Get the free Pre-Exposure Prophylaxis Drug Assistance Program (PrEP DAP)

Exposure Prophylaxis Drug Assistance Program (PrEP DAP) Agreement, Release of Information & Assignment of Benefits DOH 150103 May 2017SECTION 5: Agreement, Release of Information & Assignment of Benefits

How to fill out pre-exposure prophylaxis drug assistance

How to fill out pre-exposure prophylaxis drug assistance

1. Gather all necessary information about the patient's eligibility for pre-exposure prophylaxis drug assistance program.
2. Download or obtain the application form for the program.
3. Carefully read and understand the instructions on the application form.
4. Provide personal information of the patient, such as name, date of birth, address, and contact details.
5. Provide the necessary medical information, including HIV test results and doctor's recommendation for pre-exposure prophylaxis.
6. Include information about the patient's insurance coverage, if applicable.
7. Attach any required supporting documents, such as income proof or prescription from a healthcare provider.
8. Review the completed application form for accuracy and completeness.
9. Submit the application form and all required documents through the designated method specified in the instructions.
10. Follow up with the program to ensure the application is received and processed.
11. If approved, follow the program guidelines for obtaining pre-exposure prophylaxis drugs.

Who needs pre-exposure prophylaxis drug assistance?

1. Individuals who are at high risk of acquiring HIV infection, such as those who engage in unprotected sex with HIV-positive partners or use injection drugs.
2. People who are in serodiscordant relationships, where one partner is HIV-positive and the other is not.
3. Individuals who have had a recent sexually transmitted infection (STI) or have a history of STIs.
4. Individuals who engage in risky sexual behaviors, such as having multiple sex partners or not using condoms consistently.
5. Men who have sex with men (MSM) and transgender women who have sex with men.
6. People who have been exposed to HIV through occupational or non-occupational exposure, such as healthcare workers or sexual assault survivors.
7. Individuals who are seeking additional protection against HIV infection and have been recommended pre-exposure prophylaxis by a healthcare provider.

For pdfFiller’s FAQs

Can I create an electronic signature for signing my pre-exposure prophylaxis drug assistance in Gmail?

You can easily create your eSignature with pdfFiller and then eSign your pre-exposure prophylaxis drug assistance directly from your inbox with the help of pdfFiller’s add-on for Gmail. Please note that you must register for an account in order to save your signatures and signed documents.

How can I edit pre-exposure prophylaxis drug assistance on a smartphone?

The pdfFiller mobile applications for iOS and Android are the easiest way to edit documents on the go. You may get them from the Apple Store and Google Play. More info about the applications here. Install and log in to edit pre-exposure prophylaxis drug assistance.

How do I complete pre-exposure prophylaxis drug assistance on an Android device?

On Android, use the pdfFiller mobile app to finish your pre-exposure prophylaxis drug assistance. Adding, editing, deleting text, signing, annotating, and more are all available with the app. All you need is a smartphone and internet.