Office of AIDS

Health Insurance Premium Payment (OA-HIPP) Program Forms

OA-HIPP is subsidy program that pays monthly health insurance premiums for eligible clients.   

Required forms for all clients

• OA-HIPP Program Application (CDPH 8522) (PDF)

• IAS Consent Form (CDPH 8685) (PDF)
• ARIES OA-HIPP / OA-PCIP Client Consent Form (CDPH 8454) (PDF)

Additional Resources

• OA HIPP Brochure (PDF)
• Payee Data Record (STD 204) (PDF)
• OA-HIPP Client Responsibilities (PDF) 
• IAS Fax Coversheet (PDF) - This coversheet must accompany all faxes sent to CDPH/IAS.  Faxed documents submitted without this coversheet will be discarded.
• Enrollment Worker Confidentiality Agreement - CDPH 8689 (PDF)- This form must be submitted by each certified enrollment worker once every two years.
• Partial Payment Agreement OA-HIPP Program - CDPH 8722 (PDF)- This form must be submitted by clients who have a monthly insurance premium that exceeds the OA-HIPP program threshold.

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