Oregon Department of Human Services - CAREAssist by elb10874

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									  Oregon Department of Human Services - CAREAssist Confidential Application
Part 1: Applicant Information

Name: ______________________________________________________
                    ( your Full Legal Name: first name middle initial last name )

What should we call you? (Do you go by your middle name or a nickname?)___________________

Date of birth: ________________Age: ________ Social Security Number: ____________________
                ( month / day / year )

Gender:         Male

                Female

                Transgender

Ethnicity/Origin:        Hispanic/Latino or Latina

                         Not Hispanic/not Latino or Latina

Race:           White

                Black or African American

                Asian

                Native Hawaiian/Pacific Islander

                American Indian/Alaska Native

                More than one race ________________________________

Preferred Language:                English

                                  Spanish

                                  Other ___________________

How did you hear about the CAREAssist Program?

                                          Case Manager                      Friend

                                          Doctor                            Other____________________________
                        For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 2: Address Information
Important: We must have up-to-date information on how to contact you. Failure
to maintain current information may result in cancellation of our help.

If we are unable to get a current address for you within 60 days of getting mail
returned, you will be discontinued from CAREAssist.
Home address
       I do not have a home address

          I do have a home address:

                Address 1: _____________________________________________________________

                           _____________________________________________________________

                City: ________________________________ State: _________ Zip: _______________

                County: __________________________________

Mailing address
        My mailing address is the same as my home address

          My mailing address is different from my home address:

                Address 2: _________________________________________________________

                         _________________________________________________________

                City: ________________________________ State: _________ Zip: _______________



If you recently moved to Oregon, when did you move here? _______________________________
                                                                          ( month / day / year )

From which state did you move to Oregon? _____________________________________________




                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 3: Phone Information

Home phone: ________________________ May we leave a detailed message?                       Yes      No

Work phone: ________________________ May we leave a detailed message?                       Yes      No

Mobile phone: _______________________ May we leave a detailed message?                     Yes       No

Message Phone: ______________________ May we leave a detailed message?                      Yes      No

May we contact you by email?        Yes      No    E-mail address: _____________________________

Special Instructions:     I have a friend or family member you may also talk to:

Name: _______________________________________________

Relationship: _____________________________ Phone number: _________________________

Part 4: Other CAREAssist Clients

Are there any of your family members also enrolled in CAREAssist?

If so, please list their names and relationship:
                          Name                                            Relationship




Part 5: HIV Case Manager

Please list your HIV case manager.

          I do not have an HIV case manager

          My HIV case manager is:

        Name: _______________________________________________

        Phone number: ________________________________________



                      For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 6a: Financial Information – Income
Important: Must include Proof
Note: If you have not included proof of income, this application will be rejected and returned
to you. For proof of income, please send in two recent full months’ income documents. Also, if
you file, please send a copy of the most recent year’s Federal Income Tax Return. If you have
no income, you must complete section 6c, Affidavit of Zero Income.
Family size: _____________

Income sources/monthly amount (before taxes are taken out) – Complete all that apply.
You must list the income of all family members and include proof of income for all those family
members.

           Work income (not self-employment income)               $______________/month

           Self employment income                                 $______________/month

           Long-Term Disability                                   $______________/month

           Pension / retirement income                            $______________/month

           Child support                                          $______________/month

           Alimony                                                $______________/month

           Social Security Income (SSI)                           $______________/month

           Social Security Disability Income (SSDI)               $______________/month

                Date you began receiving SSDI_____________________
                                                      ( month / day / year )


          General Assistance (GA)                                 $______________/month

           Unemployment Income                                    $______________/month

           Other Income: _________________________                $______________/month

The following information is used only to help us determine your monthly income.

Please list the name of your employer, if you have one: ______________________________

Please list the date your job began with this employer: ______________________________
                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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    Oregon Department of Human Services - CAREAssist Confidential Application
Part 6a: Financial Information (continued)

If the income information listed on the previous page does not accurately describe your current
income status, please explain:




Part 6a: Financial Information (continued)

If you listed more than one person as your household size, please list the full name, birth date, and
relationship of the other family members you included.
               Full name                  Birth date (month/day/year)               Relationship




Part 6b: Financial Information - Assets

Please refer to instructions on how to complete this. The limit for assets for CAREAssist clients
is $10,000. If you are income-eligible for OHP, your limit is $2,000 for a one-person household, or
$3,000 for a family. *You do not need to list the exempted items discussed in the instructions.

1        Total liquid assets – savings & other bank          $
         accounts, etc
2        Total value of all real estate holdings other       $
         than one house (owned or buying). This
         includes vacation homes, rental property,
         business property.
3        All investments at the reasonable market            $
         value for those holdings – including stocks,
         bonds, securities, etc.
4        All limited partnerships, expense                   $
         reimbursements, compensations to expense
         accounts as officers or employees of a
         corporation.

         TOTAL                                               $
                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 6c: Zero Income Statement

                                  Affidavit of Zero Income
        I, ______________________________ hereby verify that I do not receive income from
        any of the following sources.

        Income includes, but is not limited to:

            • Wages from employment (including commissions, fees, tips, bonuses, etc.);
            • Income from operation of business;
            • Rental income from real or personal property;
            • Interest or dividends from assets;
            • Social Security payments, annuities, insurance policies, retirement funds,
              pensions, Supplemental Security Income (SSI), or death benefits;
            • Unemployment or Disability payments;
            • Public Assistance payments;
            • Any other source not named above.

        I use or will be using the following sources of funds to pay for rent and other
        necessities:
        ______________________________________________________________________
        ______________________________________________________________________
        ______________________________________________________________________
        ______________________________________________________________________
        ____

        I understand that I must report to CAREAssist any change which affects my income
        and/or assets. I must report the change to CAREAssist in writing within ten business
        days of the change.

        I understand that false statements or false information are grounds for termination from
        the CAREAssist Program. Persons who are found to have intentionally provided false,
        fraudulent or misleading information will be barred from the program for a period of
        one year and could be asked to repay the program for the costs of services provided.

        _________________________________________                      ________________________
        Client Signature                                               Date




                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application

Part 7: Health Insurance

Do you have health insurance?

          Yes, I have health insurance
              You must also complete the following:
                    Part 8: Health Insurance Type
                    Part 9: Financial Assistance for Health Insurance Premiums
                    Part 10: Additional Household Members
                    Part 11: Health Insurance Policy Information

          No, I do not have health insurance

                Have you applied for health insurance?

                        Yes, I have applied for health insurance and a health insurance company
                            is currently reviewing my application

                             Please list that insurance company: ___________________________

                             When did you apply? __________________
                                                         ( month / day / year )


                        No, I have not applied for health insurance

                      If no, skip to Part 12: Prescription Drug Coverage




                        For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application


Part 8: Health Insurance Type
(Complete Part 8 only if you checked “Yes, I have health insurance” in Part 7: Health Insurance)

          I have health insurance through work

                  My employer pays all of the premiums

                  My employer pays part of the premiums

          I have my own private/individual health insurance policy

          I have COBRA or other insurance continuation

                COBRA coverage start date: ________________
                                                  ( month / day / year )


                COBRA coverage end date: _________________
                                                  ( month / day / year )


          I have a health insurance policy through the Oregon Medical Insurance Pool (OMIP)

                My OMIP plan is:              Plan 1           Plan 2      Plan 3        Plan 4

          I have a health insurance policy through the Oregon Health Plan (OHP), also known as
              Medicaid

          I have Medicare coverage

                What Medicare parts/supplements do you have? (check all that apply)

                         I have Medicare Part A

                         I have Medicare Part B

                         I have Medicare Part D

                         I have a Medicare Supplemental Policy

          I have coverage through the Veterans Administration (VA) (Note: those who get care
        through the VA are eligible for help with drug co-pays and may have incomes up to 300%
        FPL.)
                        For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application

Part 9: Financial Assistance for Health Insurance Premiums
(Complete Part 9 only if you checked “Yes, I have health insurance” in Part 7: Health Insurance)

Do you need help paying your health insurance premiums?

          No, I do not need help paying for health insurance premiums

          Yes, I do need help paying for health insurance premiums

                Who should the check be made out to? ______________________________________
                                                                (company name)

                Who should premium payment be sent to?

                Name: ________________________________________________________________

                Address: ______________________________________________________________

                        ______________________________________________________________

                City: _____________________________State: __________ Zip: _________________

                Contact name: _________________________ Phone: ________________________


                Payee’s Federal Tax ID Number: ____________________________

                Premium amount: $__________________

                Premium paid:         Monthly                      Bi-monthly (every two months)

                                      Quarterly                    Other____________________________

                I have health coverage paid up through: ______________________________
                                                                        ( month / day / year )


                My next premium payment is due: __________________________________
                                                                   ( month / day / year )




                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application

Part 10: Additional Household Members
(Complete Part 10 only if you checked “Yes, I have health insurance” in Part 7: Health Insurance)

Does your health insurance policy also cover additional household members?

          No, my health insurance policy does not cover additional household members

          Yes, my health insurance policy does cover additional household members

                 Number of household members besides me that are covered:______________

                                 Date of                                                              HIV
                Name              Birth          Race         Gender           Relationship         Positive?




                         For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application

Part 11: Health Insurance Policy Information
(Complete Part 11 only if you checked “Yes, I have health insurance” in Part 7: Health Insurance)

Health insurance company name: ___________________________________________________

Whose name is listed as the policy holder?

          My name is listed as the policy holder

          Another name is listed as the policy holder

                List the policy holder name: _______________________________________________

Your health insurance identification number: ___________________________________________

Do you have an insurance group number?

          No, I do not have an insurance group number

          Yes, I have an insurance group number

                List your insurance group number: __________________________________________

Do you have a contact person at the health insurance company?

          No, I do not have a contact person at the health insurance company

                List the customer or membership service phone number: ______________________

          Yes, I do have a contact person at the health insurance company

                Contact person name: ___________________________________________________

                Contact person phone number: ______________________________________

Are you in a waiting period for pre-existing conditions?

          No

          Yes        When will that period end? __________________________________
                                                                ( month / day / year )

                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application

Part 12: Prescription Drug Coverage

Are you currently taking prescription drugs for your HIV? (Antiretrovirals)              No       Yes
Do you need help paying for prescription drugs?

          No, I do not need help paying for prescription drugs

          Yes, I need help paying for all or part of my prescription drug costs

                Which pharmacy would you like to use?

                      Pharmacy name: ___________________________________________________

                      Pharmacy phone: ___________________________________________________

                How are your prescription drugs paid for?

                        I must pay because my health insurance does not cover prescription drugs

                        I must pay because I do not have health insurance

                        My health insurance covers prescription drugs but I must pay deductibles
                           and/or co-payments

Note: If you have health insurance to pay for part of your prescriptions,
you must attach a copy of your “Prescription Summary of Benefits.”
                Does your health insurance company make you pay for your prescription
                      drugs up front and then reimburse you?

                        Yes           No

                Do you use a mail order pharmacy service for any of your prescriptions?

                        No            Yes – please list the mail order pharmacy name and address

                              Name: ____________________________________________

                              Address: __________________________________________

                              City, State & Zip: ___________________________________
                        For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 13: Health Care Provider(s)

Primary health care provider name: __________________________________________________
                                                 (name of doctor, nurse practitioner, or other care provider)

Phone number: ____________________________

Specialist health care provider name: _________________________________________________
                                                 (name of doctor, nurse practitioner, or other care provider)

Phone number: ____________________________


When was the last time you saw the HIV Health Care Provider listed above? __________________
                                                                                                   ( month / day / year )



Part 14: Laboratory Test Results

What were the results of your last CD4 Count test?

          I do not know the results of my last CD4 Count test.

          My last CD4 Count test result was __________ cells/:L on __________________
                                                                                        ( month / day / year )

What were the results of your last Viral Load test?

          I do not know the results of my last Viral Load test.

          My last Viral Load test result was __________ copies/mL on __________________
                                                                                          ( month / day / year )




                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application

Part 15: Authorization
I am applying for financial assistance from CAREAssist. By signing at the end of this authorization,
I state I have read this application and understand the conditions of my participation, which include
the following:

1. I will be disqualified from this program for a period of 12 months and may be asked to repay the
   costs of the services provided by the program for willfully giving false information to
   CAREAssist of the Oregon Department of Human Services (hereafter referred to as
   “Department”).

2. I will respond to requests from the Department within the deadlines issued by the Department.
   This includes, but is not limited to, requests for eligibility reviews, current contact (address and
   phone) information, current insurance information, payment of Cost-Share, and application to
   other programs as specified. I understand if I do not respond by the deadline, I may be removed
   from the program. I understand that if I am removed from CAREAssist, I may reapply after a
   three-month exclusion period. I understand that I will be removed from the program if my
   health insurance is terminated due to my inaction. Inaction may include (but is not limited to)
   failing to notify the Department in a timely manner of a different premium amount, a new
   insurance company name or insurance company address, or failing to reapply for an insurance
   policy where necessary (Oregon Health Plan). I understand the Department must have two weeks
   to issue a premium payment. I understand that if I lose my insurance, I may not be eligible to re-
   apply to CAREAssist until that insurance is restored (or another equivalent insurance is in effect).

3. The Department will review my eligibility at least every six months.

4. If I become ineligible for financial assistance and/or receive insurance refunds, I agree to
   reimburse the Department any overpayments made on my behalf.

5. The Department may discuss this application with my physician and other health care providers,
   and with my case manager.

6. If the Department is helping pay my health insurance premiums, the Department may contact my
   employer or insurer concerning payment of those premiums.

7. The Department may give my name and other limited information to the companies helping
   provide the services of CAREAssist. These companies have agreed to hold this information
   confidential.

8. The Department shall have access to insurance claim information about me while I participate in
   the program. This may include information from private insurance companies or other public
   entities.
                                     (Continued next page)
                     For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 15: Authorization (continued)

9. I understand the Department may ask me for more information about my treatment or related
   services. I agree to give such information to the Department or arrange to have it given.

10. I understand the Department will collect information about me during my participation. The
    Department will use this information to make plans for and evaluate the program. No information
    that could identify me will be published or disclosed to third parties not directly involved in
    providing the services of CAREAssist.

11. I understand that the friend or family member I have authorized CAREAssist to talk to will
    remain valid until I give CAREAssist written instructions saying it is no longer valid or until I
    name another person on a client eligibility review.

12. If my eligibility is renewed, the Department will provide services as long as I remain eligible for
    participation and Department funds are available.

13. I understand the Department is wholly dependent on public funds. If the funding is reduced or
    stopped, the Department may have to reduce or stop the financial assistance provided. In addition,
    I understand that CAREAssist program priorities may change over time, which could affect my
    eligibility for assistance

14. I understand the Department has a responsibility to be cost effective. This may mean I am asked
    to use all other available programs (such as health insurance, the Oregon Health Plan, and the
    Medically Needy Spend-Down Program) prior to and in conjunction with CAREAssist financial
    assistance.

15. I understand that CAREAssist has grievance procedures, which are available upon request. I
    understand that making a grievance will not adversely affect my services through CAREAssist.


Signature:______________________________________________Date:______________________
                   (applicant or legal guardian’s signature)                        ( month / day / year )



Applicant’s name:____________________________________________
                                                  ( print )




                     For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 16: Checklist – Must have all information

                Everyone must complete Parts 1 - 7 and 13 - 17 on the application

                If you have health insurance, you must complete Parts 8 - 11, as applicable.

                If you are taking prescription drugs, you must complete Part 12, as applicable.

                Sign and date Part 17: Authorization. Please note on the back of page 17 is a
                prescription questionnaire. If you take medications, please complete it.

                Include proof of all your sources of income as well as that of all other family members

                Include a copy of last year’s Federal Income Tax Return

                Verify your health care provider has completed the “HIV/AIDS Confirmation Form”
                and sent it to us

                If you do not have health insurance but have applied for health insurance, include a
                copy of your health insurance application

                If you have health insurance and your health insurance covers prescription drugs, you
                must include a copy of your prescription drug summary of benefits.

                Send this application to:         CAREAssist
                                                  PO Box 14450
                                                  Portland, OR 97293




                        For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application
Part 17: HIV/AIDS Confirmation Form


Part 17 A:                                Applicant Section

Applicant’s name: __________________________________ Date of birth: ________________
                                   ( please print)                                     ( month / day / year )

I authorize the health care provider listed below to inform the Oregon Department of Human Services about the
HIV status of the applicant listed above.

                         ____________________________________________
                                        ( applicant or legal guardian’s signature )


Part 17 B:                            Health Care Provider Section
The applicant named above has applied for assistance from the Oregon Department of Human
Services under the CAREAssist program. In order to qualify for CAREAssist, the applicant must
have been diagnosed with HIV or AIDS. Please provide the following information and return this
form in an envelope marked “CONFIDENTIAL” to:

Oregon Department of Human Services
                     CAREAssist
                     PO Box 14450
                     Portland, OR 97293-0450

Health care provider: ___________________________________________________________

Address: _____________________________________________________________________

            _____________________________________________________________________
City: ____________________________ State: ________________ Zip: __________________

Phone: ___________________________________ Fax ________________________________

The HIV Status of the applicant named above is:                  Applicant is HIV positive, not AIDS
                                                                 Applicant is HIV positive, with AIDS
                                                                 Applicant is not HIV positive.

Signature: _______________________________________ Date: ________________________
             (Must be signed by health care provider)


                       For information or assistance, call 971-673-0144 or 1-800-805-2313
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  Oregon Department of Human Services - CAREAssist Confidential Application

CAREAssist
Prescription Information
Name: ______________________________                                Date:_________________________

Please complete the following by listing all of your prescription drugs. If we know what
prescriptions you are currently taking and when you may run out, it will help us know which options
to suggest to you at the time of application.

    Name of medication                       Medication Strength (i.e. mg.)          Days supply left
    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.
    10.
    11.
    12.
    13.
    14.
    15.




                    For information or assistance, call 971-673-0144 or 1-800-805-2313
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