DHHS 3056-ADAP Authorization Application (Nov 2012) - Epi

1. Last Name
2. Patient SS#
First Name MI N.C. Department of Health and Human Services
Division of Public Health
Purchase of Medical Care Services
1907 Mail Service Center
Raleigh, NC 27699-1907
3. Date of Birth (MM/DD/YYYY)
4. Gender 1. Male 2. Female 3. Transgender
5. Transgender Status 1. Male to Female 2. Female to Male
3. Unknown
6. Race 1. White 2. Black or African American
3. American Indian or Alaska Native 4. Asian
5. Native Hawaiian/Pacific Islander 6. Unknown
7. More Than One Race
Authorization
Request
Program 15. Authorization Number
ADAP
16. Current POMCS/ADAP Case Number – If Known
7. Ethnicity 1. Hispanic/Latino(a) 2. Non-Hispanic 3. Unknown 17. Provider of Requested Service
8. Preferred Language
(Select one of the languages below and enter the 2 letter code in the block above)
Arabic (AR) Cambodian (CA) Chinese (CH) English (EN)
French (FR) French Creole (FC) German (GE) Greek (GR)
Gujarati (GU) Hindi (HI) Hmong (HM) Hungarian (HU)
Italian (IT) Japanese (JA) Koran (KO) Laotian (LA)
Miao (MI) Mon-Khmer (MK) Other (OT) Persian (PE)
Polish (PO) Portuguese (PG) Russian (RU) Serbo-Croatian (SC)
Russian (RU) Spanish (SP) Tagalog (TA) Thai (TH)
Urdu (UR) Vietnamese (VI)
9. Incarcerated Yes No
Local County Jail (Name)
10. County of Residence County Code
Walgreen’s Pharmacy
1-800-573-3602
18. Requested Dates of Service
11. Applicant’s Address (Street or RFD) 19. Applicant’s Mailing Address (Even if same as in #11–#12)
12. City State Zip Code
Check if the address is the same
Care of, if applicable
13. Telephone Number (Include Area Code)
(Home/Cell)
(Work)
Address (Street or RFD)
14. Alternate Clinical/Professional Contact (See Instructions)
Last Name First Name MI
Phone Number
20. Diagnostic Code/Diagnosis: Primary Secondary
042
City State Zip Code
21. Pregnancy Status (Is the client currently pregnant) 1. Yes 2. No 3. Not Applicable 4. Unknown
22. First HIV/AIDS Diagnosis Date (Include Month and Year, If Known) 1. Month (MM) ____ 2. Year (YYYY) ________ 3. Unknown
23. HIV/AIDS Status 1. HIV Positive–Not AIDS 2. HIV Positive–CDC defined AIDS 3. HIV Positive–AIDS Status Unknown
24. COMPLETE FOR ALL HIV REQUESTS (DOCUMENTATION OF MOST RECENT LAB RESULTS WITHIN LAST 12 MONTHS — REQUIRED)
A. CD 4 Count
Date (MM/DD/YYYY)
25. FOR ALL HIV REQUESTS
Clinician’s Information:
Phone #:
Fax #:
N.C. License #:
27. Type or Print Clinician’s Name
B. Viral Load
Date (MM/DD/YYYY)
26. Requesting Office
Agency:
Contact:
Address:
Phone #:
Date: (MM/DD/YYYY)
28. I certify that the above named individual has prescriptions for medications listed on the current N.C. ADAP Formulary (Documentation
required — attach a copy of the prescription to this form)
Clinician’s Signature:
DHHS 3056-ADAP (11/12)
Purchase of Medical Care Services (Review 11/15)
Date:

Instructions for Authorization Request
All form fields must be completed or form will be pended.
PURPOSE
This form is used to request authorization for the ADAP program.
Processing time is reduced when this form is legible and complete. If requested, additional information must be
received within six months. Incomplete forms will be pended.
INSTRUCTIONS FOR COMPLETING CERTAIN ITEMS ON THIS FORM
9. If applicant/patient is incarcerated, check the box and indicate where applicant is currently residing.
NOTE: Patients who are incarcerated in a state or federal prison cannot participate in the ADAP
Program.
11. If applicant/patient provides an alternate mailing address (see #24) — all correspondence should be sent
to that address.
14. This alternate clinical/professional contact will be contacted by the ADAP office and/or pharmacy if the
interviewer on file (the person submitting this form) is not the best clinical/professional contact.
15. For POMCS use only. Do not complete this item.
18. Will be the authorization date unless another date is requested and specified in this box.
20. If applicable, enter secondary diagnosis code.
28. Must be signed and dated or the application will be pended.
Mail (do not Fax) this application and documentation to:
DHHS Division of Public Health, Purchase of Medical Care Services, 1907 Mail Service Center, Raleigh, NC 27699-1907
DHHS 3056-ADAP (11/12)
Purchase of Medical Care Services (Review 11/15)