Help you qualify for 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the Demographics section. Fill in your legal first name, middle name, last name, and preferred name. Provide your date of birth and select your current gender and sex at birth.
3. Complete the contact information fields, including home address, mailing address (if different), phone numbers, and email. Ensure all details are accurate for effective communication.
4. In the Health Insurance Information section, indicate whether you have private insurance or Medicare. Provide plan names and numbers where applicable.
5. For Household and Income Information, specify your household size and total annual income. Describe your housing status clearly.
6. Fill out the HIV Care section with details about your healthcare providers and type of medical care used.
7. Review the Client Agreements and Consent to Services section carefully. Initial each statement to confirm understanding before signing the form.
8. Attach all required documents as listed in the Attachments section to complete your application.

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