DIRECT EMERENCY FINANCIAL ASSISTANCE DEFA PROGRAM - PDF document

1 PHMC DIRECT EMERENCY FINANCIAL ASSISTA
PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 1 APPLICATION COVER PAGE Place a √ next to the application pages that are enclosed with this submission. ___ Page 2 , Applicant Demographic & Personal Data ___ Page 7 Financial Request Form ___ Page 3 , Description of Applic ant’s Residence ___ Page 8 , Intent to Rent Letter ___ Page 4, Household Members ___ Page 9 , Statement of Back Rent ___ Pages 5 , Financial Counseling Form ___ Page 1 0 , Consent f or Service Form ___ Page 6 , Certification of Medical Necessity Agency: ___________________________________________________________________ Address: ______________________________________________________________ _____ Street City State Zip Code CM/SW: ______________________________________ Phone: ______________________ Print Name Fax: ________________________ Email: ____________________________________ I attest that all of the informatio n in this application is true and accurate and that all appropriate documentation and information have been verified. (Signature) Date Submitted to PHMC: _________________________ [ ] Regular Mail [ ] Express Mail [ ] Personal Delivery PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 2 APPLICANT DEMOGRAPHIC & PERSONAL DATA DATE OF INTAKE: ________________ COUNTY OF RESIDENCE: _______________

2 __________________ _________ APPLICA
__________________ _________ APPLICANT’S NAME: ______________________________________ ____ SSN: ________________________ __ _ GENDER: [ ] M [ ] F [ ] T DOB: __________________ AGE: [ ] UNDER 17 [ ] 18 - 30 [ ] 31 - 50 [ ] OVER 50 ADDRESS: ______________________________________________________________________________ _________ STREET/APT #/CITY/STATE/ZIP CO DE PROVIDE ALTERNATE ADDRESS IF APPLICANT CANNOT RECEIVE MAIL AT ADDRESS ABOVE. ADDRESS: ______________________________________________________________________________ _________ STREET/APT #/CITY/STATE/ZIP CODE PHONE # __________________ OTHER PHONE CONTACT & RELATIONSHIP: __________________ _____________ MARITAL STATUS: [ ] SINGLE [ ] MARRIED [ ] DIVORCED [ ] SEPARATED [ ] WIDOWED [ ] DOMESTIC PARTNER TOTAL # OF PERSONS IN HOUSEHOLD : ___________ # OF ADULTS: ________ # OF CHI LDREN: _________ # OF MALES: _______ # OF FEMALES: _______ # OF TRANSGENDER: ______ # OF DEPENDANTS: ________ IS APPLICANT HEAD OF HOUSEHOLD? [ ] YES [ ] NO IF APPLICANT IS NOT HEAD OF HOUSEHOLD, PROVIDE HEAD OF HOUSEHOLD NAME: _________________ ___________________ ___________________ RACE : [ ] BLACK/AFRICAN AMERICAN [ ] ASIAN [ ] WHITE [ ] NATIVE HAWAIIAN/PACIFIC ISLANDER [ ] WHITE & NATIVE AMERICAN/ALASKAN [ ] NATIVE AMERICAN/ALASKAN [ ] ASIAN & WHITE [ ] BLACK/AFRICAN AMERICAN & WHITE [ ] AFRI CAN AMERICAN & NATIVE ALASKAN/ALASKAN [ ] OTHER MULTI - RACIAL ETHNICITY : [ ] HISPANIC/LATINO [ ] NON - HISPANIC/LATINO PRIMARY INSURANCE : [ ] PRIVATE [ ] MEDICARE [ ] MEDICAID [ ] OTHER PUBLIC [ ] NO INSURANCE [ ] OTHER [ ] UNKNOWN _____________________ ____________________________________________________________________________ PRIMARY HIV/AIDS MEDICAL CARE : [ ] PUBLI

3 CLY FUNDED CLINIC OR HEALTH DEPT. [ ]
CLY FUNDED CLINIC OR HEALTH DEPT. [ ] PRIVATE PRACTICE [ ] HOSPITAL OUTPATIENT CENTER [ ] EMERGENCY ROOM [ ] NO PRIMARY SOURCE OF CARE [ ] OTHER MEDICAL STATUS : VERIFICATION OF MET NEED WITHIN 12 MONTHS OF APPLICATION DATE [ ] HIV + [ ] AIDS VIRAL LOAD (VL) TESTING [ ] OR CD4 COUNT [ ] OR PROVISION OF ART [ ] HIV RISK FACTORS : [ ] MSM [ ] IDU [ ] HETEROSEXUAL CONTACT [ ] UNKNOWN [ ] HEMOPHILIA [ ] PERINATAL TRANSMISSION [ ] TRANSFUSION [ ] OTHER PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 3 DESCRIPTION OF APPLICANT’S RESIDENCE DO YOU RECEIVE A HOUSING SUBSIDY? YES NO SOURCE: DO YOU RECEIVE LOW INCOME HOUSING? YES NO SOURCE: CURRENT LIVI NG ARRANGEMENTS ( PLEASE CHECK ONE FROM EACH LINE ): PERMANENTLY HOUSED NON - PERMANENTLY HOUSED SHARE EXPENSES NO EXPENSES RENT OWN SINGLE ROOM OCCUPANCY GROUP HOME SHELTER EFFICIENC Y APARTMENT HOUSE NUMBER OF BEDROOMS: 1 2 3 4 5 6 HOW LONG HAVE YOU LIVED THERE? _______ PRIOR TO YOUR CURRENT HOUSING SITUATION, WHICH BEST DESCRIBES YOUR PRIOR LIVING SITUATION? DATE ____/____/_____ (PLEASE CH ECK ONLY ONE BOX) HOMELESS (FROM THE STREET) LIVING WITH RELATIVES HOMELESS (@ AN EMERGENCY SHELTER) LIVING WITH FRIENDS CHRONICALLY HOMELESS (2 YEARS OR MORE) VETERAN TRANSITIONAL HOUSING PSYCHIATRIC FACILITY/HOSPITAL RECENTLY INCARCERATED SUBSTANCE/TREATME

4 NT FACILITY OWN HOUSE
NT FACILITY OWN HOUSE RENTING AN APARTMENT RENTING HOUSE SINGLE ROOM OCCUPANCY DOMESTIC VIOLENCE SITUATION EFFICIENCY GROUP HOME/FOSTER CARE PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 4 HOUSEHOLD MEMBERS COPY THE PAGE FOR ADDITIONAL HOUSEHOLD MEMBERS. NAME: __________________________________________ _____ ____ ____ GENDER: [ ] M [ ] F [ ] T BIRTHDATE : __________________ AGE: [ ] UNDER 17 [ ] 18 - 30 [ ] 31 - 50 [ ] OVER 50 RACE : [ ] BLACK/AFRICAN AMERICAN [ ] ASIAN [ ] WHITE [ ] ASIAN & WHITE [ ] NATIVE HAWAIIAN/PACIFIC ISLANDER [ ] WH ITE & NATIVE AMERICAN/ALASKAN [ ] NATIVE AMERICAN/ALASKAN [ ] BLACK/AFRICAN AMERICAN & WHITE [ ] AFRICAN AMERICAN & NATIVE ALASKAN/ALASKAN [ ] OTHER MULTI - RACIAL ETHNICITY : [ ] HISPANIC/LATINO [ ] NON - HISPANIC/LATINO NAME: _______ ________________________________________ ________ GENDER: [ ] M [ ] F [ ] T BIRTHDATE: __________________ AGE: [ ] UNDER 17 [ ] 18 - 30 [ ] 31 - 50 [ ] OVER 50 RACE : [ ] BLACK/AFRICAN AMERICAN [ ] ASIAN [ ] WHITE [ ] ASIAN & WHITE [ ] NATIVE HAWAIIAN/PACIFIC ISLANDER [ ] WHITE & NATIVE AMERICAN/ALASKAN [ ] NATIVE AMERICAN/ALASKAN [ ] BLACK/AFRICAN AMERICAN & WHITE [ ] AFRICAN AMERICAN & NATIVE ALASKAN/ALASKAN [ ] OTHER MULTI - RACIAL ETHNICITY : [ ] HISPANIC/LAT INO [ ] NON - HISPANIC/LATINO NAME: __________

5 _____________________________________ __
_____________________________________ ________ GENDER: [ ] M [ ] F [ ] T BIRTHDATE: __________________ AGE: [ ] UNDER 17 [ ] 18 - 30 [ ] 31 - 50 [ ] OVER 50 RACE : [ ] BLACK/AFRICAN AMERICAN [ ] ASIAN [ ] WHITE [ ] ASIAN & WHITE [ ] NATIVE HAWAIIAN/PACIFIC ISLANDER [ ] WHITE & NATIVE AMERICAN/ALASKAN [ ] NATIVE AMERICAN/ALASKAN [ ] BLACK/AFRICAN AMERICAN & WHITE [ ] AFRICAN AMERICAN & NATIVE ALASKAN/ALASKAN [ ] OTH ER MULTI - RACIAL ETHNICITY : [ ] HISPANIC/LATINO [ ] NON - HISPANIC/LATINO PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 5 FINANCIAL COUNSELING FORM Applicant Name : _______________________ Case Manag er Name: _________________________ Current Address: ____________________ _____________________________ _________________ City/Town Zip Code Proposed Address: ____________________ _ ___________________ _________________________ City/Town Zip Code Monthly Income: _________ Housing Amount: ________ __ (Anticipated) Average Utilities: ________ Rent/Utilities to income ______% 1. Please describe the circumstances leading to the current crisis. Use an additional page if necessary. I attest that I have received counseling with the goal of maintaining myself without need for further DEFA assistance. Applicant Date I attest that the applicant has received counseling pursuant to this application and that such counseling is reviewed at a minimum of once every six months. Case Manager Dat e PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ _

6 __ ___ ___ ___ ___ DEFA Program PHMC D
__ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 6 CERTIFICATION OF MEDICAL NECESSITY (The primary physician, clinical nurse specialist, nurse practitioner or physician assistant completes the form.) Patient: ____________________________________________ _____________________________ Medical Professional’s Name & Addre ss : _____________________________________________ __ ______________________ ______ ________ ________________________________ __________ Medical Professional’s Telephone#______________________________________ I certify that ___________________________________ _____________is currently facing complications in HIV related health status and/or the care and treatment of HIV/AIDS disease. Obtaining emergency financial assistance is medically necessary for the applicant t o gain or maintain access and compliance with HIV related medical care and treatment. I also certify the following information: Determined HIV Seropositive ____________________ (date of diagnosis) Patient had a CD4 or Viral Load test in the last 12 months . ____ Yes ____ No Patient is on H IV medications. ____ Yes ____ No __________________________________________ ____________________ Medical Professional’s Signature Date ( valid for 90 days) PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 7 FINANCIAL REQUEST FORM GRANT REQUEST: PAYMENT DELIVERY: [ ] BACK RENT [ ] 1ST & LAST MONTH RENTS [ ] MAIL CHECK [ ] 1 ST MONTH & SECURITY DEPOSIT [ ] PICK UP CHECK [ ] MORTGAGE [ ] HEATING OIL [ ] ESSENTIAL UTILITIES

7 [ ] PHARMACEUTICAL
[ ] PHARMACEUTICAL VENDOR COMPANY: CONTACT: ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO: FAX NO: ACCOUNT NUMBER: AMOUNT REQUESTED $ GRANT REQUEST: PAYMENT DELIV ERY: [ ] BACK RENT [ ] 1ST & LAST MONTH RENTS [ ] MAIL CHECK [ ] 1 ST MONTH & SECURITY DEPOSIT [ ] PICK UP CHECK [ ] MORTGAGE [ ] HEATING OIL [ ] ESSENTIAL UTILITIES [ ] PHARMACEUTICAL VENDOR COMPANY: CONTACT: ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO: FAX NO: ACCOUNT NUMBER: AMOUNT REQUESTED $ TOTAL GRANT AMOUNT REQUESTED : $ PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 8 PHMC INTENT TO RENT LETTER The Tenant, _______________________________ ____________________________will rent property located at________________________________________________ _____________. Landlord, ______________________________________________________ ____ and Tenant have entered an agreement prior to the lease for 1 st month's rent $ ____________________ , last month’s rent $____________________ , or securit y deposit $____________________ , for a total of $_________________, in order for the Tenant to occup y the above property. Initial One Statement Below: _____ Note: Landlord or Tenant must return security deposit to Public Health Management Corporation upon termination of lease. _____ Note: The Tenant is responsible for security deposit. Sign atures: ________________________________ ___________________________________ Landlord

8 – Print Name Te
– Print Name Tenant – Print Name ________________________________ ___________________________________ Landlord – Signature Tenant – Signature ___________________ ________________ Date Date Landlord’s address: ______________________________________________________________________________ Landlord’s phone number: ( ) __________________________ __ PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (DEFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 9 PHMC STATEMENT OF BACK RENT The Tenant, _____________________________________________________________ is currently behind in rent. Landlord, _____________________________________________, and Tenant have entered into a repayment agreement , by which both parties have agreed to bring the Tenant’s rental account current. The amount of the Tenant’s arrears is $ ____________________ for the month(s) of _____________ ______________________________________________________________ (year). Note : The Tenant is responsible for all late fees and service charges. ___________________________________ ____________________________________ Landlord – Print Name Tenant – Print Name ___________________________________ ______ _______________________________ Landlord – Signature Tenant – Signature ___________________ ____________________ Date Date Landlord’s address: __________________________________________________________________________ ____ Landlord’s phone number: ( ) ____________________________ PHMC DIRECT EMERENCY FINANCIAL ASSISTANCE (D

9 EFA) PROGRAM Application File Number
EFA) PROGRAM Application File Number : ___ ___ ___ ___ __ _ ___ ___ ___ ___ ___ DEFA Program PHMC DEFA Application March 2013 Page | 10 CONSENT FOR SERVICE FORM I, ________________________________ (print full name) am applying for Direct Emergency Financial Assistance. I agree to cooperate with referring and administering agency staff in providing additional information as required to complete the application. I have answered the questions on the application form and have submitted all necessary documentation to support my request for assistance. I consent to the agency’s assessment of my financial need. The assessment is to identify possible resources to meet my needs in an ongoing way. Applications are considered by the requirements outlined in the DEFA Program Guide. The Provider agencies may select a C ommittee, which consists of a minimum of three members who are conflict free to review all applications. Agency staff will provide any assistance needed by applicants in the application and appeal processes. CONFIDENTIALITY STATEMENT Assigning an "indi vidual identification number" to the application and maintaining records in a locked file assures the applicant's privacy. Records are maintained for seven years and then destroyed. Application forms are open to inspection only to those professionals who a re licensed or fund the activities of the DEFA program and for internal contract review, when necessary. Neither this agency nor its representatives will reveal the applicant's personal health or medical information to anyone without a release form in acco rdance with Pennsylvania Act 59 . The Provider agency reserves the right to deny or limit service based on its professional judgment of needs. A negative decision will be discussed with you. You have the right to appeal this decision. The agency will make every effort to provide satisfactory servic

10 e in every respect; however, if you shou
e in every respect; however, if you should experience an unusual difficulty, please contact the agency's Executive Director who will act promptly to assist you. In regards to any of the above items, you may reque st a detailed copy of the agency's relevant appeals process. You may also request to appeal the decision by contacting the Health Information Hotline at 1 - 800 - 985 - 2437 or 215 - 985 - 2437 . This information has been disclosed to you from records protected by P ennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or if authorization by the confidentiality of H IV - related information Act, 35 P.S. Section 7601. Et Seq . A general authorization for the release of medical or other information is not sufficient for this purpose. APPLICANT STATEMENT I have been offered, read and signed a copy of the agency's release form in accordance with Pennsylvania Act 148 which will allow the agency to contact other organizations, companies or agencies that will allow this agency to collect information that may be required to complete my application. I have been offered a copy of this Consent form which I accepted/ rejected . (Circle one) I have read this application in full. All the information given to the agency concerning this emergency grant is correct to t he best of my knowledge. If any informat ion provided is found purposely inaccurate or false, I am responsible for paying back the money given to me, and I will not be able to re - apply for emergency funding. ____________________________________________________________________________ Applicant ’s Signature Date ____________________________________________________________________________ Cas e Manager’s Signature D