Section 692.15  Application Requirements

Applications for participation in ADAP shall be submitted on forms provided by the Department.  Information requested on the application will include, but not be limited to:

a)         Patient information, including marital status, race/ethnicity, pregnancy information, and risk factors;

b)         Residency information, including mailing address and prescription address, if different from mailing address;

c)         Demographic (name, date of birth, relationship) and income information on household members who qualify as legal dependants to the ADAP applicant, and who may also contribute to the household income, which would  affect the federal poverty level for the applicant as defined by ADAP's federal partner, the United States Health Resources and Services Administration (HRSA);

d)         Applicant's income information, including, but not limited to:

1)         Gross monthly income, from sources such as wages, unemployment compensation, Social Security, Social Security Disability, veterans' pension, veterans' disability, private disability, workers' compensation, temporary assistance for needy families, general assistance, retirement income, child support, alimony or other spousal support, or any/or all other sources of income provided by the applicant;

2)         Documentation of income from paycheck stubs, benefit statement, award letter, court order, federal tax return, or other documentation provided by the applicant or available to the Department;

e)         Medical provider information, including, but not limited to, HIV physician, prescribing physician if HIV physician does not prescribe HIV medication, and ADAP liaison (individual to contact on applicant's behalf);

f)         Insurance/benefit information, including, but not limited to, prescription insurance, Medicare,  Medicare Part D, Medicare Supplement, Medicaid, Illinois Cares Rx, and veterans' benefits;

g)         Clinical information, including, but not limited to, current diagnosis, initial diagnosis, most recent CD4 count, and most recent viral load count; and

h)         Client verification and authorization to release confidential information.

(Source:  Added at 36 Ill. Reg. 3909, effective February 22, 2012)