DOH Form 150-103 "Agreement, Release of Information & Assignment of Benefits - Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap)" - Washington

What Is DOH Form 150-103?

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 May 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 150-103 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download DOH Form 150-103 "Agreement, Release of Information & Assignment of Benefits - Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap)" - Washington

Download PDF

Fill PDF online

Rate (4.7 / 5) 28 votes
Page background image
Pre-Exposure Prophylaxis Drug Assistance Program (PrEP DAP)
Agreement, Release of Information & Assignment of Benefits
DOH 150-103 May 2017
SECTION 5: Agreement, Release of Information & Assignment of Benefits
Eligibility:
To be eligible for PrEP DAP, you must meet certain conditions. Please check the boxes that best describe your current risk for
HIV-1 infection. I am a person who:
Is male or transgender who has sex with men and has one or more of the following risks: (Check all that apply)
Diagnosis of rectal or urethral gonorrhea, rectal chlamydia or early syphilis in the prior 12 months
Methamphetamine or popper use in the prior 12 months
History of providing sex for money, drugs, food, shelter or transportation in the prior 12 months
Unprotected anal sex outside of a long-term, mutually monogamous relationship
Is in an ongoing sexual relationship with an HIV-infected person who:
Is not on antiretroviral therapy (ART)
Is on ART but is not virologically suppressed
Is within 6 months of initiating ART
Is on ART and is virologically suppressed
Is in an ongoing sexual relationship in which the female partner is trying to get pregnant
Is a woman who provides sex for money, drugs, food, shelter or transportation
Injects drugs that are not prescribed by a medical provider
Agreement:
I am applying for services (coverage of TRUVADA®) from the PrEP Drug Assistance Program (PrEP DAP). By signing at the end of
this section, I state that I have read and understand this application and agree to the following:
I have a right to:
• Be treated with respect, consideration and honesty.
• Receive PrEP DAP services without discrimination on the basis on race, color, sex/gender, ethnicity, national origin, religion, age,
class, sexual orientation or physical or mental ability.
• Have my records protected and treated confidentially.
• File an appeal about eligibility and coverage decisions.
I have the responsibility to:
• Treat PrEP DAP staff with respect, consideration and honesty.
• Give true, correct and complete information.
• Adhere to medically recommended testing and treatment, including all activities recommended in current PrEP standards of practice.
I understand that:
• I must use a pharmacy approved by the State of Washington Department of Health.
• I must notify PrEP DAP of any changes that affect my eligibility. These changes include address, health insurance coverage and
risk conditions. I must send this notice within 20 days of the change. Failure to do so can lead to eligibility termination.
• PrEP DAP funding is limited. Services may change or end with short notice. Currently, only Truvada® is covered through the
program. Truvada® is covered either at full cost (with approval) or co-pay (if insured).
• If I give false or incomplete information PrEP DAP may deny or stop my eligibility. I may have to pay for services I received if I
was not eligible for them.
• PrEP DAP will use other state and federal data systems and other information to verify the information I give them.
• I must respond to PrEP DAP requests for information. Failure to do so can lead to eligibility termination or denial.
Release of Information:
I give my permission for PrEP DAP to share information from this application and from documentation obtained by PrEP DAP with
contracted providers, pharmacies, case managers, navigators, contracted vendors and family/friends I listed in the Authorized
Representative section of this application. I give this permission for one year and 60 days from the date I sign this authorization.
Assignment of Benefits:
I hereby assign to the Washington State Department of Health any right to drug or medical benefits to which I may be entitled under
any other plan of assistance or insurance from any other eligible third party. I consent to the assignment of these benefits to the
Washington State Department of Health and I understand the Washington State Department of Health is entitled to repayment for
incorrectly provided benefits or benefits to which a third party is liable.
____________________________________________________
______________________________________
Applicant or Legal Guardian Signature
Today’s Date (mm/dd/yyyy)
(Do Not Leave Blank)
(Do Not Leave Blank)
Client Name: ____________________________ PrEP DAP ID: _____________
PAGE 1
For people 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)
Agreement, Release of Information & Assignment of Benefits
DOH 150-103 May 2017
SECTION 5: Agreement, Release of Information & Assignment of Benefits
Eligibility:
To be eligible for PrEP DAP, you must meet certain conditions. Please check the boxes that best describe your current risk for
HIV-1 infection. I am a person who:
Is male or transgender who has sex with men and has one or more of the following risks: (Check all that apply)
Diagnosis of rectal or urethral gonorrhea, rectal chlamydia or early syphilis in the prior 12 months
Methamphetamine or popper use in the prior 12 months
History of providing sex for money, drugs, food, shelter or transportation in the prior 12 months
Unprotected anal sex outside of a long-term, mutually monogamous relationship
Is in an ongoing sexual relationship with an HIV-infected person who:
Is not on antiretroviral therapy (ART)
Is on ART but is not virologically suppressed
Is within 6 months of initiating ART
Is on ART and is virologically suppressed
Is in an ongoing sexual relationship in which the female partner is trying to get pregnant
Is a woman who provides sex for money, drugs, food, shelter or transportation
Injects drugs that are not prescribed by a medical provider
Agreement:
I am applying for services (coverage of TRUVADA®) from the PrEP Drug Assistance Program (PrEP DAP). By signing at the end of
this section, I state that I have read and understand this application and agree to the following:
I have a right to:
• Be treated with respect, consideration and honesty.
• Receive PrEP DAP services without discrimination on the basis on race, color, sex/gender, ethnicity, national origin, religion, age,
class, sexual orientation or physical or mental ability.
• Have my records protected and treated confidentially.
• File an appeal about eligibility and coverage decisions.
I have the responsibility to:
• Treat PrEP DAP staff with respect, consideration and honesty.
• Give true, correct and complete information.
• Adhere to medically recommended testing and treatment, including all activities recommended in current PrEP standards of practice.
I understand that:
• I must use a pharmacy approved by the State of Washington Department of Health.
• I must notify PrEP DAP of any changes that affect my eligibility. These changes include address, health insurance coverage and
risk conditions. I must send this notice within 20 days of the change. Failure to do so can lead to eligibility termination.
• PrEP DAP funding is limited. Services may change or end with short notice. Currently, only Truvada® is covered through the
program. Truvada® is covered either at full cost (with approval) or co-pay (if insured).
• If I give false or incomplete information PrEP DAP may deny or stop my eligibility. I may have to pay for services I received if I
was not eligible for them.
• PrEP DAP will use other state and federal data systems and other information to verify the information I give them.
• I must respond to PrEP DAP requests for information. Failure to do so can lead to eligibility termination or denial.
Release of Information:
I give my permission for PrEP DAP to share information from this application and from documentation obtained by PrEP DAP with
contracted providers, pharmacies, case managers, navigators, contracted vendors and family/friends I listed in the Authorized
Representative section of this application. I give this permission for one year and 60 days from the date I sign this authorization.
Assignment of Benefits:
I hereby assign to the Washington State Department of Health any right to drug or medical benefits to which I may be entitled under
any other plan of assistance or insurance from any other eligible third party. I consent to the assignment of these benefits to the
Washington State Department of Health and I understand the Washington State Department of Health is entitled to repayment for
incorrectly provided benefits or benefits to which a third party is liable.
____________________________________________________
______________________________________
Applicant or Legal Guardian Signature
Today’s Date (mm/dd/yyyy)
(Do Not Leave Blank)
(Do Not Leave Blank)
Client Name: ____________________________ PrEP DAP ID: _____________
PAGE 1
For people 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).