PrEP-AP Client Application Forms
Client Application Forms
Review the list of
PrEP-AP acceptable eligibility documents. 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.
General PrEP-AP Client Forms
Residency Documentation
CDPH 8727
|
ADAP/PrEP-AP Residenāācy Verification Affidavit (PDF)
|
November 2023 |
ADAP/PrEP-AP |
CDPH 8727 SP
|
ADAP/PrEP-AP Residency Verification Affidavit (Spanish) (PDF)
|
November 2023 |
ADAP/PrEP-AP |
| āCDPH 8727 ZHS |
āADAP/PrEP-AP Residency Verification Affidavit (Simplified Chinese) (PDF), available upon request
|
āNovember 2023
|
āADAP/PrEP-AP |
| āCDPH 8727 KO |
āADAP/PrEP-AP Residency Verification Affidavit (Korean) (PDF), available upon request
|
āNovember 2023 |
āADAP/PrEP-AP |
| āCDPH 8727 TL |
āADAP/PrEP-AP Residency Verification Affidavit (Tagalog) (PDF), available upon request
|
āNovember 2023 |
āADAP/PrEP-AP |
āCDPH 8727 VI
|
āADAP/PrEP-AP Residency Verification Affidavit (Vietnamese) (PDF), available upon requestā
|
āNovember 2023 |
āADAP/PrEP-AP |
Identity Documentation
Clinical Documentation
Income Documentation
Eligibility Exception Request and Temporary Access Period Forms
PrEP-AP Confāidentiality & Minors Forms
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. Minors are ages 12-17.
PrEP-AP Immediate Access Program Forms
These forms are typically completed via DocuSign.ā
āā