1 - UEA Referral/Intake

OFFICE USE ONLY
MHC staff entering information into Provide:
Provide ID #
Client URN #
Provide Expiration Date:

MonthDayYear
Date
Documents Needed:
Referral Status:
Todays Date

MonthDayYear
Date
Hour MinutesAM/PM Option
The person completing this form is:
How are you completing this referral?

Client Notification Regarding Consent Form for Eligibility Processing

Please inform the client that a representative from MHC will be reaching out to obtain their signature on the Provide Enterprise Consent Form. This form authorizes MHC to conduct the client's eligibility assessment on behalf of the Virginia Department of Health (VDH), your agency, and the client, facilitating the provision of necessary services.
Client Information
Client Name

Legal First NameMiddle InitialLegal Last NameName Suffix Jr Sr I II Etc
Other Name Used
Please upload unexpired state issued Photo ID (front)

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Please upload unexpired state issued Photo ID (back)

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Is client's current address the same as ID?
Client's Home Address

Street Address

Street Address Line 2

CityState

Zip
Is it ok to send mail to this address?
Do you have another address to send mail to?
Please upload proof of residency: Chose one - (Lease, light bill, gas bill, water bill, vehicle registration, voters, registration ect.) (Must show clients name and current Date)

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Client Mailing Address

Mailing Address If Different

Street Address Line 2

CityState

Zip
Client's Email

Confirmation Emailexample@example.com
Ok to email detailed message?

SSN
Age
Client's Birth Date

MonthDayYear
Date
Diagnosis Information
HIV Status:
HIV positive (not AIDS) Date:

MonthDayYear
Date
HIV positive (AIDS unknown) Date

MonthDayYear
Date
CDC-Defined AIDS Date

MonthDayYear
Date

Does client have proof of HIV dx (required to complete enrollment) See list below)
File Upload

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HIV RISK FACTORS
Check All That Apply:

Other

Household members

Below only list information about individuals other than yourself.
Household Member #1

NameBirth DateRelationship
Does Household Member #1 Have income?
Household Member #2

NameBirth DateRelationship
Does Household Member #2 Have income?
Household Member #3

NameBirth DateRelationship
Does Household Member #3 Have income?
Household Member #4

NameBirth DateRelationship
Does Household Member #4 Have income?

Does Client Have Income (Paycheck-SSI-SSDI-Retirement etc.)
Client gets paid:
Client's Pay Document #1

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Client's Pay Document #2

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Client's Pay Document #3

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Client's Pay Document #4

Cancelof

Spouse's Income
Spouse Pay Document #1

Cancelof
Spouse Pay Document #2

Cancelof
Spouse Pay Document #3

Cancelof
Spouse Pay Document #4

Cancelof

Is Client Currently Taking Antiretroviral Therapy?
If No, please explain why?

Other
Estimated Date Antiretroviral Therapy Started:

MonthDayYear
Date
Name of HIV Medication(s):
Client Acknowledgment & Certification

By signing and submitting this form, I affirm that the information I have provided is accurate, complete, and truthful to the best of my knowledge. I understand that this information is essential for determining my eligibility for services under the Minority Health Consortium’s Ryan White Program.

I acknowledge that knowingly providing false or misleading information may result in delays, denial of services, or removal from the program, and could carry legal consequences. I also understand that I may be asked to submit additional documents or clarification to support the details shared in this form.

My signature indicates that I am submitting this information willingly and in good faith, and that I am committed to working in partnership with the MHC team to access the care and support I need. I appreciate the dedication of the staff and the care being taken to ensure fair and accurate assessments for all clients.
Client's Signature

Clear
Should be Empty: