× The federal government has shut down due to the failures of the President and Congress to continue government funding. Millions of Californians receiving benefits from state programs may be impacted. For now, California’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) will continue to provide services and enroll eligible families as long as funding is available. No new federal funding to California WIC will be provided until the President and Congress take action. Families should continue to use their WIC benefits and attend their WIC appointments. This information is subject to change, so please monitor the California WIC website for updates.

Please be wary of potential highly partisan political messaging while visiting federal government websites for information related to the federal government shutdown.

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 Office of AIDS Forms

 

CDPH 8439 (PDF) - AIDS Drug Assistance Program Enrollment Application

CDPH 8439 SP (PDF) - AIDS Drug Assistance Program Enrollment Application

CDPH 8440 (PDF) - Diagnosis Form

CDPH 8441 (PDF) - Income Verification Affidavit

CDPH 8441 SP (PDF) - Income Verification Affidavit (Spanish Version)

CDPH 8442 (PDF) - Provider Verification of Identity

CDPH 8443 (PDF) - Insurance Premium Payment Assistance Medical Out-of-Pocket Claim Form

CDPH 8443 SP (PDF) - Insurance Premium Payment Assistance Medical Out-of-Pocket Claim Form (Spanish Version)

CDPH 8444 (PDF) - Important Information Regarding Your Prescription Coverage

CDPH 8444 SP (PDF) - Important Information Regarding Your Prescription Coverage

CDPH 8445 (PDF) - 2018 Comprehensive Health Care Coverage

CDPH 8445 SP (PDF) - 2018 Comprehensive Health Care Coverage (Spanish Version)

CDPH 8456 (PDF) - Special Power of Attorney

CDPH 8456 A (PDF) - Revocation of Special Power of Attorney

CDPH 8459 (PDF) - Report of Request and Decision for HIV, HEP B, and/or HEP C Testing

CDPH 8479 (PDF) - Report of Potential HIV Exposure to Law Enforcement Employees

CDPH 8485 (PDF) - Confidential Report of Court-Ordered HIV Testing

CDPH 8532 (PDF) - Request for HIV/AIDS Summary Data

CDPH 8542 (PDF) - Medication and Insurance Assistance Programs Grievance Form

CDPH 8542 SP (PDF) - Medication and Insurance Assistance Programs Grievance Form (Spanish Version)

CDPH 8685 (PDF) - AIDS Drug Assistance Program Consent Form

CDPH 8685 SP (PDF) - AIDS Drug Assistance Program Consent Form (Spanish Version)

CDPH 8689 (PDF) - Agreement by Employee/Contractor to Comply with Confidentiality Requirements

CDPH 8718 (PDF) - Local Health Jurisdiction Local Evaluation Online (LEO) Data File Request Form

CDPH 8719 (PDF) - Request for HIV Prevention Program Reports

CDPH 8720 (PDF) - Agreement by Employee/Contractor to Comply with Confidentiality Requirements

CDPH 8722 (PDF) - Partial Payment Agreement ADAP OA-HIPP Program

CDPH 8722 SP (PDF) - Partial Payment Agreement ADAP OA-HIPP Program

CDPH 8723 (PDF) - AIDS Drug Assistance Program (ADAP) Client Attestation

CDPH 8723 SP (PDF) - AIDS Drug Assistance Program (ADAP) Client Attestation (Spanish Version)

CDPH 8724 (PDF) - AIDS Drug Assistance Program (ADAP) Medi-Cal Eligibility Exception Request (MEER)

CDPH 8726 (PDF) - Self Employment Affidavit

CDPH 8726 SP (PDF) - Self Employment Affidavit (Spanish Version)

CDPH 8727 (PDF) - Residency Verification Affidavit

CDPH 8727 SP (PDF) - Residency Verification Affidavit (Spanish Version)

CDPH 8728 (PDF) - AIDS Drug Assistance Program (ADAP) Temporary Access Period (TAP) Request

CDPH 8728 SP (PDF) - AIDS Drug Assistance Program (ADAP) Temporary Access Period (TAP) Request (Spanish Version)

CDPH 8729 (PDF) - AIDS Drug Assistance Program (ADAP) Eligibility Exception Request (EER)

CDPH 8730 (PDF) - Confidential Fax Submission

CDPH 8731 (PDF) - AIDS Drug Assistance Program New Enrollment Worker Training Request

CDPH 8732 (PDF) - OA-HIPP Client Responsibilities

CDPH 8732 SP (PDF) - OA-HIPP Client Responsibilities (Spanish Version)

CDPH 8733 (PDF) - Pre-Exposure Prophylaxis Assistance Program Consent Form

CDPH 8733 SP (PDF) - Pre-Exposure Prophylaxis Assistance Program Consent Form (Spanish Version)

CDPH 8735 (PDF) - Pre-Exposure Prophylaxis Assistance (PrEP-AP) Clinical Provider Application

CDPH 8736 (PDF) - Pre-Exposure Prophylaxis Assistance (PrEP-AP) Medi-Cal Eligibility Request (MEER)

CDPH 8737 (PDF) - AIDS Drug Assistance Program Health Insurance Assistance Family Plan Consent Form

CDPH 8738 (PDF) - Acknowledgement of Policies and Responsibilities Health Insurance Premium Payment (HIPP) Program Family Plan

CDPH 8739 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Provider Referral (Uninsured)

CDPH 8740 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Temporary Access Period (TAP) Request

CDPH 8740 SP (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Temporary Access Period (TAP) Request (Spanish Version)

​CDPH 8741 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Provider Referral (Insured)

CDPH 8742 (PDF) - Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Provider Referral (Kaiser Only)

CDPH 8745 (PDF) - Request for Services-Minors

CDPH 8745 SP (PDF) - Request for Services-Minors (Spanish Version)

CDPH 8746 (PDF) - Request for Services – Confidentiality Concerns

CDPH 8746 SP (PDF) - Request for Services-Confidentiality Concerns (Spanish Version) 

CDPH 8747 (PDF) - Certification of Justice Involved Client Eligibility

CDPH 9117 (PDF) - Enrollment Worker Attestation






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