Eligibility Form Preferred Name Last Name Pronouns She/Her He/Him They/Them Other Email Telephone Do you have an occupation? Yes No What is your total household income Do you have access to health insurance Yes No Do you receive any government assistance for insurance or health-related issues? (e.g., Medicaid, ADAP, etc.) If so, what? Please check the box if any of the following apply to you: Taking HRT for Gender-affirming care Taking/need PrEP Diagnosed with HIV If you have been diagnosed with HIV, have you ever been a part of the Ryan White Program or ADAP? N/A ADAP ADAP Premium Do you have any additional information to help us determine your eligibility for this insurance program? Send
