Eligibility Assessment Determination

Eligibility Assessment Determination
I am completing this form as a client or MHC Staff?

PERSONAL INFORMATION
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HIV Status:
Date of HIV Diagnosis: (Estimated)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of AIDS Diagnosis (if applicable): (Estimated)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

Legal First NameMiddle InitialLegal Last NameName Suffix (Jr., Sr., I, II, Etc.
Name you would like to be called:
Date of Birth:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is it ok to send mail to this address?
Do you have an address you would like to send mail to?
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Phone
Email
example@example.com
Identification

Please upload a copy of your State ID or Passport
Upload Format:
Take a CLEAR Picture of Your State Issued Photo ID (FRONT)
Take a CLEAR Picture of Your State Issued Photo ID (BACK)
Please upload a CLEAR Picture of Your State Issued Photo ID (FRONT and BACK)

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Client's HIV Clinic Information:

Clinic NameClinic Phone Number
Client's HIV Care Provider:

Provider NameProvider Phone NumberProvider Email address
HIV Case Manager:

Case Manager NameCase Manager Phone NumberCase Manager Email address
Pharmacy Information:

Pharmacy NamePharmacy Phone NumberCase Manager Email address

Housing Status:
Housing Type:
Are you a Veteran:
Marital Status:
Household Size:
Household Member #1: (SELF)

Name

D.O.B.

Relationship to clientIs this person working

Does this person know your status?
Household Member #2:

Name

D.O.B.

Relationship to clientIs this person working

Does this person know your status?
Household Member #3:

Name

D.O.B.

Relationship to clientIs this person working

Does this person know your status?
Household Member #4:

Name

D.O.B.

Relationship to clientIs this person working

Does this person know your status?
Household Member #5:

Name

D.O.B.

Relationship to clientIs this person working

Does this person know your status?
Household Member #6:

Name

D.O.B.

Relationship to clientIs this person working

Does this person know your status?
Type of Income:
Pay Schedule:
Monthly amount of income
Income Verification Requirements

To complete your eligibility assessment, the Virginia Department of Health (VDH) Ryan White Part B Program must receive one full month of current income documentation.

________________________________________________________

If a full month of income information is not provided, we will not be able to process your application for services and benefits.

Please submit the documents that apply to you:

If you are employed:
- Paid weekly: Submit 4 consecutive pay stubs
- Paid every two weeks (bi-weekly) Submit 2 consecutive pay stubs
- Paid on the 1st and 15th of each month: Submit 2 consecutive pay stubs
- Paid monthly: Submit 1 current pay stub
If you receive benefits or other income:
Examples include:

Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Pension benefits
Retirement income
Other award or benefit letters
Please submit all pages of the award letter, benefit statement, or other income documentation.

If you are self-employed:
Please submit the following documents from the most recent tax year:

IRS Form 1040
Schedule C
Note: Form 1040-SE alone cannot be used to verify income.

If you receive cash payments or have no income:
A case manager will contact you with instructions on the documentation needed to verify your income status.

________________________________________________________________

Important:

Applications cannot be approved until all required income documentation has been received and reviewed.
Please upload a CLEAR copy of your income: (Check Stub/ SSI/SSDI Award Letter/ Pension Statement etc. " Up to 10 documents can be uploaded at the same time"

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Insurance
Type of Insurance
Primary Policy Holder Name:
Are you currently taking HIV medication?
Why are you not currently taking HIV medication?
Date HIV Meds Started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of HIV Medication: (click all that apply)
Upload Format:
Take A clear Photo of your insurance card - FRONT
Take A clear Photo of your insurance card - BACK
Please upload a CLEAR copy of your Insurance(s) Card: (Front and Back) * PLEASE ALL INSURANCE CARDS ARE NEEDED IF APPLICABLE: (Private, Employer, Medicaid, Medicare A/B/C, Rx Cards) " Up to 10 documents can be uploaded at the same time"

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I have read and understand the Grivance Procedure.

I have read and understand the Ryan White Consent and Authorization Form.

I have read and understand the Client Rights and Responsibilities.
By signing below, I certify that I have read, understood, and agree to all statements, notices, authorizations, releases, and terms contained in this MHC Ryan White Eligibility Determination Packet. I attest that the information and supporting documentation provided are true, accurate, and complete to the best of my knowledge and understand that eligibility for Ryan White Program services is subject to verification and applicable program requirements.
Would you like a copy of these forms sent to you via email?

Would you like information about Virginia Quality of Care Consumer Advisory Committee "VACAC"?

Would you like information about our Support Groups?
Should be Empty:

Eligibility Assessment Determination

Clients Release of Information:

Service Plan Information

PERSONAL INFORMATION

Identification

Insurance

Non-Medical Case Management Service Plan / MCM Referral