Office of aids

ADAP Client Application Forms

Client Application Forms

Review the list of Acceptable Supporting Documentation (Acceptable Supporting Documentation (Spanish)) for ADAP clients. The following lists contain forms that may be applicable to each client type, please note that not every form in the list will be required for each client.

General ADAP Forms

CDPH Form #	Form	Last Revised	Client Type
CDPH 8439	ADAP Application (PDF)	August 2019	ADAP
CDPH 8439 SP	ADAP Application (Spanish) (PDF)	August 2019	ADAP
CDPH 8439 ZHS	ADAP Application (Simplified Chinese) (PDF)	August 2019	ADAP
CDPH 8439 KO	ADAP Application (Korean) (PDF)	August 2019	ADAP
CDPH 8439 TL	ADAP Application (Tagalog) (PDF)	August 2019	ADAP
CDPH 8439 VI	ADAP Application (Vietnamese) (PDF)	August 2019	ADAP
CDPH 8456	ADAP Special Power of Attorney (PDF)	March 2019	ADAP
CDPH 8456A	ADAP Revocation of Special Power of Attorney (PDF)	July 2017	ADAP
CDPH 8685	ADAP Consent Form (PDF)	January 2025	ADAP
CDPH 8685 SP	ADAP Consent Form (Spanish) (PDF)	January 2025	ADAP
CDPH 8685 ZHS	ADAP Consent Form (Simplified Chinese) (PDF)	September 2024	ADAP
CDPH 8685 KO	ADAP Consent Form (Korean) (PDF)	September 2024	ADAP
CDPH 8685 TL	ADAP Consent Form (Tagalog) (PDF)	September 2024	ADAP
CDPH 8685 VI	ADAP Consent Form (Vietnamese) (PDF)	September 2024	ADAP
CDPH 8723	ADAP/PrEP-AP Client Attestation Form (PDF)	May 2023	ADAP/PrEP-AP
CDPH 8723 SP	ADAP/PrEP-AP Client Attestation Form (Spanish) (PDF)	May 2023	ADAP/PrEP-AP
CDPH 8723 ZHS	ADAP/PrEP-AP Client Attestation Form (Simplified Chinese) (PDF)	May 2023	ADAP/PrEP-AP
CDPH 8723 KO	ADAP/PrEP-AP Client Attestation Form (Korean) (PDF)	May 2023	ADAP/PrEP-AP
CDPH 8723 TL	ADAP/PrEP-AP Client Attestation Form (Tagalog) (PDF)	May 2023	ADAP/PrEP-AP
CDPH 8723 VI	ADAP/PrEP-AP Client Attestation Form (Vietnamese) (PDF)	May 2023	ADAP/PrEP-AP
CDPH 8747	Certification of Justice-Involved Client Eligibility (PDF)	November 2020	ADAP
CDPH 9117	Enrollment Worker Phone Enrollment Attestation (PDF)	April 2022	ADAP/PrEP-AP
CDPH 8542	Grievance Form (PDF)	February 2022	ADAP/PrEP-AP
CDPH 8542 SP	Grievance Form (Spanish) (PDF)	March 2018	ADAP/PrEP-AP
CDPH 8542 ZHS	Grievance Form (Simplified Chinese) (PDF), available upon request	November 2024	ADAP/PrEP-AP
CDPH 8542 KO	Grievance Form (Korean) (PDF), available upon request	November 2024	ADAP/PrEP-AP
CDPH 8542 TL	Grievance Form (Tagalog) (PDF), available upon request	November 2024	ADAP/PrEP-AP
CDPH 8542 VI	Grievance Form (Vietnamese) (PDF), available upon request	November 2024	ADAP/PrEP-AP

Residency Documentation

CDPH Form #	Form	Last Revised	Client Type
CDPH 8727	Residency Verification Affidavit (PDF)	August 2023	ADAP/PrEP-AP
CDPH 8727 SP	Residency Verification Affidavit (Spanish) (PDF)	August 2023	ADAP/PrEP-AP
CDPH 8727 ZHS	Residency Verification Affidavit (Simplified Chinese) (PDF), available upon request	November 2023	ADAP/PrEP-AP
CDPH 8727 KO	Residency Verification Affidavit (Korean) (PDF), available upon request	November 2023	ADAP/PrEP-AP
CDPH 8727 TL	Residency Verification Affidavit (Tagalog) (PDF), available upon request	November 2023	ADAP/PrEP-AP
CDPH 8727 VI	Residency Verification Affidavit (Vietnamese) (PDF), available upon request	November 2023	ADAP/PrEP-AP

Identity Documentation

CDPH Form #	Form	Last Revised	Client Type
CDPH 8442	Provider Verification of Identity (PDF)	April 2020	ADAP/PrEP-AP

Clinical Documentation

CDPH Form #	Form	Last Revised	Client Type
CDPH 8440	ADAP Diagnosis Form (PDF)	October 2024	ADAP

Income Documentation

CDPH Form #	Form	Last Revised	Client Type
CDPH 8441	ADAP/PrEP-AP Income Verification Affidavit (PDF)	August 2022	ADAP/PrEP-AP
CDPH 8441 SP	ADAP/PrEP-AP Income Verification Affidavit (Spanish) (PDF)	August 2022	ADAP/PrEP-AP
CDPH 8441 ZHS	ADAP/PrEP-AP Income Verification Affidavit (Simplified Chinese) (PDF)	August 2022	ADAP/PrEP-AP
CDPH 8441 KO	ADAP/PrEP-AP Income Verification Affidavit (Korean) (PDF)	August 2022	ADAP/PrEP-AP
CDPH 8441 TL	ADAP/PrEP-AP Income Verification Affidavit (Tagalog) (PDF)	August 2022	ADAP/PrEP-AP
CDPH 8441 VI	ADAP/PrEP-AP Income Verification Affidavit (Vietnamese) (PDF)	August 2022	ADAP/PrEP-AP
CDPH 8726	ADAP/PrEP-AP Self-Employment Affidavit (PDF)	October 2024	ADAP/PrEP-AP
CDPH 8726 SP	ADAP/PrEP-AP Self-Employment Affidavit (Spanish) (PDF)	August 2022	ADAP/PrEP-AP
CDPH 8726 ZHS	ADAP/PrEP-AP Self-Employment Affidavit (Simplified Chinese) (PDF)	August 2024	ADAP/PrEP-AP
CDPH 8726 KO	ADAP/PrEP-AP Self-Employment Affidavit (Korean) (PDF)	August 2024	ADAP/PrEP-AP
CDPH 8726 TL	ADAP/PrEP-AP Self-Employment Affidavit (Tagalog) (PDF)	August 2024	ADAP/PrEP-AP
CDPH 8726 VI	ADAP/PrEP-AP Self-Employment Affidavit (Vietnamese) (PDF)	August 2024	ADAP/PrEP-AP

Eligibility Exception Request and Temporary Access Period Forms

CDPH Form #	Form	Last Revised	Client Type
CDPH 8729	ADAP Eligibility Exception Request (EER) (PDF)	April 2024	ADAP
CDPH 8724	ADAP Medi-Cal Eligibility Exception Request (MEER) (PDF)	April 2024	ADAP
CDPH 8728	ADAP Temporary Access Period (TAP) (PDF)	January 2022	ADAP
CDPH 8728 SP	ADAP Temporary Access Period (TAP) (Spanish) (PDF)	January 2022	ADAP
CDPH 8728 ZHS	ADAP Temporary Access Period (TAP) (Simplified Chinese) (PDF)	July 2024	ADAP
CDPH 8728 KO	ADAP Temporary Access Period (TAP) (Korean) (PDF)	July 2024	ADAP
CDPH 8728 TL	ADAP Temporary Access Period (TAP) (Tagalog) (PDF)	July 2024	ADAP
CDPH 8728 VI	ADAP Temporary Access Period (TAP) (Vietnamese) (PDF)	July 2024	ADAP

Insurance Assistance Program Forms

CDPH Form #	Form	Last Revised	Client Type
CDPH 8738	ADAP Acknowledgement of Policies and Responsibilities (PDF)	February 2022	OA-HIPP
CDPH 8737	ADAP Health Insurance Assistance – Family Plan Consent Form (PDF)	February 2024	OA-HIPP
CDPH 8722	ADAP Partial Payment Agreement (PDF)	January 2025	OA-HIPP/EB-HIPP/MPPP
CDPH 8722 SP	ADAP Partial Payment Agreement (Spanish) (PDF)	January 2025	OA-HIPP/EB-HIPP/MPPP
CDPH 8722 ZHS	ADAP Partial Payment Agreement (Simplified Chinese) (PDF), available upon request	January 2025	OA-HIPP/EB-HIPP/MPPP
CDPH 8722 KO	ADAP Partial Payment Agreement (Korean) (PDF), available upon request	January 2025	OA-HIPP/EB-HIPP/MPPP
CDPH 8722 TL	ADAP Partial Payment Agreement (Tagalog) (PDF), available upon request	January 2025	OA-HIPP/EB-HIPP/MPPP
CDPH 8722 VI	ADAP Partial Payment Agreement (Vietnamese) (PDF), available upon request	January 2025	OA-HIPP/EB-HIPP/MPPP
CDPH 8443	Medical Out-Of-Pocket (MOOP) Claim Form (PDF)	March 2022	OA-HIPP/EB-HIPP/MPPP
CDPH 8443 SP	Medical Out-Of-Pocket (MOOP) Claim Form (Spanish) (PDF)	March 2022	OA-HIPP/EB-HIPP/MPPP
CDPH 8443 ZHS	Medical Out-Of-Pocket (MOOP) Claim Form (Simplified Chinese) (PDF), available upon request	March 2022	OA-HIPP/EB-HIPP/MPPP
CDPH 8443 KO	Medical Out-Of-Pocket (MOOP) Claim Form (Korean) (PDF), available upon request	March 2022	OA-HIPP/EB-HIPP/MPPP
CDPH 8443 TL	Medical Out-Of-Pocket (MOOP) Claim Form (Tagalog) (PDF), available upon request	March 2022	OA-HIPP/EB-HIPP/MPPP
CDPH 8443 VI	Medical Out-Of-Pocket (MOOP) Claim Form (Vietnamese) (PDF), available upon request	March 2022	OA-HIPP/EB-HIPP/MPPP
N/A	OA-HIPP Client Responsibilities (PDF)	September 2024	OA-HIPP
N/A	OA-HIPP Client Responsibilities (Spanish) (PDF)	September 2024	OA-HIPP
N/A	OA-HIPP Client Responsibilities (Simplified Chinese) (PDF)	September 2024	OA-HIPP
N/A	OA-HIPP Client Responsibilities (Korean) (PDF)	September 2024	OA-HIPP
N/A	OA-HIPP Client Responsibilities (Tagalog) (PDF)	September 2024	OA-HIPP
N/A	OA-HIPP Client Responsibilities (Vietnamese) (PDF)	September 2024	OA-HIPP

Additional ADAP Forms

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

CDPH 8444 (PDF) – Client Handout Form

CDPH 8730 (PDF) - Confidential Fax Submission

CDPH 8731 (PDF) - New Enrollment Worker Training Request Form

CDPH 9114 (PDF) - PrEP-AP Pharmacy User Training Request

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