Medical eligibility form 2026

1. Click ‘Get Form’ to open the medical eligibility form in the editor.
2. Begin by entering the client’s name and date at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill in the social security number and address fields. This information helps verify the client's identity and residency.
4. Indicate whether the client has AIDS or is HIV positive by checking the appropriate boxes. Provide dates where required, such as the initial AIDS diagnosis or most recent HIV test.
5. Complete the section regarding work capability by selecting 'Yes' or 'No' and estimating how long the patient will be unable to work.
6. If applicable, detail any opportunistic infections by initialing next to each infection listed. This section is vital for assessing medical eligibility.
7. Finally, ensure that a physician completes their details, including signature and license number, before submitting.

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