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ADAP Client Application Forms

Client Application Forms

Review the list of Accepta​ble Supporting Documentation (Acceptable Supporting Documentation (Spanish)) for ADAP clients. 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 ADAP Forms​​

​CDPH Form #​

​Form

​Last Revised

​Client Type
​CDPH 8​439
 ​ADAP Application (PDF)​
 ​August 2019
 ​ADAP
​CDPH 8439 SP
 ​ADAP Application (Spanish) (PDF)
 ​August 2019
 ​ADAP
​CDPH 8439 ZHS
 ​​ADAP Application (Simplified Chinese) (PDF)
 ​August 2019
 ​​ADAP
​CDPH 8439 KO
 ​​ADAP Application (Korean) (PDF)
 ​August 2019
 ​​ADAP
​CDPH 8439 TL
 ​​ADAP Application (Tagalog) (PDF)
 ​August 2019
 ​​ADAP
​CDPH 8439​ VI
 ​​ADAP Application (Vietnamese) (PDF)​
 ​August 2019​
 ​​ADAP
​CDPH 8456​
 ​ADAP ​Special Power of Attorney (PDF)
 ​March 2019
 ​ADAP

​CDPH 8456A​

​ADAP Revocation of Special Power of Attorney (PDF)

​July 2017

​ADAP
​CDPH 8685
 ​ADAP Consent Form (PDF)
 ​January 2025
 ​ADAP

​CDPH 8685 SP

​ADAP Consent Form (Spanish) (PDF)

January 2025​

​ADAP
​CDPH 8685 ZHS
 ​ADAP Consent Form (Simplified Chinese) (PDF)
 ​September 2024
 ​​ADAP
​CDPH 8685 KO
 ​ADAP Consent Form (Korean) (PDF)
 ​September 2024
 ​​ADAP
​CDPH 8685 TL
 ​ADAP Consent Form (Tagalog) (PDF)
 ​September 2024
 ​​ADAP
​CDPH 8685​ VI
 ​ADAP Consent Form (Vietnamese) (PDF)
 ​September 2024​
 ​​ADAP

​CDPH 8723

​ADAP/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 8747​
 ​​Certification of Justice-Involved Client Eligibility​ (PDF)​
 ​November 2020​
 ​ADAP
​CDPH 9117
 ​​​Enrollment Worker Phone Enrollment Attestation​ (PDF)
 ​April 2022
 ​​ADAP/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
 November 2024
 ​ADAP/PrEP-AP
​CDPH 8542 KO
 ​​Grievance Form (Korean) (PDF), available upon request
 November 2024
 ​ADAP/PrEP-AP
​CDPH 8542 TL
 ​Grievance Form (Tagalog) (PDF), available upon request
 November 2024
 ​ADAP/PrEP-AP
​CDPH 8542 VI
 ​​Grievance Form (Vietnamese) (PDF), available upon request
 ​November 2024
 ​ADAP/PrEP-AP
 

Residency Documentation​​

​CDPH For​m #

​Form

Last Revised

​Client Type

​CDPH 8727

​Residency Verification Affidavit (PDF)

​August 2023

​​​ADAP​/PrEP-AP
​​CDPH 8727 SP​
 ​​Residency Verification Affidavit (Spanish) (PDF)
 ​​August 2023
 ​​​​ADAP​/PrEP-AP
​​CDPH 8727 ZHS
 ​Residency Verification Affidavit (Simplified Chinese) (PDF), available upon request
 ​November 2023
 ​ADAP​/PrEP-AP
​​CDPH 8727 KO
 ​Residency Verification Affidavit (Korean) (PDF), available upon request
 ​November 2023
 ​ADAP​/PrEP-AP
​​CDPH 8727 TL
 ​Residency Verification Affidavit (Tagalog) (PDF), available upon request
 ​November 2023
 ​ADAP​/PrEP-AP
​​CDPH 8727 VI
 ​Residency Verification Affidavit (Vietnamese) (PDF), available upon request
 ​November 2023​
 ​ADAP​/PrEP-AP


Identity Documentation

​CDP​H ​Form #

​Form

​Last Revised

​​Client Type

​CDPH 8442

​Provider Verification of Identity (PDF)

​April 2020

​​​ADAP​/PrEP-AP


Clinical Documentation

​​​CDPH​ Form #​

​Form

​Last Revised

​​Client Type
​​CDPH 8440​​
 ADAP Diagnosi​s Form​ (PDF)
 ​October 2024
 ​ADAP​

​

Income Documentation

​​CDPH Form #

​Form

​Last Revised

​​Client Type

​CDPH 84​41

​ADAP/PrEP-AP Income Verification Affidavit (PDF)

​August 2022

​​​ADAP​/PrEP-AP

​CDPH 84​41 SP

​ADAP/PrEP-AP Income Verification Affidavit (Spanish) (PDF)

​August 2022

​​​ADAP​/PrEP-AP
​CDPH 84​41 ZHS
 ​ADAP/PrEP-AP Income Verification Affidavit (Simplified Chinese) (PDF)​
 ​​August 2022
 ​ADAP​/PrEP-AP
​CDPH 84​41 KO
 ​ADAP/PrEP-AP Income Verification Affidavit (Korean) (PDF)
 ​​August 2022
 ​ADAP​/PrEP-AP
​CDPH 84​41 TL
 ​ADAP/PrEP-AP Income Verification Affidavit (Tagalog) (PDF)
 ​​August 2022
 ​ADAP​/PrEP-AP
​CDPH 84​41 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 F​orm #

​Form

​Last Revised

​​Client Type

​CDPH 8729

​ADAP Eligibility Exception Request (EER) (PDF)

​April 2024

​ADAP

​CDPH 8724​

​ADAP Medi-Cal Eligibility Exception Request (MEER) (PDF)

​April 2024

​ADAP

​CDPH 8728

​ADAP Temporary Access Period (TAP) (PDF)

​January 2022

​ADAP
​CDPH 8728 SP
 ​ADAP Temporary Access Period (TAP) (Spanish)​ (PDF)
 ​​January 2022
 ​ADAP
​CDPH 8728 ZHS
 ​ADAP Temporary Access Period (TAP) (Simplified Chinese) (PDF)
 ​July 2024
 ​ADAP
​CDPH 8728 KO
 ​ADAP Temporary Access Period (TAP) (Korean) (PDF)
 ​​July 2024
 ​ADAP
​CDPH 8728 TL
 ​ADAP Temporary Access Period (TAP) (Tagalog) (PDF)
 ​​July 2024
 ​ADAP
​CDPH 8728 VI
 ​ADAP Temporary Access Period (TAP) (Vietnamese) (PDF)
 ​​July 2024​
 ​ADAP


Insurance Assistance Program Forms

​CDPH F​orm #

​Form

​Last Revised

​​Client Type

​CDPH 8738

​ADAP Acknowledgement of Policies and Responsibilities (PDF)

​February 2022

​OA-HIPP

​CDPH 8737​

​ADAP Health Insurance Assistance – Family Plan Consent Form (PDF)

​February 2024

​OA-HIPP

​CDPH 8722

​ADAP Partial Payment Agreement (PDF)

​January 2025

​OA-HIPP/EB-HIPP/MPPP

​CDPH 8722 SP

ADAP Partial Payment Agreement (Spanish) (PDF)​

​January 2025

​OA-HIPP/EB-HIPP/MPPP
​​CDPH 8722 ZHS
 ​ADAP Partial Payment Agreement (Simplified Chinese) (PDF), available upon request
 ​January 2025
 ​​OA-HIPP/EB-HIPP/MPPP
​​CDPH 8722 KO
 ​ADAP Partial Payment Agreement (Korean) (PDF), available upon request
 ​January 2025
 ​​OA-HIPP/EB-HIPP/MPPP
​​CDPH 8722 TL
 ​ADAP Partial Payment Agreement (Tagalog) (PDF), available upon request
 ​January 2025
 ​​OA-HIPP/EB-HIPP/MPPP
​​CDPH 8722 VI​
 ​ADAP Partial Payment Agreement (Vietnamese) (PDF), available upon request
 ​January 2025​
 ​​OA-HIPP/EB-HIPP/MPPP​
​​CDPH 8443
 ​Medical Out-Of-Pocket (MOOP) Claim Form (PDF)
 ​March 2022
 ​OA-HIPP/EB-HIPP/MPPP
​CDPH 8443 SP
 ​Medical Out-​Of-Pocket (MOOP) Claim Form (Spanish) (PDF)​
 ​March 2022
 ​OA-HIPP/EB-HIPP/MPPP​
​CDPH 8443 ZHS
​Medical Out-Of-Pocket (MOOP) Claim Form (Simplified Chinese) (PDF), available upon request
​March 2022
​​OA-HIPP/EB-HIPP/MPPP​
​CDPH 8443 KO
​Medical Out-Of-Pocket (MOOP) Claim Form (Korean) (PDF), available upon request
​March 2022
​​OA-HIPP/EB-HIPP/MPPP​
​CDPH 8443 TL
​Medical Out-Of-Pocket (MOOP) Claim Form (Tagalog) (PDF), available upon request
​March 2022
​​OA-HIPP/EB-HIPP/MPPP​
​CDPH 8443 VI
​Medical Out-Of-Pocket (MOOP) Claim Form (Vietnamese) (PDF)​, available upon request​
​March 2022​
​​OA-HIPP/EB-HIPP/MPPP​
​N/A
 ​OA-HIPP Client Responsibilities (PDF)
 ​September 2024
 ​​​OA-HIPP
​​N/A
 ​OA-HIPP Client Responsibilities (Spanish) (PDF)
 ​September 2024
 ​​​OA-HIPP
​​N/A
 ​OA-HIPP Client Responsibilities  (Simplified Chinese) (PDF)
 ​September 2024
 ​​​OA-HIPP
​​N/A
 ​OA-HIPP Client Responsibilities (Korean) (PDF)
 ​September 2024
 ​​​OA-HIPP
​​N/A
 ​OA-HIPP Client Responsibilities (Tagalog) (PDF)
 ​September 2024
 ​​​OA-HIPP
​​N/A
 ​OA-HIPP Client Responsibilities (Vietnamese) (PDF)​
 ​September 2024​
 ​​​OA-HIPP

Additional ADAP Forms

CDPH 8689 (PDF)​ - Agreement by Employee/Contractor to Comply with Confidentiality Requirements

CDPH 8444 (PDF) – Client Handout Form

CDPH 8730 (PDF) - Confidential Fax Submission​

CDPH 8731 (PDF) - New Enrollment Worker Training Request Form

CDPH 9114 (PDF) - PrEP-AP Pharmacy User Training Request​
​​

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