HDAP RAPID ELIGIBILITY FORM

Massachusetts HIV Drug Assistance Program (HDAP)

*Special Note regarding COVID-19, effective immediately:

For NEW clients applying to HDAP: If clients/case managers are unable to submit a complete application for new clients, CRI will accept this rapid eligibility form. Eligible clients will be approved for three months of HDAP coverage.

Please submit this form via fax to 617-502-1703 or via our secure email system by:

Please contact HDAP at 617-502-1700 with any questions and to alert HDAP staff to any urgent client cases.

 

Rapid Eligibility Form: Statement of Intent and Instructions

Community Research Initiative/HDAP has created a one-page rapid eligibility form to facilitate the rapid start of antiretrovirals for HIV positive individuals newly diagnosed or re-engaging in care who meet certain eligibility criteria. The goal of this one-page eligibility determination is to enable providers to enroll clients into HDAP simultaneously with HIV testing and treatment.

To qualify for HDAP rapid eligibility, individuals must be HIV positive, not currently active in HDAP, and inject drugs and/or have had an HIV diagnosis in the last three months.

Approval for rapid eligibility through this form does not fully enroll the client into HDAP, but provides immediate, temporary coverage until the client submits a completed full application (or long form). The full application (long form) must be completed within 30 days of eligibility approval to maintain HDAP enrollment and coverage of the client’s medication/s for the full six-month HDAP certification period.

 

Instructions:

This form must be completed by the client’s health care provider and/or case manager. Please complete all sections clearly and as completely as possible. It is very important that both the client and provider signatures are completed in order for HDAP to process this form.

Please submit all forms via fax to 617-502-1703. Then call 617-502-1700 and ask for our designated rapid-eligibility specialist to alert them to the urgent need.