Forms and Applications

On this page:

• Apply for CAREAssist
• Client Eligibilty Review (CER)
  
• Medication Therapy Management
  

Apply for CAREAssist

BREAKING NEWS:   CAREAssist has expanded their Federal Poverty Level limit to 550% effective October 1, 2021.

CAREAssist is for HIV positive individuals who need financial help to pay for their HIV medications. CAREAssist can pay for medications and medical services for those who qualify.

Application materials are listed below. Please take a minute to review the Instructions. Most of the questions are easy to understand, but some may need an explanation. You may also have to gather information from your personal records to complete the application.

If you need help with any part of the application, please contact CAREAssist.

English	en español
Application	Solicitud confidencial de CAREAssist
Instructions	Instrucciones
HIV/AIDS Confirmation Form Must be signed by a health care provider	Formulario de Confirmación VIH/Sida A ser llenada por el proveedor médico
CAREAssist Residency Verification PDF Word	Verificacion de residencia PDF Word
Note: The Residency Verification form is only needed when no other verification documents can be obtained.

Client Eligibility Review

A Client Eligibility Review (CER) must be completed every six months. Failure to complete and return the CER could delay or end your eligibility with the CAREAssist program.

Medication Therapy Management

In partnership with Ramsell, CAREAssist is pleased to offer Medication Therapy Management (MTM) to eligible clients who are having difficulty adhering to medication regimens.

• MTM provides phone-based support to patients through direct adherence counseling with an HIV pharmacist.
• Both medical providers and Ryan White case managers can refer clients of concern to the MTM program.
• For more information, please call the program at 971-673-0144
  
• MTM Direct Referral Form