Additional information

DHS-3539-ENG 1-25 (2.2.0)

Ryan White Program Application

MN Ryan White Forms (Program HH)

New descriptions for form options

New Client

I am not currently enrolled AND have never been enrolled in MN Ryan White Programs (Program HH) and need to enroll.

Annual Renewal or Returning Client

I am currently enrolled in MNRWP and need to renew my eligibility. OR I have previously been enrolled in MNRWP and need to re-enroll.

Information Change Form

I am currently enrolled in MN Ryan White Programs (Program HH) and need to submit changes to my personal or eligibility information.

I am attaching Documents ONLY

I have recently submitted a form and/or I have been asked by MN Ryan White Programs (Program HH) staff to submit additional eligibility verifications.

Please select from the options below to complete an application form, report a change or attach documents needed to determine eligibility for MN Ryan White Programs (Program HH):

New Client

Annual Renewal or Returning Client

Information Change Form

I am attaching Documents ONLY

If you are still unsure of which scenario to choose, please call Customer Care at 651-431-2398.

If you would rather print and complete this form, use the fillable forms that can be found on our website:
(Minnesota HIV Services (Apply to MN Ryan White Programs - Program HH)

Answer the following questions in the order they appear on your screen. This will help us appropriately collect your information regarding your eligibility.

Applicant information

Previous full legal name

FIRST NAME

MIDDLE NAME

LAST NAME

Current full legal name (as shown on your ID or Driver's License)

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

PMI NUMBER

Do you have a Social Security Number?

SOCIAL SECURITY NUMBER

OTHER NAMES USED

COUNTRY OF BIRTH

Do you need an interpreter?

PREFERRED LANGUAGE

SEX AT BIRTH

CURRENT GENDER

PRONOUNS YOU USE

MARITAL STATUS

Are you currently pregnant?

Yes

N/A

EMAIL ADDRESS

Can we email you?

Yes

PRIMARY PHONE NUMBER

Can we call you at this number?

Yes

Can we leave a message at this number?

Yes

SECONDARY PHONE NUMBER

Can we call you at this number?

Yes

Can we leave a message at this number?

Yes

COUNTY OF RESIDENCE

What is your current housing status?

Can we send you mail?

Yes

Are you homeless?

Yes

RESIDENTIAL STREET ADDRESS

APT. NO.

CITY

STATE

ZIP CODE

Is your Mailing Address different from your residential address?

Yes

MAILING ADDRESS (if you are homeless, please provide a mailing address so that we can send you mail)

APT. NO.

CITY

STATE

ZIP CODE

What is your Citizenship status? We ask for information about your citizenship status to help determine which healthcare programs you may qualify for. You may choose to answer this question or not. If you do not, it may result in our program making incorrect insurance referrals.

What type of Visa do you have?

We may need more information from you to ensure your program eligibility is not limited. Describe other citizenship status.

Have you needed help to pay for medications in the past three months?

Yes

Do you have one of the following? (if yes, select options and complete information below)

Benefits Counselor

NAME

PHONE NUMBER

ORGANIZATION

Case Manager

NAME

PHONE NUMBER

ORGANIZATION

Social Worker

NAME

PHONE NUMBER

ORGANIZATION

Is there someone else who you allow us to speak with about your eligibility and benefits?

Yes

NAME

PHONE NUMBER

RELATIONSHIP TO YOU

Proof of Residency

You must provide a copy of at least one of the following proofs of residency.

Indicate which document you are attaching to your application. It must be current and have your name and address on it.

Pay check stub

Tribal nation enrollment

Annual income award letter from a government agency or pension

Driver's license or state ID card

Document/mail with my name and address (e.g., utility bill, bank statement, other bills, etc.)

Mortgage or lease/rental agreement

Only PDF, Word, Excel, JPG, GIF, PNG, BMP or text files may be uploaded.

The file was not added as an attachment.

I am homeless and do not have proof of residency, but I attest that I am a resident of Minnesota

I need to submit this document at a later time. By selecting this, I understand that my application will not be considered complete until my proofs are submitted.

Household

Spouse

SPOUSE NAME

RELATIONSHIP TO YOU

DATE OF BIRTH

Are there additional household members?

Yes

List family members

(e.g., legal spouse, dependents 18 and younger who live with you or dependents 19-24 years old if full-time student) ADAP Policy Manual

NAME

RELATIONSHIP TO YOU

DATE OF BIRTH

Is this dependant a full time student?

Yes

HouseholdAge

Diagnosis Information/Risk Factors

DATE OF HIV+ DIAGNOSIS

Is this date estimated?

Yes

How were you exposed to HIV? (check all that apply)

Male-to-male sex

Male-to-female sex

Injection drug use

Blood recipient

Perinatal (mother to infant/fetus)

Hemophilia

Other/Unknown/Not reported/Not identified

Diagnosis Documentation

New applicants must provide proof of their positive HIV diagnosis. Documentation must contain your full legal name.

Attach one of the following options to this application and check the box that indicates which document you provided.

Supplemental testing to confirm HIV diagnosis

A completed and signed Ryan White Healthcare Provider Request (DHS-3539D)

HIV lab report that shows a detectable viral load

Note from staff at medical facility signed by prescribing nurse practitioner, physicians assistant, or doctor with your full legal name

Only PDF, Word, Excel, JPG, GIF, PNG, BMP or text files may be uploaded.

The file was not added as an attachment.

I need to submit this document at a later time. *sending in documentation separate from the application may cause delays in response times

Mail or Fax HIV Diagnosis Documentation:

ADAP at Minnesota Dept of Human Services
P.O. Box 64972
St. Paul, MN 55164-0972

Fax: 651-431-7414

Additional information

List any information you would like to add before you submit.

FormStateCd

Signature

Who is completing this form? Authorized Representatives can be a legal guardian or power of attorney, and requires documentation to be submitted. Parents signing on behalf of minors do not need to provide documentation.

Applicant/Client

Authorized Representative

Provide legal documentation (ie: signed legal guardian or power of attorney forms). Parents signing on behalf of minors do not need to provide documentation.

Only PDF, Word, Excel, JPG, GIF, PNG, BMP or text files may be uploaded.

The file was not added as an attachment.

Download and review the Ryan White Program Notice of Privacy Practices, Rights, and Responsibilities (DHS-3539E-ENG) before submitting this application:

You must click the button above to review the document.

I have reviewed the Ryan White Program Notice of Privacy Practices, Rights and Responsibilities (DHS-3539E-ENG)

I agree and give my consent to the release of my Minnesota Health Care Program health records to the following; Ryan White healthcare providers, ombudsman, health plans, insurance agencies, Minnesota Health Care Programs, my case manager(s) and their contractors/subcontractors to determine health care payments, coordinate health care services, research and audit reviews. I affirm the eligibility information provided on this form and in supporting documents is correct and complete to the best of my knowledge. I understand it is my responsibility to inform DHS of changes in the information I provided on this application. I understand that under penalty of perjury (not telling the truth), all parts of this update are true and correct statements, to the best of my knowledge.

YOUR ELECTRONIC SIGNATURE (type your full legal name)

DATE

AUTHORIZED REPRESENTATIVE'S SIGNATURE

DATE

Do you want a copy of your completed form emailed to you?

Yes

Disclaimer: We will send you a secure email with a copy of the application you submitted. Please note that secure emails do expire.

Disclaimer: You have chosen to not receive a copy of the application emailed to you even if you provided an email address as part of your application above.

EMAIL ADDRESS

If you do not want a copy of the application you are about to submit, but would like to save and/or print a copy for your records, please click on the "Print this form" button and save the application to your computer/device).

Once you submit the application you will not be able to obtain a copy of the application unless you saved, printed, or requested a copy of the application via email before you click SUBMIT.

For accessible formats of this information or assistance with additional equal access to human services, email us at DHS.info@state.mn.us, call 651-431-2414, toll-free 800-657-3761, or use your preferred relay service. _{ADA1 (3-24)}

NO ENGLISH

651-431-2414 or 800-657-3761

Attention. If you need free help interpreting this document, call the number in the box above.

wáŋ. héčiŋhaŋ niyé wačhíŋyAŋ wayúiyeska ki de wówapi sutá, ečíyA kiŋ wóiyawa ed ophíye waŋ. _Dakota

Paunawa. Kung kailangan mo ng libreng tulong sa pag-unawa sa kahulugan ng dokumentong ito, tawagan ang numero sa kahon sa itaas. _{Filipino (Tagalog)}

Attention. Si vous avez besoin d’aide gratuite pour interpréter ce document, appelez le numéro indiqué dans la case ci-dessus. _French

Lus Ceeb Toom. Yog tias koj xav tau kev pab txhais lus dawb ntawm cov ntaub ntawv no, ces hu rau tus nab npawb xov tooj nyob hauv lub npov plaub fab saum toj no. _Hmong

Baldarî. Ger ji bo wergerandina vê belgeyê hewcedariya we bi alîkariya belaş hebe, ji kerema xwe bi hejmara li qutiya jorîn re telefon bikin. _{Kurdish Kurmanji}

Hoȟpíŋ. Tóháŋ waŋží thí wíyukčaŋpi kiŋ yuhá níyuŋspe héčha čhéya, lé tkíčhuŋ kiŋ k'é náŋpa opáwiŋyaŋ. _Lakota

Pa̱lɛ rɔ piny: Mi gööri luäk lɔrä kɛ luɔ̱c kä mɛmɛ, yɔtni nämbär ɛmɔ tëë nhial guäth ɛmɛ. _Nuer

Mah Biz'sin'dan. Keesh'pin nan'deh'dam'mun chi'wee'chi'goo'yan chi'nis'too'ta'man oo'weh ooshii'be'kan. Ishi'kidoon ah'kin'das'soon ka'ooshi'bee'kadehk ish'peh'mik ka'shi ka'ka'kak. _Ojibwe

Hubachiisa: Yoo barreeffama kana hiikuuf gargaarsa bilisaa barbaaddan, lakkoofsa saanduqa armaan olii keessa jirun bilbilaa. _Oromo

Atenção. Se você precisar de ajuda gratuita para interpretar este documento, ligue para o número na caixa acima. _Portuguese

Внимание! Если Вам нужна бесплатная помощь в переводе этого документа, позвоните по телефону, указанному в рамке выше. _Russian

Pažnja. Ukoliko vam je potrebna besplatna pomoć u tumačenju ovog dokumenta, pozovite broj naveden u kvadratu iznad. _Serbian

Fiiro gaar ah. Haddii aad u baahan tahay caawimo bilaash si laguugu turjumo dukumiintigan, wac lambarka ku jira sanduuqa sare. _Somali

Atención. Si necesita ayuda gratuita para interpretar este documento, llame al número que aparece en el recuadro superior. _Spanish

Zingatia. Iwapo unahitaji msaada usio na malipo wa kutafsiri hati hii, piga simu kwa namba iliyo kwenye kisanduku hapo juu. _Swahili

Увага! Якщо Вам потрібна безкоштовна допомога в перекладі цього документа, зателефонуйте за номером, вказаним у рамці вище. _Ukrainian

Xin lưu ý: Hãy liên hệ theo số điện thoại trong ô trên nếu bạn cần bất kỳ sự hỗ trợ miễn phí nào để hiểu rõ về tài liệu này. _Vietnamese

Àkíyèsí. Tí o bá nílò ìrànlówọ́ pẹ̀lú tí tú mọ̀ àkọ̀ọ́lẹ̀ yìí, pe nọ́mbà tó wà nínú àpótí tí wà ló kè. _Yoruba

LB (7-24)

Ryan White Program Application

Applicant information

Proof of Residency

Household

Spouse

List family members

Income

Yourself

Spouse

Verification

Insurance

Type of insurance

Assessment for Insurance Premium Assistance

Diagnosis Information/Risk Factors

Diagnosis Documentation

Additional information

Signature