FL RW Portal

Are you HIV positive?

Yes No Unknown

When were you first diagnosed with HIV?

First Name*

Middle Name

Last Name *

Date of Birth *

Gender*

Ethnicity

Hispanic Not Hispanic

Languages Spoken *

Race *

Are you pregnant? *

Are you a veteran?

Yes No

Are you receiving veteran's benefit's?

Yes No

Do you have a housing need?

Yes No

Do you rent?

Yes No
Monthly Rent ($)

Do you own a house?

Yes No
Monthly Payments ($)

Mailing Address*

City*

State*

Zip Code*

County*

Mailing address same as personal address

Mailing Address

City

State

Zip Code

Mail County Name

Home Telephone

Work Telephone

Other Contact

Email Address

How many adults live with you? *

How many children live with you? (under 18 years) *

Check how you prefer staff to contact you: *

Home Phone

Work Phone

Other Contact Phone

Mail

Other

Specify Other

Do you have an existing health insurance policy?

Yes No

If Yes, provide name of insurance company

If No, does your employer offer health insurance as benefit?

Yes No

If No, Provide proof from employer showing insurance is not available

Are you taking a prescription drug(s)?

Yes No

If Yes, please list

Screening for other programs
Please check if you are participating in one of the following programs, and bring the award letter, eligibility letter, or card as proof

Medicaid

Medicare

Project AIDS Care (PAC)

Supplemental Nutrition Assistance Program (SNAP)

Women, Infants, and Children (WIC)

Temporary assistance for needy families

Specify Other

If you have a case manager please provide his or her name

Household monthly income before taxes and deductions (Gross Income)
Household income means gross income from all sources received by the applicant and applicant's spouse (if married)

Name	Relationship	Monthly Work Income	Monthly Social Security	Monthly SSI Retirement Income	Unemployment, Child Suppport, Public Assistance, other	Monthly Totals	If No income
Houshold Name 1	Relationship 1	$ Monthly Work Income 1	$ Monthly Social Security 1	$ Monthly Retirement Income 1	$ Child Support Income 1	$ Monthly Total 1	No Income 1
Houshold Name 2	Relationship 2	$ Monthly Work Income 2	$ Monthly Social Security 2	$ Monthly Retirement Income 2	$ Child Support Income 2	$ Monthly Total 2	No Income 2
Houshold Name 3	Relationship 3	$ Monthly Work Income 3	$ Monthly Social Security 3	$ Monthly Retirement Income 3	$ Child Support Income 3	$ Monthly Total 3	No Income 3
Houshold Name 4	Relationship 4	$ Monthly Work Income 4	$ Monthly Social Security 4	$ Monthly Retirement Income 4	$ Child Support Income 4	$ Monthly Total 4	No Income 4
Houshold Name 5	Relationship 5	$ Monthly Work Income 5	$ Monthly Social Security 5	$ Monthly Retirement Income 5	$ Child Support Income 5	$ Monthly Total 5	No Income 5

Do you have a checking account?

Yes No

If Yes, what is your current balance?

Do you have a savings account?

Yes No

If Yes, what is your current balance?

Are you self employed?

Yes No

If Yes, what type of business?

Employer Name

Business Street Address*

City*

State*

Zip Code*

I understand that I am responsible for giving truthful and correct information on this application to the best of my knowledge. Failure to be truthful may prevent or delay a determination of eligibility to receive services.

I understand if I knowingly give information that is not true or withhold information and receive services that I am not eligible to receive, I may be lawfully punished and have to reimburse the Department of Health for services.

I understand the information I provide may be verified that may include computer matching, and the information I give about my income may be checked.

I understand that the information will be kept confidential in accordance with Florida and Federal law.

I understand not all services I am eligible to receive may be available, accessible, or funded; and I may not meet specific program qualifications for some programs.

I understand that at any time during the application process, I can be denied eligibility if my actions are uncooperative, disruptive of office procedures, threatening, or hostile toward staff.

I understand that the Department of Health eligiblity staff cannot discriminate because of race, color, sex, age, disability, religion, nationality, or political beliefs.

I understand I have the right to ask for a fair hearing if I think the decision of my case was unfair or incorrect.

System Support

Eligibility Application Form