ADAP Client Application Forms
Client Application Forms
General ADAP Forms
Residency Documentation
CDPH 8727
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Residency Verification Affidavit (PDF)
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August 2023
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ADAP/PrEP-AP
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CDPH 8727 SP
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Residency Verification Affidavit (Spanish) (PDF)
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August 2023
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ADAP/PrEP-AP
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CDPH 8727 ZHS
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Residency Verification Affidavit (Simplified Chinese) (PDF), available upon request
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November 2023
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ADAP/PrEP-AP
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CDPH 8727 KO
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Residency Verification Affidavit (Korean) (PDF), available upon request
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November 2023
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ADAP/PrEP-AP
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CDPH 8727 TL
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Residency Verification Affidavit (Tagalog) (PDF), available upon request
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November 2023
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ADAP/PrEP-AP
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CDPH 8727 VI
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Residency Verification Affidavit (Vietnamese) (PDF), available upon request
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November 2023
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ADAP/PrEP-AP
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Identity Documentation
Clinical Documentation
Income Documentation
Eligibility Exception Request and Temporary Access Period Forms
Insurance Assistance Program Forms
Additional
ADAP Forms
CDPH 8689 (PDF) - Agreement by Employee/Contractor to Comply with Confidentiality Requirements
CDPH 8444 (PDF) – Client Handout Form
CDPH 8730 (PDF) - Confidential Fax Submission
CDPH 8731 (PDF) - New Enrollment Worker Training Request Form
CDPH 9114 (PDF) - PrEP-AP Pharmacy User Training Request