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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

CDPH Form # Form Last Revised Client Type
CDPH 8723

AD​AP/PrEP-AP Client Attestation Form (PDF)
May 2023
ADAP/PrEP-AP
CDPH 8723 SP​
ADAP/PrEP-AP Client Attestation Form (Spanish) (PDF)
May 2023 ADAP/PrEP-AP
​CDPH 8723 ZHS
​ADAP/PrEP-AP Client Attestation Form (Simplified Chinese) (PDF)
​May 2023 ​ADAP/PrEP-AP
​CDPH 8723 KO
​ADAP/PrEP-AP Client Attestation Form (Korean) (PDF)
​May 2023
​ADAP/PrEP-AP
​CDPH 8723 TL
​ADAP/PrEP-AP Client Attestation Form (Tagalog) (PDF)
​May 2023 ​ADAP/PrEP-AP
​CDPH 8723 VI
​ADAP/PrEP-AP Client Attestation Form (Vietnamese) (PDF)
​May 2023 ​ADAP/PrEP-AP
CDPH 8733 PrEP-AP Consent Form (PDF)
July 2024
PrEP-AP
CDPH 8733 SP
PrEP-AP Consent Form (Spanish) (PDF)
July 2024
PrEP-AP ​
​CDPH 8733 ZHS ​PrEP-AP Consent Form (Simplified Chinese) (PDF)
July 2024 ​PrEP-AP ​
​CDPH 8733 KO
​PrEP-AP Consent Form (Korean) (PDF)
​July 2024 ​PrEP-AP ​
​CDPH 8733 TL ​PrEP-AP Consent Form (Tagalog) (PDF)
​July 2024 ​PrEP-AP ​
​CDPH 8733 VI ​PrEP-AP Consent Form (Vietnamese) (PDF)​
​July 2024 ​PrEP-AP ​
CDPH 8542 
Grievance Form (PDF)
February 2022
ADAP/PrEP-AP
​CDPH 8542 SP
​Grievance Form (Spanish) (PDF)
March 2018​
​ADAP/PrEP-AP
​CDPH 8542 ZHS ​Grievance Form (Simplified Chinese) (PDF), available upon request
​February 2022
​ADAP/PrEP-AP
​CDPH 8542 KO
​Grievance Form (Korean) (PDF), available upon request
February 2022
​ADAP/PrEP-AP
​CDPH 8542 TL
​Grievance Form (Tagalog) (PDF), available upon request
​February 2022
​ADAP/PrEP-AP
​CDPH 8542 VI
​Grievance Form (Vietnamese) (PDF), available upon request​
February 2022
​ADAP/PrEP-AP

Residency Documentation

CDPH Form #​ Form Last Revised Client Type
CDPH 8727
ADAP/PrEP-AP Residen​​cy Verification Affidavit (PDF)
November 2023 ADAP/PrEP-AP
CDPH 8727 SP
ADAP/PrEP-AP Residency Verification Affidavit (Spanish) (PDF)
November 2023 ADAP/PrEP-AP
​CDPH 8727 ZHS ​ADAP/PrEP-AP Residency Verification Affidavit (Simplified Chinese) (PDF), available upon request
​November 2023
​ADAP/PrEP-AP
​CDPH 8727 KO ​ADAP/PrEP-AP Residency Verification Affidavit (Korean) (PDF), available upon request
​November 2023 ​ADAP/PrEP-AP
​CDPH 8727 TL ​ADAP/PrEP-AP Residency Verification Affidavit (Tagalog) (PDF), available upon request
​November 2023 ​ADAP/PrEP-AP
​CDPH 8727 VI
​ADAP/PrEP-AP Residency Verification Affidavit (Vietnamese) (PDF), available upon request​
​November 2023 ​ADAP/PrEP-AP

Identity Documentation

CDPH Form #​ Form Last Revised Client Type
CDPH 8442
PrEP-AP Provider Verification of Identity (PDF)
April 2020
ADAP/PrEP-AP

 

Clinical Documentation

CDPH Form #​ Form Last Revised Client Type
CDPH 9123
PrEP-AP Provider Referra​l Form (PDF)
May 2024
PrEP-AP
​CDPH 9123 SP
​PrEP-AP Provider Referra​l Form (Spanish) (PDF)​
​May 2024
​PrEP-AP

 

Income Documentation

CDPH Form #​ Form Last Revised
Client Type
CDPH 8441
ADAP/PrEP-A​​P Income Verification Affidavit (PDF)
August 2022 ADAP/PrEP-AP
CDPH 8441 SP
ADAP/PrEP-AP Income Verification Affidavit  (Spanish) (PDF)
August 2022 ADAP/PrEP-AP
​CDPH 8441 ZHS ​ADAP/PrEP-AP Income Verification Affidavit (Simplified Chinese) (PDF)
​August 2022 ​ADAP/PrEP-AP
​CDPH 8441 KO ​ADAP/PrEP-AP Income Verification Affidavit (Korean) (PDF)
​August 2022 ​ADAP/PrEP-AP
​CDPH 8441 TL ​ADAP/PrEP-AP Income Verification Affidavit (Tagalog) (PDF)
​August 2022 ​ADAP/PrEP-AP
​CDPH 8441 VI ​ADAP/PrEP-AP Income Verification Affidavit (Vietnamese) (PDF)​
​August 2022 ​ADAP/PrEP-AP
CDPH 8726 ADAP/PrEP​-AP Self-Employment Affidavit (PDF)
October 2024
ADAP/PrEP-AP
CDPH 8726 SP
ADAP/PrEP-AP Self-Employment Affidavit (Spanish) (PDF)
August 2022
ADAP/PrEP-AP
​CDPH 8726 ZHS ​ADAP/PrEP-AP Self-Empl​​oyment Affidavit (Simplified Chinese) (PDF)
​August 2024 ​ADAP/PrEP-AP
​CDPH 8726 KO ​ADAP/PrEP-AP Self-Employment Affidavit (Korean) (PDF)
​August 2024 ​ADAP/PrEP-AP
​CDPH 8726 TL ​ADAP/PrEP-AP Self-Employment Affidavit (Tagalog) (PDF)
​August 2024 ​ADAP/PrEP-AP
​CDPH 8726 VI ​ADAP/PrEP-AP Self-Employment Affidavit (Vietnamese) (PDF)​
​August 2024 ​ADAP/PrEP-AP

 

Eligibility Exception Request and Temporary Access Period Forms

CDPH Form #​

Form

Last Revised

Client Type

CDPH 8729

ADAP/PrEP-AP Eligibility Exception Request (EER) Form (PDF)

April 2024

ADAP/PrEP-AP

CDPH 8736 

ADAP/PrEP-AP Medi-Cal Eligibility Exception Request (MEER)​ Form (PDF)

August 2021

ADAP/PrEP-AP

CDPH 8740

PrEP-AP Temporary A​ccess Period (TAP) Request (PDF)

August 2022

PrEP-AP

CDPH 8740 SP

PrEP-AP Temporary Access Period (TAP) Request (Spanish) (PDF)​

August 2022

PrEP-AP

​CDPH 8740 ZHS

​PrEP-AP Temporary Access Period (TAP) Request (Simplified Chinese) (PDF)

​August 2022

​PrEP-AP

​CDPH 8740 KO

​PrEP-AP Temporary Access Period (TAP) Request (Korean) (PDF)

​August 2022

​PrEP-AP

​CDPH 8740 TL

​PrEP-AP Temporary Access Period (TAP) Request (Tagalog) (PDF)

​August 2022

​PrEP-AP

​CDPH 8740 VI

​PrEP-AP Temporary Access Period (TAP) Request (Vietnamese) (PDF)​

​August 2022

​PrEP-AP

​CDPH 9117

​ADAP/PrEP-AP Enrollment Worker Phone Enrollment Attestation (PDF)​

April 2022

​ADAP/PrEP-AP

PrEP-AP Conf​identiality & 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.

CDPH Form #​​ Form Last Revised Client Type
CDPH 8746 Request for Services - Clients with Confidentiality Concerns​ (PDF)

July 2020​

PrEP-AP Confidentiality
CDPH 8746 SP
Request for Services - Clients with ā€‹Confidentiality Concerns (Spanish) (PDF)​
August 2020
PrEP-AP Confidentiality
​CDPH 8746 ZHS ​Request for Services - Clients with Confidentiality Concerns (Simplified Chinese) (PDF)
​October 2024 ​PrEP-AP Confidentiality
​CDPH 8746 KO ​Request for Services - Clients with Confidentiality Concerns (Korean) (PDF)
​October 2024
​PrEP-AP Confidentiality
​CDPH 8746 TL ​Request for Services - Clients with Confidentiality Concerns (Tagalog) (PDF)
​October 2024 ​PrEP-AP Confidentiality
​CDPH 8746 VI ​Request for Services - Clients with Confidentiality Concerns (Vietnamese) (PDF)​
​October 2024 ​PrEP-AP Confidentiality
CDPH 9122
PrEP-AP Confidentiality Concerns Enrollment Worker Verification Affidavit (PDF)
July 2024
PrEP-AP Confidentiality
CDPH 8745 Request for Sevice​s - Minors​ (PDF)
October 2024
PrEP-AP Minors
CDPH 8745 SP
Request for Services - Minors (Spanish) (PDF)
August 2020 PrEP-AP Minors
​CDPH 8745 ZHS ​Request for Sevices - Minors (Simplified Chinese) (PDF)
​October 2024
​PrEP-AP Minors
​CDPH 8745 KO​
​Request for Sevices - Minors​ (Korean) (PDF)
​October 2024 ​PrEP-AP Minors
​CDPH 8745 TL ​Request for Sevices - Minors​ (Tagalog) (PDF)
​October 2024 ​PrEP-AP Minors
​CDPH 8745 VI​ ​Request for Sevices - Minors​ (Vietnamese) (PDF)​
​October 2024 ​PrEP-AP Minors

 

PrEP-AP Immediate Access Program Forms

These forms are typically completed via DocuSign.​

CDPH Form #​ Form​ Last Revised Client Type
CDPH 9115
Immediate Access Client Atte​station Form (PDF)
February 2022 Immediate Access
CDPH 9115 SP

Immediate Access Client Attestation Form (Spanish) (PDF)
February 2022 Immediate Access
​CDPH 9115 ZHS
​Immediate Access Client Attestation Form (Simplified Chinese) (PDF)
August 2024
​Immediate Access
​CDPH 9115 KO
​​Immediate Access Client Attestation Form (Korean) (PDF)
August 2024
​Immediate Access
​CDPH 9115 TL
​​Immediate Access Client Attestation Form (Tagalog) (PDF)​
August 2024
​Immediate Access
​CDPH 9115 VI
​​Immediate Access Client Attestation Form (Vietnamese) (PDF)
​August 2024​
​Immediate Access​
CDPH 9116

Immediate Access Client Consent Form (PDF)
February 2022 Immediate Access
​CDPH 9116 SP
​Immediate Access Client Consent Form (Spanish) (PDF)
​February 2022
​Immediate Access
​CDPH 9116 ZHS
​Immediate Access Client Consent Form (Simplified Chinese) (PDF)
​August 2024
​​Immediate Access
​CDPH 9116 KO
​​Immediate Access Client Consent Form (Korean) (PDF)
​August 2024
​​Immediate Access
​CDPH 9116 TL
​​Immediate Access Client Consent Form (Tagalog) (PDF)
​August 2024
​​Immediate Access
CDPH 9116 VI
​Immediate Access Client Consent Form (Vietnamese) (PDF)​​
August 2024
​Immediate Access


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