State of California—Health and Human Services Agency
California Department of Public Health

ADAP MM 2025-01

January 9, 2025

TO:

ADAP and PrEP-AP Enrollment Workers

SUBJECT:

Enrollment Worker Attestation Form (CDPH 9117)

The purpose of this memo is to inform AIDS Drug Assistance Program (ADAP) and Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Enrollment Workers (EW) about a policy update regarding the EW Attestation form, also known as form CDPH 9117.

Background

On May 5, 2022, the EW Attestation Form was released during the COVID-19 State of Emergency to remain flexible and ensure clients impacted by the pandemic did not lose eligibility. The form was used by EWs to enroll clients by telephone and to attest that the client was eligible for ADAP/PrEP-AP, agreed to consent language, and would provide documentation within 12 months.

On May 14, 2024, Management Memo 2024-10 was sent out informing EWs that the EW Attestation Form was discontinued due to the end of the State of Emergency.

Program Update

Effective immediately, a revised EW Attestation Form is being reinstated to be used to enroll clients via telephone into ADAP or PrEP-AP for a 30-day temporary access period (TAP). This is a change from the previous form which could be used for a 12-month eligibility period. The form can only be used once per enrollment or re-enrollment period. The form may be used when a client is temporarily unable to do all the following:

Meet in person;
Submit items electronically; and
Mail the documents required for enrollment.

Procedure

To use the form for telephone enrollment or re-enrollment, the EW will attest to the following:

They have read the consent language from the ADAP/PrEP-AP Consent Form to the client, and the client verbally attests to enrolling into ADAP/PrEP-AP;
They informed the client that all required documentation must be provided within 30 days, or the client will be disenrolled; and
They will make three attempts within 30 days to collect documentation.

Note: A new ADAP client without proof of HIV status cannot be enrolled on a TAP.

If you have any questions regarding the information provided in this memo, please contact your OA Advisor.

Thank you,

Joseph Lagrama Signature.png