Additional information

DHS-3539-ENG 11-25 (2.3.1)

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?

Are you homeless?

Yes

RESIDENTIAL STREET ADDRESS

APT. NO.

CITY

STATE

ZIP CODE

Can we send you mail at your residential address?

Yes

We require a mailing address to communicate with you. Your mailing address can be a P.O Box. You can also talk with your provider if you have one about receiving mail on your behalf at your agency.

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 TRS: 711

ATTENTION: If you speak English, free language assistance services are available to you free of charge and without unnecessary delay. Additionally, appropriate auxiliary aids and services to provide information in accessible formats are available free of charge and in a timely manner. Please call the number above or speak to your provider. _English

Image of Cantonese (Traditional Chinese) language

Á, DÉ YAWÁ PO! Dakhód'iyaye héčiŋhaŋ, iyápi-wóokiye išíčhona yaŋké. Ka nakúŋ wanáȟ'uŋpi-wóokiye išíčhona yaŋké. Héčhed wónaȟ'uŋ kiŋ iyóhiphiča dó. Wóokiye kiŋ dená išíčhona ičúphiča naháŋ yuthéhaŋšniyaŋ ičúphiča dó. Wičhóiye kiŋ dená iwáŋkab, wóiyawa waŋ yaŋké kiŋ mas'ákiphapi na wóokiye-wičháša kičhí wóhdaka po. _Dakota

PAUNAWA: Kung nagsasalita ka ng Filipino, ang mga libreng serbisyo ng tulong sa wika ay magagamit sa iyo nang walang bayad at walang hindi kinakailangang pagkaantala. may mga angkop na pantulong na kagamitan at serbisyo upang maibigay ang impormasyon sa naaangkop na anyo, nang libre at sa tamang oras. Mangyaring tawagan ang numero sa itaas o makipag-usap sa iyong provider. _{Filipino (Tagalog)}

ATTENTION: Si vous parlez français, des services d'assistance linguistique gratuits sont à votre disposition, sans frais et sans délai. En outre, des aides et services auxiliaires appropriés pouvant fournir des informations dans des formats accessibles sont disponibles gratuitement et rapidement. Veuillez appeler le numéro ci-dessus ou contacter votre fournisseur. _French

CEEB TOOM: Yog koj hais lus Hmoob, muaj kev pab txhais lus dawb rau koj siv. Koj tsis tas them nqi thiab yuav tsis qeeb. Kuj muaj cuab yeej thiab kev pab los pab koj nyeem cov ntaub ntawv kom yooj yim nkag siab. Koj hu tau rau tus xov tooj saum toj no lossis nrog koj tus kws kho mob tham. _Hmong

BALDARÎ: Heke hûn bi Kurdîya Kurmancî diaxivin, xizmetên alîkarîya ziman bêpere û bêyî derengmayîneke nehewce ji we re peyda dibin. Her wiha, hevkariyên guncaw û karûbarên alîkar bêpere û di heman demê de ji bo dabînkirina agahdariya guncaw hene. Ji kerema xwe bi jimareya jorîn re telefon bikin an jî bi dabînkerê xwe re biaxivin. _{Kurdish Kurmanji}

Á, LÉ YAWÁ PO! Lakȟól'iyaye héči, iyápi-wóokiye išíčhola yaŋké. Naháŋ nakúŋ wanáȟ'uŋpi-wóokiye išíčhola yaŋké. Héčhel wónaȟ'uŋ kiŋ iyóhiphiča yeló. Wóokiye kiŋ lená išíčhola ičúphiča naháŋ yutȟéhaŋšniyaŋ ičúphiča yeló. Wičhóiye kiŋ lená iwáŋkab, wóiyawa waŋ yaŋké kiŋ mas'ákipȟapi na wóokiye-wičháša kičhí wóglaka po. _Lakota

Image of Mandarin (Simplified Chinese) language

PALɛ Rɔ PINY: Mi ruaci kɛ thok Nuärä, luäk mi lɔr kɛ kuic thuok kɛnɛ lät tin jiëkɛ tëë thin baaŋ a thiɛl mi yuɔr kɛ piny kä thiɛlɛ mi gaal jɛ. Min dëë nyɔk kɛ mat thin, ɛ luäk mi dɔdiɛn kɛnɛ lät tin kɔkiɛn tin nööŋ kɛ läri kɛ duɔp min jiëkɛ kɛɛ tëë kɛ thin baaŋ thilɛ mi yuɔrkɛ piny kɛ kuicdiɛn kɛ guath mi gɔa. Mi nhɔk i jɛ yɔtni nämbär ɛmɔ tëë nhial ɔ ikä kiɛ ruacni kɛ ram min luäkdu. _Nuer

MAH BIZ'SIN'DAN: Keesh'pin, keen Ojibwe'mo, kaa'ween ina'gin'de wiiji'kaa'kii'ki'do miina'waa ke'nebe-naa'ta'maw chi'nis'too'ta'man noon'goom. Da'kon'an, wee'chi'ma'zinaa'beke'webene'kan'an ozhe'che'kan miina'waa kinah ozhee'bee'geh ma'zenah'egan'an kaa'ween ina'gin'de miina'waa da'daa'ta'be'bee'an. Da'gah'na'sa ka'noozh aseh'ge'beh'egan ish'peh'meng ge'maa kee'kidoon wii'doo'kaa'geh. _Ojibwe

HUBADHAA: Yoo Afaan Oromoo dubbattu ta'e, tajaajila gargaarsa turjumaana afaanii biliisaan akkasumas turtii barbaachisaa hin taane hambisu danda'u isiniif dhihaatee jira. Dabalataanis, odeeffannoo haala salphaan argamuu danda'an dhiyeessuuf gargaarsa fi tajaajiloota deeggarsaa qama midhamtootaaf mijatoo ta'an, kaffaltii tokko malee fi yeroo isaa eeggatee kennamu dhihaatee jira. Odeeffanno dabalataaf lakkoofsa armaan oliitti fayyadamuun namoota gargaarsa kana isiniif kennan qunnamaa. _Oromo

ATENÇÃO: Se fala português, tem à sua disposição serviços de assistência linguística gratuitos e sem demoras desnecessárias. Além disso, estão disponíveis, gratuitamente e numa forma atempada, ajudas e serviços auxiliares adequados para fornecer informações em formatos acessíveis. Por favor, contacte o número acima ou fale com o seu prestador de serviços. _Portuguese

ВНИМАНИЕ: Если вы разговариваете на русском языке, воспользуйтесь услугами языковой поддержки бесплатно и без лишних проволочек. Также бесплатно и незамедлительно предоставляются соответствующие вспомогательные средства и услуги по обеспечению информацией в доступных форматах. Позвоните по указанному выше номеру или обратитесь к своему поставщику услуг. _Russian

PAŽNJA: Ako govorite srpski, besplatne usluge jezičke pomoći su vam dostupne besplatno i bez nepotrebnog odlaganja. Pored toga, odgovarajuća pomoćna sredstva i usluge za pružanje informacija u pristupačnim formatima dostupne su besplatno i blagovremeno. Molimo vas da pozovete gore navedeni broj ili razgovarate sa vašim pružateljem usluga. _Serbian

FIIRO GAAR AH: Haddii aad ku hadasho Soomaali, waxaa si bilaash ah kuugu diyaar ah adeegyada caawinada luuqadeed oo aan lahayn daahitaan aan munaasib ahayn. Intaas waxaa dheer, waxaa la heli karaa adeegyada iyo kaabitaanka naafada ee haboon si macluumaadka loogu bixiyo qaabab la adeegsan karo oo bilaash ah laguna bixinayo waqqigeeda. Fadlan wac lambarka kore ama la hadal adeegbixiyahaaga. _Somali

ATENCIÓN: si habla español, tiene a su disposición los servicios gratuitos de traducción sin costo alguno y sin demoras innecesarias. Además, se encuentran disponibles de forma gratuita y oportuna ayuda y servicios auxiliares adecuados con el fin de brindarle información en formatos accesibles. Llame al número indicado anteriormente o hable con su proveedor. _Spanish

ZINGATIO: Ikiwa unazungumza Kiswahili, huduma za msaada wa lugha zinapatikana kwa ajili yako bila malipo na bila ucheleweshaji usio wa lazima. Aidha, vifaa saidizi vya mawasiliano na huduma kwa walemavu ili kutoa habari katika miundo inayofikika zinapatikana bila malipo na kwa wakati. Tafadhali piga simu kwa namba ya hapo juu au zungumza na mtoa huduma wako. _Swahili

УВАГА: Якщо ви розмовляєте українською мовою, ви можете скористатися послугами мовної підтримки безкоштовно та без зайвих зволікань. Ви також можете безкоштовно та оперативно отримати відповідні допоміжні засоби та послуги з надання інформації у доступному форматі. Зателефонуйте за вказаним вище номером або поговоріть зі своїм постачальником послуг. _Ukrainian

LƯU Ý: Nếu bạn nói tiếng Việt, bạn có thể được hỗ trợ ngôn ngữ miễn phí mà không phải chờ đợi lâu. Ngoài ra, các thiết bị hỗ trợ và dịch vụ phù hợp để cung cấp thông tin ở định dạng dễ tiếp cận cũng có sẵn miễn phí và kịp thời. Vui lòng gọi số điện thoại phía trên hoặc trao đổi với nhân viên y tế của bạn. _Vietnamese

ÌKÉDE PÀTÀKÌ: Tí o bá leè sọ èdè Yorùbá, àwọn ètò ìrànlówọ́ èdè wà fún ọ ní ọ̀fẹ́ tí kò sì ní ìdènà nínú. Ní àfikún, àwọn ìlànà isẹ́ àti ohun èlò ìrànlówọ́ tó pé ye wá ní ẹ̀kúnrẹ́rẹ́ láti pèsè àlàyé èyíkéyìí tí o bá nílò ní ọ̀fẹ́ àti ní òrèkóòrè. Jọ̀wọ́, pe ẹ̀rọ Ìbánisọ̀rọ̀ tó wà lókè tàbí kí o bá aṣojú rẹ sọ̀rọ̀. _Yoruba

LB (7-25)

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