Client Eligibility Checklist Agency Name:________________________________________________ ELIGIBILITY CATEGORY DOCUMENTATION PRESENTED (Copies of all documentation are to be filed with this form and retained by the provider agency) HIV+ diagnosis test (Western Blot, etc.) sent from lab or physician Lab Required only at intake. Check Previously obtained/Is in client file. one: Verification of Residency Tier 1 (one of the following) Tier 2 (two of the following if Client must provide one of the Unexpired Virginia Driver none from Tier 1 available) following: License Current Virginia Voter (Documentation must include Unexpired Tribal ID (current Registration card (current client's full legal name and match address) address) residential address on Unexpired Virginia State ID Letter from lease holding application.) Utility Bill (cell phone bills not roommate1 accepted) Copy of public assistance/ Lease, rental, or mortgage benefits document agreement Court Corrections Proof of Current property tax document Identity Homeowner's association Military/Veteran's Affairs Virginia vehicle or registration card Other: Insurance Status Health Insurance Marketplace Private Insurance Client must provide Health Assistance Program HIMAP Enrolled in ICAP Insurance Status (copy of card) VA Benefits Medicaid (if qualified not No Insurance eligible) Medicare Part A, B, D(copy of card) Enrolled in MPAP Low income subsidy Proof and Verification of Employment income (copies of Net rental income -after Income Status (Individual or 3 most recent pay stubs that expenses (complete copy of family income must be at or below show gross income and payroll most recent Federal 500% FPL) deductions) Tax Return) Self-employment (notarized Alimony/child support (copy of copy of most recent Federal benefit letter or other official Tax Return) document showing amount Veteran’s or retirement received on a regular basis) benefits (copy of benefit Government benefits and/or award letter or other official award, i.e, Social Security and document showing the unemployment benefits (copy amount received on a regular of award letters showing basis.) current dollar amount received
Client Eligibility Checklist Agency Name:________________________________________________ ELIGIBILITY CATEGORY DOCUMENTATION PRESENTED (Copies of all documentation are to be filed with this form and retained by the provider agency) HIV+ diagnosis Required only at intake. Check one: Lab test (Western Blot, etc.) sent from lab or physician Previously obtained/Is in client file. Verification of Residency Client must provide one of the following: (Documentation must include client's full legal name and match residential address on application.) Tier 1 (one of the following) Unexpired Virginia Driver License Unexpired Tribal ID (current address) Unexpired Virginia State ID Utility Bill (cell phone bills not accepted) Lease, rental, or mortgage agreement Current property tax document Tier 2 (two of the following if none from Tier 1 available) Current Virginia Voter Registration card (current address) Letter from lease holding roommate1 Copy of public assistance/ benefits document Court Corrections Proof of Identity Homeowner's association Military/Veteran's Affairs Virginia vehicle or registration card Other: Insurance Status Client must provide Health Insurance Status Health Insurance Marketplace Assistance Program HIMAP (copy of card) Medicaid (if qualified not eligible) Medicare Part A, B, D(copy of card) Enrolled in MPAP Low income subsidy Private Insurance Enrolled in ICAP VA Benefits No Insurance Proof and Verification of Status (Individual or family income must be at or below 500% FPL) Employment income (copies of 3 most recent pay stubs that show gross income and payroll deductions) Self-employment (notarized copy of most recent Federal Tax Return) Veteran’s or retirement benefits (copy of benefit award letter or other official document showing the amount received on a regular basis.) Net rental income -after expenses (complete copy of most recent Federal Income Tax Return) Alimony/child support (copy of benefit letter or other official document showing amount received on a regular basis) Government benefits and/or award, i.e, Social Security and unemployment benefits (copy of award letters showing current dollar amount received
Client-Eligibility-Checklist-GY17-1.docx