HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS (HOPWA)
CLIENT MEDICAL ELIGIBILITY FORM
CLIENT’S NAME: ______________________________ DATE: ________________________
SOCIAL SECURITY NUMBER:_______________________________________
ADDRESS: ____________________________________________________________________
Dear Doctor:
The person named above is applying for assistance through our Housing Opportunities for Persons
With AIDS (HOPWA) program. Please fill out the information on page 5 and 6, pertaining to this
client’s HIV/AIDS status andreturn the form to him/her.
Does this client have AIDS?
 Yes
No
Date of Initial AIDS Diagnosis ______________
(As Defined by the CDC)
Is client HIV+?
 Yes
Date of Most Recent HIV Test ______________
No
Is the patient able to work?
 Yes
No
Approximately how long will the patient be unable to work? _____________
The Florida Fraud Law states that a person who knowingly aids and abets another person in
obtaining aid or benefits under a state or federally funded assistance program by failing to
disclose a material fact used in making a determination as to such a person’s qualifications to
receive aid or benefits, is guilty of a punishable crime.
I hereby certify that the above-name individual is my patient and that he/she has tested HIV+ or
has AIDS as defined by the Centers for Disease Control (CDC).
_________________________________
Physician’s Name (print)
_______________________________
Signature
_________________________________
Clinic/Hospital/Healthcare Agency
_______________________________
Florida License Number
Telephone: _____________________
Fax: __________________________
-5-
Please turn page for additional information.
Form H16(6/19/2007)
AIDS without opportunistic infection
Clients CD 4 count __________ percentage ___________
CD 4 – Absolute count of less than 200
OR
CD 4 percentage of less than 14
AIDS with opportunistic infection
Indicate below which opportunistic infections the client has had. Please initial after every
opportunistic infection designated.
Infection
Candidiasis of bronchi, lungs or trachea
Candidiasis, esophageal
Cervical cancer, invasive
Coccidioidomyocis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal > 1 mo. duration
Cytomegalovirus disease (other than liver, spleen, nodes)
Cytomegalovirus retinitis (w/loss of vision)
Encephalopathy, HIV-related
Herpes simplex, chronic ulcer(s) > 1 mo. duration or bronchitis, pneumonitis
or esophagitis
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal ( > 1 mo. duration)
Kaposis’s sarcoma
Lymphoma, Burkitt’s (or equivalent term)
Lymphoma, immunoblastic (or equivalent term)
Lymphoma, primary, of brain
Mycobacterium avium complex or M. kansasii
disseminated or extrapulmonary
Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary)
Mycobacterium, other species or unidentified species,
disseminated or extrapulmonary
Pneumonia, recurrent
Progressive multifocal leukoencephalopathy
Salmonella septicemia, recurrent
Toxoplasmosis of brain
Wasting syndrome due to HIV
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Consent for Release and Exchange of Information
I, _______________________________________ hereby agree to allow City of Miami HOPWA Program to obtain
(Client’s Name)
information regarding my medical condition for the purpose of qualifying me for the Housing Opportunities for Persons
with AIDS (HOPWA) Program. Such information may include HIV status, lab results, medical records and data regarding
illnesses/opportunistic infections I have had. I understand that to be eligible for HOPWA assistance there must be medical
evidence as defined by the Centers for Disease Control that I have AIDS.
____________________________________________
(Client’s Signature)
____________________________
(Date)
-6-
Form H16(5/04/07)