Ghsa Medical Eligibility Form

HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS HOPWA CLIENT MEDICAL ELIGIBILITY FORM CLIENT S NAME DATE SOCIAL SECURITY NUMBER ADDRESS Dear Doctor The person named above has applied for assistance through our Housing Opportunities for Persons With AIDS HOPWA program. Please fill out the information below pertaining to this client s HIV/AIDS status and mail it directly to the address below in an envelope identifying your practice and its address as soon as possible. Client Has AIDS Date of Initial AIDS Diagnosis As Defined by the CDC Client Does Not Have AIDS Date of Most Recent HIV Test Client is HIV Is the patient able to work Yes No Approximately how long will the patient be unable to work The Florida Fraud Law states that a person who knowingly aids and abets another person in obtaining aid or benefits under a state or federally funded assistance program by failing to disclose a material fact used in making a determination as to such a person s qualifications to receive aid or benefits is guilty of a punishable crime. I hereby certify that the above-name individual is my patient and that he/she has tested HIV or has AIDS as defined by the Centers for Disease Control CDC. Physician s Name print Signature Clinic/Hospital/Healthcare Agency Florida License Number Telephone -1Form H40 9/2/03 AIDS without opportunistic infection CD 4 Absolute count of less than OR Clients CD 4 count percentage AIDS with opportunistic infection Indicate below which opportunistic infections the client has had* Please initial after every opportunistic infection designated* Infection Candidiasis of bronchi lungs or trachea Candidiasis esophageal Cervical cancer invasive Coccidioidomyocis disseminated or extrapulmonary Cryptococcosis extrapulmonary Cryptosporidiosis chronic intestinal 1 mo. duration Cytomegalovirus disease other than liver spleen nodes Encephalopathy HIV-related Herpes simplex chronic ulcer s 1 mo. duration or bronchitis pneumonitis or esophagitis Histoplasmosis disseminated or extrapulmonary Isosporiasis chronic intestinal 1 mo. duration Kaposis s sarcoma Lymphoma Burkitt s or equivalent term Lymphoma immunoblastic or equivalent term Lymphoma primary of brain Mycobacterium avium complex or M. kansasii disseminated or extrapulmonary Pneumonia recurrent Progressive multifocal leukoencephalopathy Salmonella septicemia recurrent Toxoplasmosis of brain Wasting syndrome due to HIV Consent for Release and Exchange of Information Client s Naame information regarding my medical condition for the purpose of qualifying me for the Housing Opportunities for Persons illnesses/opportunistic infections I have had* I understand that to be eligible for HOPWA assistance there must be medical evidence as defined by the Centers for Disease Control that I have AIDS* Client s Signature Date. Client Has AIDS Date of Initial AIDS Diagnosis As Defined by the CDC Client Does Not Have AIDS Date of Most Recent HIV Test Client is HIV Is the patient able to work Yes No Approximately how long will the patient be unable to work The Florida Fraud Law states that a person who knowingly aids and abets another person in obtaining aid or benefits under a state or federally funded assistance program by failing to disclose a material fact used in making a determination as to such a person s qualifications to receive aid or benefits is guilty of a punishable crime. I hereby certify that the above-name individual is my patient and that he/she has tested HIV or has AIDS as defined by the Centers for Disease Control CDC.