Pre-Exposure Prophylaxis Assistance Program (PrEP-AP)
Acceptable Supporting Documentation
One item from each section is required unless otherwise indicated. Additional documents may be needed to determine eligibility.
Proof of Identity*
- Driver's License
- State or local ID card (e.g., DMV issued ID, Municipal ID, student ID, or an ID from the Department of Corrections (CAL-ID))
- U.S. Passport
- Permanent Residence Card
- Employment authorization card
- Military ID card
- Photo ID issued by a foreign government (e.g., voter registration card, passport, or consulate ID card)
- Birth certificate (only if client does not have one of the ID's listed above)
- Provider Verification of Identity form (PDF)
*Expired cards may be used if no other form of picture ID is available.
Proof of Residency*
These documents must be dated within thirty days, be in the client’s name, and include the client’s residential address:
- California rent or mortgage receipt
- Current utility bill with the service address listed in California (a cell phone bill is not acceptable)
- Employment paycheck stub
These documents must be dated within one year, be in the client’s name, and include the client’s residential address:
- Rental/lease agreement or annual lease renewal documentation
- Voter registration card
- Vehicle registration (not expired)
- W-2 or 1099 (prior tax year documents will be accepted until February 15. After February 15, only current tax documents will be accepted.)
- Social Security/Disability Award Letter (SSI, SSDI)
- California Employment Development Department (EDD) award letter
- Filed State or Federal tax return
- Public housing letter on official letterhead from Housing and Urban Development (HUD) or a county agency
- Notice of Action from the Department of Health Care Services
*Clients who do not have the above residency documentation may prove residency by completing and submitting the Residency Verification Affidavit form. A letter from the client’s PrEP-AP enrollment worker, an agency letterhead and containing the same information as found on the Residency Verification Affidavit (PDF)
form, is also acceptable.
HIV Negative Status
Must be dated within 6 months of PrEP-AP application.
- HIV negative lab result (lab results must be a print out from a lab, a medical record from a provider or rapid HIV Test stating the client’s name, test result, and test date)
- Copy of Patient Assistance Program approval letter (uninsured clients only)
- Patient Assistance Program Application signed by a PrEP-AP Network Provider (uninsured clients only)
- PrEP-AP Provider Referral Form (PDF) signed by a PrEP-AP Network Provider (uninsured clients only)
Proof of Income
Income documentation for all household members is required.
- Household members include:
- An applicant,
- An applicant's spouse or registered domestic partner (RDP), and
- Any tax dependents of the applicant, spouse or RDP.
- Preferred income documents for establishing Modified Adjusted Gross Income (MAGI) include:
- Federal tax returns (current and previous year only) and
- State tax returns (current and previous year only).
In addition to state and federal tax returns, IRS Form 2555 Foreign Earned Income must be submitted if applicable. If a federal or state tax return is not available to establish MAGI, then applicants may submit gross income documentation for all household members.
- Filed Federal or State tax return with W-2, 1099 or Schedule C (PrEP-AP will not accept a tax return without a W- 2, 1099 or Schedule C unless the return is signed or accompanied by proof of electronic submission)
- Form SSA-1099 Social Security Benefit Statement may be accepted without additional accompanying documents for clients with Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).
Gross Income Documents
- Pay stubs documenting three current consecutive months of income
- Three consecutive months; of current paystubs, or
- One paystub showing Year-To-Date (YTD) earnings that includes at least three months' of income, and the employment start date
- Payment/ weekly summaries or bank statements documenting three current consecutive months of income from clients who work for companies (i.e., Uber, Lyft, etc.) as independent contractors (self-employed). Payment/weekly summaries must clearly show the payment transactions are from the company the client works for and contain:
- The person's first and last name and company name
- Dates covered and the gross income from profit/ loss
- Private disability award letter (dated within one year)
- Supplemental Security Income (SSI) award letter (dated within one year)
- Social Security Disability Income (SSDI) award letter (dated within one year)
- Bank statement showing direct deposit of Unemployment Insurance, SSI/SSDI benefits. Statement must be dated within one month and clearly identify the deposit/income source (e.g., US Treasury, SSA)
- State Disability Insurance (SDI) award letter (dated within one year)
- Social Security Retirement Benefit award letter (dated within one year)
- Retirement/Pension award letter (dated within one year)
- Unemployment Insurance (UI) award letter (dated within one year)
- Spousal support court documentation
- Worker's Compensation award letter (dated within one year)
- Investment income documentation (e.g., statement or portfolio summary dated within one month)
- Veteran's Administration Benefits (VA) award letter (dated within one year)
- Rental income documentation (e.g., a signed rental agreement dated within the last year or three current bank statements showing rental income deposits)
- Employer statement (must be on company letterhead, signed by the employer and dated within 45 days of PrEP-AP application, and include, name of employer or company, name and title of person writing the letter, employer or company address and phone number, date of the letter, start date and if applicable, the end date of the employee's employment or pay and the two following statement: "I certify that [first and last name of person employed or receiving income: is/was an employee of [name of company]. [employee's name]'s gross income for this pay period is/was $[Enter Amount] and frequency of pay is [weekly, every two weeks, twice a month, or monthly]. This letter does not guarantee employment or wages." and "The information provided above is true and correct to the best of my knowledge.")
- Self-employment Profit and Loss Statement or Ledger documentation (the most recent quarterly or year-to-date profit and loss statement, or a self-employed ledger.) (Form must include the client's first and last name, company name, dates covered and the net income form profit/loss.)
- Self-Employment Affidavit (PDF) form (earnings for the past 3 months to present). This form can be used if clients are unable to obtain payment/weekly summaries from the company (i.e., Uber and Lyft) they work for as independent contractors (self-employed).
- Income Verification Affidavit (PDF) form (completed by the individual providing income support other than the applicant's spouse/RDP) (dated within one month). This form can be used if clients are seasonal workers (i.e., farmers, actors) who work during certain times of the year and are ineligible for Medi-Cal.
Proof of Medi-Cal Ineligibility*
Proof of MAGI Medi-Cal ineligibility (provide one of the following):
- Income documentation showing household income at or above 138% of the Federal Poverty Level
- ID documentation (see above for a list of examples), showing client is aged 65 or older (not applicable to undocumented clients 65 and older)
Proof of Non-MAGI Medi-Cal ineligibility (provide one of the following):
- Denial Letter for non-MAGI Medi-Cal, SSI or SSDI (dated within one year)
- Proof of employment (dated within thirty days)
- Unemployment Insurance award letter (dated within one year)
- Proof of assets in excess of Medi-Cal limits, such as:
- Vehicle registration for two or more vehicles, or
- Grant Deed or property tax statement for real estate property owned in addition to the client's principal residence, or
- Current statement from a financial institution showing balance exceeding limits outlined below:
- Household Asset Limits for Non-MAGI Programs as of July 1, 2022:
*Not applicable to clients who are 'unlawfully present' between the ages of 26 -49, or currently enrolled in Medi-Cal or Medicare
Provide all that apply:
The following forms do not need to be uploaded into AES, but should be provided to clients at initial enrollment into PrEP-AP as they serve as temporary ID cards and instruct providers in how to bill the program for PrEP-related services.