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Ghsa medical eligibility form

Medical eligibility form 2026

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The document outlines the Uninsured Care Programs offered by the New York State Department of Health, specifically targeting individuals who are HIV positive. It includes a Medical Eligibility Form that must be completed by a physician to determine a patient's eligibility for various assistance programs, such as the AIDS Drug Assistance Program and HIV Home Care Program. The form requires detailed patient and physician information, medical history related to HIV, and verification of the provided information.

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Click ‘Get Form’ to open it in the editor.
Begin with the 'Patient Information' section. Enter the patient's name, address, date of birth, and social security number. Ensure all details are accurate and clearly printed.
Proceed to 'Physician Information and Verification'. Fill in the physician's name, DEA number, NYS license number, and contact information. The physician must sign and date this section to verify the information provided.
In 'Medical Information', answer all questions regarding disease staging and history. This includes providing CD4+ counts, viral load results, and any relevant medical history. Attach lab reports as required.
Review all sections for completeness before submitting. If you have questions about medical eligibility, refer to the provided hotline.

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