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Client Application Forms

Client Application Forms by Client Type

Review the list of acceptable eligibility documents, or the list of acceptable eligibility documents for minors and clients with confidentiality concerns. The following lists contain forms that may be applicable to each client type, please note that not every form in the list will be required for each client.

Adult Uninsured (Including Medicare Without Part D)

Consent Form (English) (Spanish) (PDF)
Client Attestation (English) (Spanish) (PDF)
PrEP-AP Provider Referral Form (PDF)
PrEP-AP Medi-Cal Eligibility Exception Request (MEER) (PDF)
Income Verification Affidavit (English) (Spanish) (PDF)
Self-Employment Affidavit (PDF)
Residency Verification Affidavit (English) (Spanish) (PDF)
Temporary Access Period (TAP) Form (English) (Spanish) (PDF)
Provider Verification of Identity Form (PDF)

Adult Insured (Including Medicare With Part D & Medi-Cal Share of Cost)

Consent Form (English) (Spanish) (PDF)
Client Attestation (English) (Spanish) (PDF)
PrEP-AP Provider Referral Form (PDF)
Income Verification Affidavit (English) (Spanish) (PDF)
Self-Employment Affidavit (English) (Spanish) (PDF)
Residency Verification Affidavit (English) (Spanish) (PDF)
Temporary Access Period (TAP) Form (English) (Spanish) (PDF)
Provider Verification of Identity Form (PDF)

Adult With Confidentiality Concerns

Adults with confidentiality concerns have insurance through a parent, spouse, or registered domestic partner, but are unable to use their insurance for PrEP due to confidentiality concerns.

Request for Services Form - Confidentiality Concerns (English) (Spanish) (PDF)
PrEP-AP Confidentiality Concern Enrollment Worker Verification Affidavit (PDF)
PrEP-AP Provider Referral Form (PDF)
Residency Verification Affidavit (English) (Spanish) (PDF)
Temporary Access Period (TAP) Form (English) (Spanish) (PDF)
Provider Verification of Identity Form (PDF)

Minor (12–17 years old)

Request for Services Form - Minor (English) (Spanish) (PDF)
PrEP-AP Provider Referral Form (PDF)
Temporary Access Period (TAP) Form (English) (Spanish) (PDF)
Provider Verification of Identity Form (PDF)

Temporary Coverage

Temporary Coverage Client Attestation and Consent Form (English) (DocuSign)

Immediate Access

Immediate Access Client Attestation Form (English) (Spanish) (PDF)
Immediate Access Client Consent Form (English) (Spanish) (PDF)

Other Forms

Eligibility Exception Request (EER) (PDF)
Grievance Form (English) (Spanish) (PDF)

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