skip to content

It's a New Day in Public Health.

The Florida Department of Health works to protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.

skip to content

Eligibility Information

HIV/AIDS

ELIGIBILITY  INFORMATION FOR
HIV/AIDS PATIENT CARE PROGRAMS

This website presents eligibility requirements and procedures, which are the same for the following programs.  

Acrobat Reader* please note all files open in a new window and are less than 5mb in size.

The Florida HIV/AIDS Ryan White Part B Eligibility Procedures Manual was developed in conjunction with statute and eligibility rule requirements.
 
When determining Ryan White Part B Core Eligibility, this manual:
•    Provides eligibility staff with standardized procedures and forms
•    Applies only to the patient care programs under the Department of Health (DOH), HIV/AIDS Section, in conjunction with Chapter 64D-4, F.A.C.
•    Ensures persons requesting services from the patient care programs have been appropriately determined eligible or ineligible
•    Does not preclude local, state, or federal programs from adopting the requirements and procedures referenced in this document

HIV/AIDS patient care programs include the following:
•    Ryan White Part B Consortia and Patient Care Networks (PCN)
•    Ryan White Part B AIDS Drug Assistance Program (ADAP)
•    Ryan White Part B ADAP Premium Plus Insurance
•    State Housing Opportunities for Persons With AIDS (HOPWA) Program

Additional programmatic qualifications and requirements can be found in each program’s respective manual or guidelines.


Attachments

All files are pdf/doc format and under 5mb in size. All files open in a new window

Attachment

Name

Requirement

List of Attachments

Attachment Summary

Required

Attachment A

Ryan White Program Definitions of Eligible Services

N/A

Attachment B

DH 1120, Acceptable Use and Confidentiality Agreement

Required

Attachment C

DH 3204 Initiation of Services

Required

Attachment D1

DH 150-741, Notice of Privacy Practices

Required

Attachment D2

DH 150-741, Notice of Privacy Practices Acknowledgment Form

Required

Attachment E

DHOGC 3203, Authorization to Disclose Confidential Information

Required

Attachment F

Core Eligibility Requirements Brochure (English, Spanish, and Creole)

N/A

Attachment G

DH 150-884, Eligibility Application

Required

Attachment H

Eligibility Staff Assessment Worksheet

Required

Attachment I

Six Month Recertification Review Form

Required

Attachment J

DH 8000-PHSPM, Notice of Eligibility

Required

Attachment K

Notice of Ineligibility

Required

Attachment L

Insurance Waiver Form

Required

Attachment M

Self Employment Tracking Sheet

Required


Additional Resource:
2015 Federal Poverty Guidelines and FPL Calculator
(Note: U.S. Federal Poverty Guidelines are updated annually) 

Please see http://aspe.hhs.gov/poverty-guidelines for the most current federal poverty thresholds.