____
____ / ____ / ____
I authorize my health care provider to release the information on this form to the Washington State
Department of Health.
Required Health Care Provider Section – To be Completed by the Health Care Provider
Please answer the following questions about the patient:
(For HIV – test date, new applicants date must be within 14 days, for renewing participants date must be within 90 days)
Is your patient HIV-negative?
Yes
No
Date of the last HIV-negative test: ____ / ____ / ____
Please tell us which of the following eligibility risk factors apply to your patient:
Does your patient have sex with men?
Yes
No
In the last 12 months has your patient tested positive for chlamydia, gonorrhea or syphilis?
Yes
No
If Yes, tell us which one(s):
Chlamydia
Gonorrhea
Syphilis
In the last 12 months has your patient used methamphetamines (crystal, tina, crank, ice)?
Yes
No
In the last 12 months has your patient used poppers (alkyl or amyl nitrates)?
Yes
No
In the last 12 months, did your patient have sex without using a condom with anyone they did not consider to be a main/primary partner?
Yes
No
Is your patient in an ongoing sexual relationship with a partner who you know to be HIV-positive?
Yes
No
Is the patient’s partner on HIV medications?
Yes
No
Is the patient’s partner trying to get pregnant?
Yes
No
In the last 12 months, has your patient exchanged sex for things like money or drugs?
Yes
No
In the last 12 months, has your patient injected or shot up any drugs not prescribed by a health care provider?
Yes
No
Briefly share any information you would like PrEP DAP to consider when making the patients eligibility determination
By signing below, you:
• Declare that you are the health care provider for the patient named above
• Confirm that you have evidence of the patient’s HIV status and risk
• Understand and will follow current standards of care for PrEP
• Prescribed TRUVADA® to this patient
• Certify the information on this form is accurate and complete to the best of your knowledge.
Provider Signature: ____________________________________
Today’s Date: ____ / ____ / ____
(Do Not Leave Blank)
(Do Not Leave Blank)
Please provide us with information about your practice:
Provider Name:
Facility Name:
Facility Phone:
Provider/Facility Email:
Facility Full Address:
Mail or Fax this form to: PrEP DAP, PO BOX 47840, Olympia WA 98504 – FAX: 360-664-2216
DOH 150-101 November 2017
Client Name: ___________________________________________ PrEP DAP Client ID: __________________
For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY call 711).