PUBLIC HEALTH DIVISION
HIV Community Services Program
Intake/Eligibility Review
"Confidential  this form must be saved on a secure
network accessible only by Ryan White funded staff."
Initial intake
Social Security number:
Date completed:
-
/
/
Annual review
-
Age:
HIV positive (initial intake only)
dx date:
/
DOB:
Preferred Pro-Noun
She/Her/Her
/
/
/
County:
Legal first name
He/Him/His
Street address (if homeless, complete
affidavit on page 5)
Middle initial
They/Them/Their
City
State
Other names used
Ze/Hir/Hirs
ZIP
Other
O.K. to send mail
No
Mailing address, if different
/
/
Personal information
Legal last name
Date completed:
City
Home phone number
-
O.K. to leave message
No
Yes
Cell phone number
O.K. to leave message
Message phone number
E-mail address
No
Yes
O.K. to leave message
No
Yes
O.K. to leave message
No
Yes
State
ZIP
Yes
O.K. to send mail
No
Yes
Sex at birth:
Male
Female
Gender
Male
Female
Transgender (M  F)
Transgender (F  M)
Other
Ethnicity
Hispanic/Latino1
Non-Hispanic/Latino
Race
White/Caucasian
Black/African American
Native Hawaiian/Pacific Islander3
Asian2
American Indian/Alaska Native
Other
1 If
Hispanic/Latino:
Mexican, Mexican American, Chicano/a
Puerto Rican
Cuban
2 If Asian:
Asian Indian
Chinese
Filipino
Japanese
Korean
3 If Native Hawaiian/Pacific Islander:
Native Hawaiian
Guamanian/Chomoro
Samoan
Primary language:
Let us know if you need:
An interpreter. Language I speak:
English
Spanish
A sign language interpreter
Written materials translated (what language):
English
Materials in:
Audio tape
Large print
Braille
Client name:
Page 1 of 5
Other Hispanic origin
Vietnamese
Other Asian origin
Other Pacific Islander
Other
Spanish
Other
Computer disk
Oral presentation
OHA 8395 (6/16)
Medical insurance
Health exchange
Qualified Health Plan (QHP)
Metal level (check one):
Bronze
Silver
Gold
Platinum
Medicare (mark all that apply)
Part A
Part B
Part D:
Low income subsidy
Qualified Medicare beneficiary
Oregon Health Plan (OHP) - (Medicaid)
OHP number:
Coordinated Care Organization (CCO)
OHP Open Card
Dual Eligible Managed Care Organization (MCO):
Citizen Alien Waived Emergent Medical (CAWEM)
Private
Other public
Purchased outside the exchange
Group policy (through employer or spouse/parent employer)
COBRA (end date):
/ /
VA benefits number:
For all insurance plans:
Insurance carrier:
Policy ID number:
Prescription ID number (if different):
Primary policy holder’s name:
No insurance
Comments:
Indian Health Services
Plan name:
Policy group number:
CAREAssist:
No
Yes If yes, number:
Dental insurance:
No
Yes If yes, plan information:
Medical care:
None
Publicly-funded or Health Department
Hospital outpatient
Other:
Private practice
Emergency room
Key contacts
Other emergency contact
Relationship
Primary care physician
Phone number
Phone number
-
HIV specialist
Phone number
Pharmacist
Aware of HIV status
No
Yes
Phone number
Phone number
-
Dentist
Housing family/dependent children
Do you have dependent children (including children you are paying child support for)?:
If yes, do they live with you?
No
Yes
Client name:
Page 2 of 5
No
Yes, number:
OHA 8395 (6/16)
Household family members
Names
Relationship
Age
Aware of HIV status
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Income
Documentation presented (Copies of all documentation are to be filed with this form and
retained by the provider agency.)
HIV + diagnosis—Required only
Current CAREAssist client
at intake. Check one:
Lab test (Viral load, Western Blot, etc.) sent from lab or physician
Documentation submitted from the healthcare provider who is providing medical care
Previously obtained/is in client file
Verification of identity —
Oregon driver license
Social Security card
Required only at intake. Client
Tribal ID
Citizenship/naturalization
must provide one of the following:
Oregon state ID card
Student visa
Military ID
Birth certificate
Passport
Oregon learner’s permit or
temporary license
Student ID
List other official documents1:
Verification of residency
Current CAREAssist Card or copy
Homeowner's association statement
of
the
CAREAssist
Eligibility
Report
Client must provide one of the
Military/Veteran's Affairs documents
following (Documentation must
Unexpired Oregon State driver
Oregon vehicle title or registration card
include client’s full legal name
license, Tribal ID or Oregon State ID
Any document issued by a financial
and match residential address
Utility bill (including cell phone)
institution that includes residence address,
on application.):
such as, a bank statement, loan statement,
Lease, rental, mortgage or moorage
agreement/document
student loan statement, dividend statement,
credit card bill, mortgage document, closing
Current property tax document
paperwork, a statement for a retirement
Current Oregon Voter
account, etc.;
Registration card
Approved letter from Oregon State
Letter from lease holding roommate2
Hospital, homeless shelter, transitional
Copy of public assistance/benefits
service provider or halfway house
letter /documentation (SSI, SSDI,
Letter on company letterhead from an
TANF, etc.)
employer certifying that the client lives at
Paystubs
a non-business residence address owned
Court Corrections Proof of Identity
by the business or corporation.
Eligibility category
See “Services Guidance” in program manual for additional allowed documents.
Must include the lease holder's name, address that matches the client's application, relationship to the client and lease
holder's telephone number.
Client name:
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OHA 8395 (6/16)
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2
Verification of income
Current CAREAssist client (If not, proceed with income verification below)
Person(s)
Annual gross income
Monthly gross
Type of income
receiving
(multiply monthly
income
income
income to get annual)
Work income (wages, tips,
$0.00
commissions, bonuses):
Required documentation
Self-employment income:
$0.00
Unemployment/disability
benefits:
Stocks, bonds, cash dividends,
trust, investment income,
royalties:
$0.00
Alimony/child support,
foster care payments:
$0.00
Pension or retirement income
(not Social Security):
Social Security retirement/
survivor’s benefits:
Veterans benefits:
Social Security income (SSI/SSDI):
Temporary Assistance for
Needy Families (TANF):
$0.00
2 months current,
consecutive paystubs or
earnings statements for
all jobs.
Most recent quarterly
tax returns or
Business records for 3
consecutive months prior
to verification.
Compensations stubs or
Award letter
Documentation from
financial institution showing
income received, values,
terms and conditions.
Benefit award letter or
Official document showing
amount received regularly.
Annual benefits statement
$0.00
Annual benefit statement
$0.00
$0.00
$0.00
Worker’s Compensation or
sick benefits:
Rental income:
Other:
Total:
$0.00
Benefit award letter
Annual benefit statement
Most recent payment
statement or
Benefit notice
Benefit award letter
Monthly =
$0.00
Family size:
Do you have a payee?
Client name:
$0.00
$0.00
$0.00
Annual =
$0.00
Most recent tax documents
Document:
Federal poverty level:
No
Yes, name:
Phone:
Page 4 of 5
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OHA 8395 (6/16)
No income affidavit
I declare that I and my family have no income. I (we) get food, housing and clothing in the following ways:
I understand that I must tell my HIV case manager about any changes as part of the six month eligibility review. If I lie or do not
give complete information, my eligibility for Ryan White–funded services may be denied.
/ /
Today’s date (day/month/year)
Client (or legal guardian) signature
Homeless/residency affidavit
I am currently homeless, do not have a fixed address, and/or do not have proof of address. I am living in the city of
I most often stay at the following locations:
.
.
I am a resident of Oregon and all statements regarding my housing status are true. I understand that false or misleading
information may result in my benefits ending with the Oregon Health Authority (OHA), HIV Care and Treatment Programs,
including CAREAssist
/ /
Today’s date (day/month/year)
Client (or legal guardian) signature
Additional comments
Signature and credentials:
Client name:
Date:
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OHA 8395 (6/16)