Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) 

Acceptable Supporting Documentation Checklist for Minors and Clients with Confidentiality Concerns

 ​​One item from each section is required unless otherwise indicated. 

Additional documents may be needed to determine eligibility.

*Note: Minors are individuals aged 12-17 as defined in Section 6926 of the Family Code. Clients with Confidentiality Concerns refers to a client who has insurance through a parent, guardian, spouse, or domestic partner, but cannot use this insurance to access PrEP for confidentiality reasons.

1. Proof of Identity*

*Note: Expired cards may be used if no other form of picture ID is available

**Note: If a minor is unable to furnish any of the other IDs listed, the Request for Services Form can be used to establish their identity and status as a minor. This form is required to participate in PrEP-AP, even if it is not used for identity documentation purposes.

2. Proof of California Residency (Not applicable for minors)*

• These documents must be dated within thirty days, be in the client’s name, and include the client’s residential address: 
  
• California rent or mortgage receipt
  
• Current utility bill with the service address listed in California (a cell phone bill is not acceptable)
  
• Employment paycheck stub
  
• These documents must be dated within one year, be in the client’s name, and include the client's residential address:
  
• Rental/lease agreement or annual lease renewal documentation
  
• Voter registration card
  
• W-2 or 1099 (prior tax year documents will be accepted until February 15th. After February 15th,only current tax year documents will be accepted.)
  
• Social Security/Disability Award Letter (SSI, SSDI)
  
• California Employment Development Department (EDD) award letter
  
• Filed State or Federal tax return
  
• Public housing letter on official letterhead from Housing and Urban Development (HUD) or a county agency
  
• Notice of Action from the Department of Health Care Services
  

*Note: Clients who do not have the above residency documentation may prove residency by completing and submitting the Residency Verification Affidavit form. A letter from the client’s PrEP-AP enrollment worker, on agency letterhead and containing the same information as found on the Residency Verification Affidavit form, is also acceptable.

3. HIV Negative Status

• Must be dated within six months of PrEP-Ap application
  
• Negative HIV lab results
  
• PrEP-AP Provider Referral form signed by a PrEP-AP Network Provider
  

4. Additional Forms (provide all that apply)

• Client Attestation form
• PrEP-AP Consent form
• PrEP-AP Provider Referral form (uninsured)
• Request for Services - Minor
• Request for Services - Clients with Confidentiality Concerns