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MADAP and MADAP Plus Enrollment and Continued Eligibility

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Maryland AIDS Drug Assistance Program
1223 W. Pratt Street, Baltimore, MD 21223
Phone: (410) 767-6535 or Toll Free: 1-800-205-6308
or TTY- Maryland Relay Service 1-800-735-2258
Fax Numbers: (410) 333-2608; (410) 244-8617
Email: Client.Services@maryland.gov
Website: https://health.maryland.gov/phpa/OIDPCS/Pages/MADAP.aspx
MADAP and MADAP Plus Enrollment Application
MADAP and MADAP Plus Enrollment and Continued Eligibility Process
This enrollment application must be completed, signed, and submitted for eligibility determination
with supporting documentation applicable to your circumstances. Once your eligibility is approved,
this will be your official enrollment application on file with MADAP/MADAP Plus and will only need to
be completed once.
General Instructions for Enrollment Application
Provide all information requested including required documents. If a question or request is not
applicable to you, answer “n/a”. If you have never been a MADAP client, your clinician must
complete, sign, and submit Form A-1: MADAP Medical Eligibility Form.
If you have been a MADAP client in the past, and MADAP does not have this enrollment
application on-file, you will be required to complete and submit this MADAP enrollment
application with supporting documentation.
If you were enrolled in MADAP in the past, and MADAP does have the enrollment application on
file with MADAP, you can re-enroll in MADAP by using the Annual CEV Form for eligibility
determination.
Continuing Eligibility Verification Form (CEV Form)
Federal requirements mandate that MADAP verifies your continued eligibility every six-months. The
mid-year verification occurs by the end of the 6th month of your initial MADAP enrollment with the
annual verification occurring by the end of the 12th month of your initial MADAP enrollment.
Mid-Year CEV Form - Replaces SVN Form
By mid-year of your enrollment period you will need to verify continued eligibility for MADAP. A
Mid-Year CEV Form will be sent to you. If there was a change in your residency and/or income
you must submit the Mid-Year CEV Form with proof of change(s).
See Appendix A and B on
page 9 for acceptable forms of documentation
. If there has not been a change to your
residency or income, you must indicate “no changes” on the form, sign it, and return it to
MADAP
Annual CEV Form
Annually you will need to verify eligibility by submitting a completed and signed Annual CEV
Form (to be sent to you) along with required documents.
You must inform MADAP of any changes to your health and prescription insurance coverage at the
time of change.
Do not include this page with your Enrollment Application.
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 1 of 9
MADAP and MADAP Plus Enrollment Application
MADAP ID (if applicable): 94-___________________________________
Are you a new applicant to MADAP and MADAP Plus? ☐ Yes ☐ No
Applying for (check one):
MADAP (Drug Assistance)
MADAP and MADAP Plus (Drug and Insurance Premium Payment Assistance)
If you have prescription coverage through Maryland Medicaid, you are NOT eligible for MADAP.
Section 1: Applicant Information
First Name: Middle Initial: Last Name: Suffix:
____________________________________ _______________ ___________________________________ _______________
Date of Birth (MM/DD/YYYY): Social Security Number: _____ - _____ - __________
☐ Check if you do not have a social security number.
_________/______/________ ITIN (if applicable): ____________________________
Residential Address (proof of residency is required, see Section 2):
Street: ____________________________________________________________________________________ Apt#: _______________
City: ___________________________________________ State: ____________ Zip Code: _________________
☐ I am homeless and live in Maryland. (check if applicable, complete and submit Form A-2)
Mailing Address (if different from residential address
):
Street: ___________________________________________________________________________ Apt#: ___
___________
City: _____________________________________________ State: ___________ Zip Code: ________________
Telephone numbers where MADAP staff can reach y
ou:
Home: (_______) -________ - ____________ May we leave a detailed message? ☐ Yes ☐ No
Work: (_______) -________ - ____________ May we leave a detailed message? ☐ Yes ☐ No
Cell: (_______) -________ - ____________ May we leave a detailed message? ☐ Yes ☐ No
☐ Male ☐ Female
Gender at Birth:
Gender:
☐ Male ☐ Female ☐ Transgender ( ☐ Male to Female ☐ Female to Male)
Legal Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Separated
Sexual Orientation: ☐ Straight or Heterosexual ☐ Lesbian, Gay, or Homosexual ☐ Bisexual ☐ Don’t know
☐ Choose not to disclose ☐ Something else (please specify): ____________________
Email address (for MADAP use only): _______________________________________________________________
(see page 10 for more information)
Maryland AIDS Drug Assistance Program
1223 W. Pratt Street, Baltimore, MD 21223
Phone: (410) 767-6535 or Toll Free: 1-800-205-6308
or TTY- Maryland Relay Service 1-800-735-2258
Fax Numbers: (410) 333-2608; (410) 244-8617
Email: Client.Services@maryland.gov
Website: https://health.maryland.gov/phpa/OIDPCS/Pages/MADAP.aspx
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 2 of 9
Race (Check all that apply):
☐ Black or African American
☐ White
☐ American Indian/Alaskan Native
☐ Native Hawaiian/Pacific Islander
(Check applicable ethnic group(s) below):
☐ Native Hawaiian
☐ Guamanian or Chamorro
☐ Samoan
☐ Other Pacific Islander
Section 2: Maryland Residency: Documentation must include your name and
residential address as written in Section 1. Check the type of legible documentation being attached
to verify your Maryland residency (choose one): (See appendix for more information)
Current Utility Bill - dated within the past 60 days
Rent Receipt - dated within the past 60 days
Letter from a government agency, signed and dated within the past 60 days and mailed to client’s home
Letter from a case manager on agency letterhead signed and dated within the past 60 days and mailed
to client’s home
Homeless clients can provide a letter written on agency letterhead that is signed and dated within the
last 60 days. (see appendix for more information)
Preferred Language for:
R
eading: ☐ English ☐ Spanish ☐ Other: _______
Speaking: ☐ English ☐ Spanish ☐ Other: _______
Ethnicity:
☐ Non-Hispanic
☐ Hispanic/Latino(a) (Check applicable ethnic group(s) below):
☐ Mexican, Mexican American, or Chicano(a)
☐ Puerto Rican
☐ Cuban
☐ Another H
ispanic, Latino(a), or Spanish origin
United States Citizenship Status:
☐ U.S. Citizen
☐ Asylee (attach proof)
☐ U.S. Lawful permanent resident (attach copy of card)
☐ Not a citizen or permanent resident of the U.S.
☐ Asian (Check applicable ethnic group(s) below):
☐ Asian Indian
☐ Vietnamese
☐ Korean
☐ Japanese
☐ Chinese
☐ Filipino
☐ Other Asian
Section 3: Medical Eligibility Criteria:
Are you a new applicant to MADAP and MADAP Plus?
Accepted forms of documentation dated within 60 days of submission of application:
Current notice of decision from Medicaid
Valid Maryland driver’s license or Maryland Identification Card dated within the last 12 months of submitting application
Voter registration card dated within the last 12 months of submitting application
Signed and dated lease (within 12 months) or mortgage agreement
Other accepted forms of documentation dated within 12 months of submission of application:
Only applicants who have never been a MADAP client must submit Form A-1: Medical Eligibility Form
with your Enrollment Application. The form must be completed, signed, and dated by your licensed
medical practitioner providing your HIV-related care. The practitioner must answer all questions to support
your eligibility for MADAP. This Form can either be included with your enrollment application or sent
directly to MADAP from your practitioner’s office.
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 3 of 9
Section 4: Household/Projected Gross Income: Household includes the
applicant, spouse, and all dependents on your federal tax return. If you do not file taxes, list the
people in your household whom you support financially.
Are you under the age of 19? ☐ Yes ☐ No (If yes, please complete A, if no, proceed to B)
A.Parental Information
Parent/Guardian 1:
First Name: _________________ Middle Initial: _________ Last Name: ________________ Suffix: _____________
Date of Birth (MM/DD/YYYY): _____/_____/______
Social Security Number: _____ - _____ - __________
☐ Check if you do not have a social security number.
ITIN
(if applicable
): ____________________________
Parent/Guardian 2:
First Name: _________________ Middle Initial: _________ Last Name: ________________ Suffix: _____________
Date of Birth (MM/DD/YYYY): _____/_____/______
Social Security Number: _____ - _____ - __________
☐ Check if you do not have a social security number.
ITIN (
if applicable
): ____________________________
B.Marital Information (
if applicable)
:
Spouse:
First Name: _________________ Middle Initial: _________ Last Name: ________________ Suffix: _____________
Date of Birth (MM/DD/YYYY): _____/_____/______
Social Security Number: _____ - _____ - __________
C. Natural, Adopted, Stepchildren/Siblings (attach additional sheets if necessary):
Do you have
any children/sibling
s who live within the household who are under the age of 19? ☐ Yes ☐No.
(If yes, pl
ease list each child’s name, age and date of birth)
Name Date of Birth Age
Child 1: ________________________________________________________________________________________________________________
Child 2: _______________________________________________________________________________________________________________
Child 3: _______________________________________________________________________________________________________________
Child 4: _______________________________________________________________________________________________________________
Additional m
embers of
your household
claimed
as dependents on
you
r income taxes
(
not
l
isted above
):
Name Relationship
____________________________________________
______________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
☐ Check if you do not have a social security number.
ITIN (
if applicable
): ____________________________
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 4 of 9
D. Household Income:
You are required to report all of your
household's gross income, including your income, your legal
spouse's income, and income of any dependents. Provide the requested information:
1. Recipient
☐ Self ☐ Spouse
☐ Household member
Income Source(s) How Often
☐ Weekly ☐ Biweekly ☐ Monthly
☐ Annually ☐ Semi-Monthly
☐ Seasonal: # of Months paid:
Gross Amount
(before deductions)
$
2.
Recipient
☐ Self ☐ Spouse
☐ Household member
Income Source(s) How Often
☐ Weekly ☐ Biweekly ☐ Monthly
☐ Annually ☐ Semi-Monthly
☐ Seasonal: # of Months paid:
Gross Amount
(before deductions)
$
3.
Recipient
☐ Self ☐ Spouse
☐ Household member
Income Source(s) How Often
☐ Weekly ☐ Biweekly ☐ Monthly
☐ Annually ☐ Semi-Monthly
☐ Seasonal: # of Months paid:
Gross Amount
(before deductions)
$
4.
Recipient
☐ Self ☐ Spouse
☐ Household member
Income Source(s) How Often
☐ Weekly ☐ Biweekly ☐ Monthly
☐ Annually ☐ Semi-Monthly
☐ Seasonal: # of Months paid:
Gross Amount
(before deductions)
$
Total number of household members: _________________
Total household annual gross income: $ _________________
Check all that applies and submit a legible copy of the required supporting
documentation
a
s described in the follo
wing chart. (See appendix for more acceptable forms of income)
Wages and Salaries (including tips): One month’s gross paystubs (including tips), dated within the last
60 days
Net Income from Self-Employment: Most recent submitted quarterly tax statements, Receipts, Journal,
or Manifests for most recent 30 days or Business Checking and/or Savings Bank Statements for the most
recent 60 days
Alimony, Retirement, Pension, Annuity, Investment Dividends or Interest: Statement of monthly
payments.
Current Unemployment Benefits: Current Unemployment letter/printout with balance
Social Security: Current award letter from Social Security Administration, inclusive of disability, if
applicable
Rental Property: Statement of net income
Other Taxable Income (prizes, awards, gambling winnings): Statement and evidence of other taxable
income
No Income - supported by others: A-2: No Income and/or Homeless Verification Form -completed by the
person who supports you
Cash only Income: A-3: Cash Only Verification Form
Do not report the following types of income: child support, workers compensation, or proceeds
from loans, such as student loans, home equity loans, or bank loans.
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 5 of 9
Section 5: Health Insurance & Prescription Plan Coverage
I
nformation:
You mus
t submit a
copy of the front and back of all your insurance
card(s) with this
application, so that we can verify your benefits. Also, submit a copy of any enrollment letter(s) you have
received for LIS/Extra Help, SPDAP, or QMB/SLMB, (if applicable).
Complete the following for Health and Prescription Insurance Plans:
Primary Health Coverage (Choose plan type):
☐ Individual ☐ Individual/Spouse
☐ Family ☐ Individual/Child
Insurance company name: _______________________
Policy holder name: ____________________________
Phone number: ___________ Plan number: _________
Member ID: ______________ Group ID: ___________
Effective date: ________________________________
Secondary Health Coverage (Choose plan type):
☐ Individual ☐ Individual/Spouse
☐ Family ☐ Individual/Child
Insurance company name: _______________________
Policy holder name: ____________________________
Phone number: ____________ Plan number: ________
Member ID: _______________ Group ID: __________
Effective date: ________________________________
Company Name: _____________________________
Policy Holder Name: __________________________
Effective Date: ________________________________
Phone Number:
______________________________
Rx BIN: _____________________________
Rx PCN: ______________________________
Rx Group: ________________________________
Plan ID: _________________________________
If you do NOT have health insurance check all reasons that apply:
☐ Cost of premiums ☐ Cost of co-pays ☐ Not interested ☐ Other ( describe):
____________
☐ Check here if you need help obtaining insurance
CompletComplete e ththe e followingfollowing forfor Pharmacy Pharmacy BenefitsBenefits::
Com
plete the section below if you have pharmacy benefits or submit a copy of the front and back of your pharmacy
benefits card.
Company Name: _____________________________
Policy Holder Name: __________________________
Effective Date:
________________________________
Phone Number: ______________________________
Rx BIN: _____________________________
Rx PCN: ______________________________
Rx Group: ________________________________
Plan ID: _________________________________
Complete the following for Dental Benefits:
Complete the section below if you have dental benefits or submit a copy of the front and back of your dental benefits card.
Company Name: _________________________________
Member ID: ______________________________________
Group Number: __________________________________
Complete the following for Vision Benefits:
Complete the section below if you have vision benefits or submit a copy of the front and back of your vision benefits card.
Company Name: _________________________________
Member ID: ______________________________________
Group Number: __________________________________
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 6 of 9
Type of Plans Covered by
MADAP Plus
Payment Documentation Needed
QHP from the Maryland Health Benefits Exchange (on-
exchange)
Monthly Premium Invoice/Bill
QHP directly from the insurance carrier or throu
gh an
insurance broker (off-exchange)
Monthly Premium Invoice/Bill
Medicare Part C Plan
Invoice or Coupon Booklet
Medicare Part D - Prescription Drug/Advantage Plan
Invoice/Bill or Coupon Booklet
Medicare Supplemental Plans (Medigap), if client
has an active Part D plan or credible coverage
(employer insurance)
Invoice/Bill or Coupon Booklet
Dental and Vision Policies, only if MADAP Plus is
paying client’s health and prescription coverage.
Invoice/Bill or Coupon Booklet
Private Employer based plans (applicant’s or spouse
’s
employer, union or retirement plan), if client pays 50% or
more of the premium, the plan covers HIV drugs, and
the employer will accept 3rd party payment from State of
Maryland insurance program.
MADAP staff maintains client confidentiality of HIV
status during all contact with empl
oyers and
insurance companies.
Provide a letter from your employer that includes the cost of your
monthly premium, percentage employer pays, percentage you
pay, where to send payment with who to address the check to, and
whether your employer will accept a payment from
a State of
Maryland insurance program.
MADAP Plus staff must be able to arrange payment of the
applicant’s portion of the premium. Staff will need to
communicate with the employer to make arrangements for a
payment plan approved by the employer.
Plans not covered by MADAP Plus:
Medicare Part A – Hospital Coverage
Medicare Part B – Medical Coverage or Creditable Coverage (a plan usually obtained through an employer)
VA/Tricare; I.H.S. (Indian Health Services); Maryland Medicaid (Medical Assistance); or Maryland Children’s Health Program
Private medical or prescription plans that do not cover HIV drugs or provide HIV care and employer plans where the employer
does not accept payment from the program.
It is your responsibility to provide monthly premium statements to MADAP Plus for
timely payments.
Section 6: MADAP Plus: Premium payment assistance
If
you are interested in premium payment assistance, submit your health/prescription payment
documentation (see chart below) with this application. You will receive a
letter in the mail regarding
your MADAP Plus enrollment determination after your MADAP eligibility has been approved and
your insurance coverage has been verified.
C
heck the type of plan for which you are requesting assistance and include the required do
cumentation indicated below with this Enrollment Application.
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 7 of 9
I certify that the information provided in this application is complete and accurate, to the best of
my knowledge.
• I understand that, for the purposes of determining my eligibility for Maryland AIDS Drug Assistance
Program (MADAP), the Maryland Department of Health (MDH) may request further documentation to
verify my HIV positive serostatus, Maryland residency, household income, employment, and/or insurance
information.
• I authorize my physician, case manager/social worker, and health care providers to
exchange information with the Department that documents my diagnosis of
HIV/AIDS and my need for services from the Department.
• I authorize the Department to exchange information with my physician, case
manager/social worker, health care providers, insurance carrier(s) and/or pharmacy
provider(s) to facilitate provision of MADAP services as needed.
• I understand that I am required to verify my eligibility for continued service every six months in
accordance with the Department’s Continued Eligibility Verification process. I understand that any
change in my residency and/or income will be evaluated and that I will be notified of either continued
eligibility or denial of services.
• I understand that my non-compliance to verify my continued eligibility every six months will result in
termination of my MADAP enrollment.
• I agree to notify the Department of any circumstances affecting my participation in, or eligibility for,
MADAP. I agree to notify MADAP within 10 days if my address, income or other information changes
(COMAR 10.18.05.04A)
HIPAA Privacy Rule/Confidentiality/Acknowledgement o
f MDH Privacy Policy
• MADAP complies with the Health Insurance Portability and Accountability Act (HIPAA) privacy rule [45
CFR § 160.102]. Client-level data related to my enrollment will be reported only as required by law.
• I have the right to confidentiality of all information and records compiled, obtained and maintained in
the course of applying for and/or receiving services.
• Email addresses will not be sold to any third-party vendors or used to communicate one's specific case. This
is for MADAP to quickly relay any updates and important informaton pertaining to the program.
• My signature on this document acknowledges receipt of MDH’s Privacy Practices.
Consumer’s rights:
• If my application is denied, I have the right to request a reconsideration (COMAR 10.18.05.05A), and if I am
dissatisfied with the reconsideration (COMAR 10.18.05.05C), I may request an appeal hearing.
• I understand that I may revoke this authorization at any time in writing. However, this release shall
remain valid until I inform MADAP in writing of my wish to terminate services or until such time that I no
longer qualify for these services, whichever occurs first, except to the extent that action has been taken
in reliance on this authorization.
Section 7: Release
& Exchange of Information:
Updated: Feb 2022
MADAP and MADAP Plus Enrollment Application
Page 8 of 9
P
rovide the following:
Case Manager:
Name: _______________________ Provider Site: ________________________ Phone number: _______________
Primary HIV Physician:
Name: _______________________ Provider Site: ________________________ Phone number: _______________
Alternate Contacts:
I authorize the MADAP program to speak with the following person(s) about my application and/
or services (e.g.: family member):
Name Organization Relationship Phone number
__________________________ ________________________________ ______________ __________________
__________________________ ________________________________ ______________ __________________
I certify that the information I have given on this app
lication is true, correct, and complete. I agree
to cooperate in documenting the information I have given or providing additional information to
support my application as required by the department.
Applicant Name: _________________________________________________
(please print)
Signature of Applicant: _____________________________
___________________ Date: / /
(or legal guardian if applicant is a minor)
Spouse Signature: Date: / /
(if applicable)
Mail or fax completed application and supporting documentation to:
Maryland AIDS Drug Assistance Program
1223 W. Pratt Street
Baltimore, MD 21223
Email: Client.Services@maryland.gov
Fax: (410) 333-2608; (410) 244-8617
Please retain a copy of this application for your records.
Maryland AIDS Drug Assistance Program
1223 W. Pratt Street, Baltimore, MD 21223
Phone: (410) 767-6535 or Toll Free: 1-800-205-6308
or TTY- Maryland Relay Service 1-800-735-2258
Fax Numbers: (410) 333-2608; (410) 244-8617
Email: Client.Services@maryland.gov
Website: https://health.maryland.gov/phpa/OIDPCS/Pages/MADAP.aspx
Updated: Feb 2022
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Appendix
Appendix A:
Acceptable Residency Documentation
Residency documentation must include the client’s name and current address. Documentation must be current (e.g.
current lease, recent utility bill, etc.). Acceptable proof of residency may include, but is not limited to, the following:
o Current notice of decision from Medicaid
o Valid Maryland driver’s license or Maryland Identification Card dated within the last 12 months
o Voter registration card dated within the last 12 months
o Current signed and dated lease (within 12 months) or mortgage agreement
o Rent receipt, dated within the last 60 days
o Current utility bill, dated within the last 60 days
o Letter from a government agency, signed and dated within the last 60 days and mailed to the client’s home
o Letter from a case manager on agency letterhead, signed and dated within the last 60 days and mailed to the
client’s home
Homeless clients may provide a letter stating that they are homeless. The letter must be written on agency letterhead
and be signed and dated within the last 60 days. MADAP's A-2 Verification of No Income Form may be submitted.
The following individuals may verify that the client is homeless:
o Case manager
o Housing manager
o Any staff member employed by an agency who receives Ryan White support
Appendix B:
Acceptable Income Documentation
Income includes any income earned through employment, disability, public benefits, etc. Forms of income include,
but are not limited to, the following:
o Employment income
o Retirement income
o Unemployment benefits
o Supplemental Security Income (SSI)
o Social Security Disability Insurance (SSDI)
o Income for dependents
o Alimony payments
o Private disability
o Rental property income
o Interest income or other investment income
o Cash support from family and friends
Income information should be collected for the client and individuals over the age of 18 who share financial
responsibility. All income must be current, signed and dated (e.g. current year award letter, recent pay stubs, etc.).
Acceptable proof of income may include, but is not limited to, the following:
o One month of consecutive pay stubs
o Tax forms (W-2 form or 1099)
o Letter on letterhead from employer stating hourly wage and hours worked per week
o Pension benefits letter
o Retirement benefits check or letter
o Unemployment income check or letter
o Disability benefits check or letter
o Social Security check or award letter
o Bank direct deposit indicating payment from Social Security
o Alimony Agreement Letter
o If receiving support from family and friends, signed statement documenting who provides
monetary support, and the frequency of the support
o If no income, the A-2 Verification of no Income form may be submitted
MADAP and MADAP Plus Enrollment Application
Updated: Feb 2022
Page 9 of 9
A-2: No Income and/or Homeless Verification Form
Updated Feb 2022
ID: 94 ________________________
Instructions: Complete section 1 or 2.
First Name: __________________ MI: ___ Last Name: ____________________ Suffix: ___ Date of Birth: __/__/__
Section 1. Supporting relative or friend (all information is required)
I, _____________________________________, certify that ___________________________________________ is:
(applicant)
☐ Currently without income.
I am supporting him/her by providing the following:
☐ Payment for room and board outside of my home.
☐ Free room and board in my home.
☐ Other, please explain: ____________________________________________
☐ I certify that the information provided on this form and any attached documentation is true, correct and complete.
First Name: _______________________ Last Name: _______________________ Relationship to Applicant: __________
Street Address: _______________________________________ City: ______________ State: ____ Zip code: _____________
Phone number: ___________________________
Signature: __________________________________________________ Date: ___________________
Section 2. Shelter or Agency (if applicant is homeless)
I, ____________________________, certify that _____________________________resides at _______________________, at
(Name of Shelter Representative) (Applicant) (Facility Name)
______________________________ for the period of: ☐ less than 6 months ☐ 6 to 12 months ☐ 12 months or more.
(Facility Location)
☐ The applicant has no income. ☐ Client is homeless and is Not currently living in a shelter
☐ The applicant has income.
☐ I certify that this information is true, correct and complete.
Organization Name: _____________________________________________________________________________________
First Name: _______________________________________ Last Name: __________________________________________
Street Address: _________________________________________ City: ___________ State: ___ Zip code: _____________
Phone number: ___________________________
Signature: __________________________________________ Date: ________________________
☐ Self reported
☐ Case manager reported
A-2: No Income and/or Homeless Verification Form
Required Proof of no Income/Maryland Residency/Homelessness
Maryland AIDS Drug Assistance Program
1223 W.
Pratt Street, Baltimore, MD 21223
Phone: (410) 767-6535 or Toll Free: 1-800-205-6308
or TTY- Maryland Relay Service 1-800-735-2258
Fax Numbers: (410) 333-2608; (410) 244-8617
Email: Client.Services@maryland.gov
Website: https://health.maryland.gov/phpa/OIDPCS/Pages/MADAP.aspx
MDH 4617 (07/17) Page 1 of 2
MARYLAND DEPARTMENT OF HEALTH AND YOUR HEALTH INFORMATION
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
CAREFULLY.
Introduction
The Maryland Department of Health (MDH) is committed to protecting your health information. MDH is required by law to maintain the
privacy of Protected Health Information (PHI). PHI includes any identifiable information that we obtain from you or others that relates to
your physical or mental health, the health care you have received, or payment for health care. As required by law, this notice provides
you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. In order to provide
treatment or to pay for your healthcare, MDH will ask for certain health information and that health information will be put into your
record. The record usually contains your symptoms, examination and test results, diagnoses, and treatment. That information, referred
to as your health or medical record, and legally regulated as health information, may be used for a variety of purposes. MDH and its
Business Associates are required to follow the privacy practices described in this Notice, although MDH reserves the right to change
our privacy practices and the terms of this Notice at any time. You may request a copy of the new Notice from any MDH agency. It is
also posted on our website at https://health.maryland.gov.
Permitted Uses & Disclosures
MDH employees will only use your health information when doing their jobs. For uses beyond what MDH normally does, MDH must
have your written authorization unless the law permits or requires it, and you may revoke such authorization with limited exceptions.
The following are some examples of our possible uses and disclosures of your health information:
Uses and Disclosures without Consent Relating to Treatment, Payment, or Health Care Operations:
• For treatment: MDH may use or share your health information to approve, deny treatment, and to determine if your medical
treatment is appropriate. For example, MDH health care providers may need to review your treatment with your healthcare
provider for medical necessity or for coordination of care.
• To obtain payment: MDH may use and share your health information in order to bill and collect payment for your health care
services and to determine your eligibility to participate in our services. For example, your health care provider may send claims
for payment of medical services provided to you
.
• For health care operations: MDH may use and share your health information to evaluate the quality of services provided, or
to our state or federal auditors
.
Other Uses and Disclosures of Health Information Required or Permitted by Law:
• Information purposes: Unless you provide us with alternative instructions, MDH may send appointment !reminders and other
materials about the program to your home.
• Required by law: MDH may disclose health information when a law requires us to do so.
• Public health activities: MDH may disclose health information when MDH is required to collect or report information about
diseases, injuries, or to report vital statistics to other divisions in the department and other public health authorities
.
• Health oversight activities: MDH may disclose your health information to other divisions in the department and other
agencies for oversight activities required by law. Examples of these oversight activities are audits, inspections, investigations,
and licensure.
• Coroners, Medical Examiners, Funeral Directors and Organ Donations: MDH may disclose health information relating to a
death to coroners, medical examiners or funeral directors, and to authorized organizations relating to organ, eye, or tissue
donations or transplants.
• Research purposes: In certain circumstances, and under the supervision of our Institutional Review Board or other
designated privacy board, MDH may disclose health information to assist medical research. !MDH 4617 (07/17) Page 1 of
3
• Avert threat to the health or safety: In order to avoid a serious and imminent threat to health or safety, MDH may disclose
health information as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm
.
• Abuse and neglect: MDH will disclose your health information to appropriate authorities if we reasonably believe that you
may be a possible victim of abuse, neglect, domestic violence, or some other crime. MDH may disclose your health
information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
• Specific government functions: MDH may disclose health information of military personnel and veterans in certain
situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment,
and for national security reasons, such as protection of the President.
• Family, friends, or others involved in your care: MDH may share your health information with people as it is directly relat
ed
to their involvement in your care or payment for your care. MDH may also share your health information with people to notify
them about your location, general condition, or death.
• Worker’s compensation: MDH may disclose health information to worker’s compensation programs that provide benefits for
work-related injuries or illnesses without regard to fault.
• Patient directories: MDH entities generally do not maintain directories for disclosures to callers or visitors who ask for you by
name. However, if a MDH entity does maintain a directory, you will not be identified to an unknown caller or visitor without
MDH 4617 (07/17) Page 2 of 2
authorization, and the limited information we disclose may include your name, location in the entity, your general condition
(e.g., fair, stable, etc.) and your religious affiliation. !
• Lawsuits, disputes and claims: If you are involved in a lawsuit, a dispute, or a claim, MDH may disclose your health
information in response to a court or administrative order, subpoena, discovery request, the investigation of a complaint fil
ed
on your behalf, or other lawful process.
• Law enforcement: MDH may disclose your health information to a law enforcement official for purposes that are required by
law or in response to a subpoena
.
• Other parties for conducting permitted activities: MDH may conduct the above-described activities ourselves, or we may
use non-MDH entities (known as Business Associates) to perform those operations. In those instances where we disclose
your PHI to a third party acting on our behalf, we will protect your PHI through an appropriate privacy agreemen
t.
• Fundraising Activities: MDH may use information about you to contact you in an effort to raise money for MDH and its
operations. The information we release about you will be limited to your contact information, such as your name, address and
telephone number and the dates you received treatment or services at MDH
.
Your Rights !
You Have a Right to: !
• Request restrictions: You have the right to request a restriction or limitation on the health information MDH uses or discloses
about you. MDH will accommodate your request if possible, but is not legally required to agree to the requested restriction.
Except as otherwise required by law, MDH must accommodate your request if the disclosure is to a health plan for purposes of
carrying out payment or health care operations (and is not for purposes of carrying out treatment); and the protected health
information pertains solely to a health care item or service for which the health care provider involved has been paid out of
pocket in full.
• Request confidential communication: You have the right to ask that MDH send you information at an alternative address or
by alternative means. MDH must agree to your request as long as it is reasonably easy for us to do so.
• Inspect and copy: With certain exceptions (such as psychotherapy notes, information collected for certain legal proceedings,
and health information restricted by law), you have a right to see your health information upon your written request. If you want
copies of your health information, you may be charged a reasonable and cost-based fee for copying, postage, and prepari
ng
an explanation or summary of the protected health information. You have a right to choose what portions of your information
you want copied and to have prior information on the cost of copying. If MDH maintains your health information using
electronic health records, we will provide access in electronic format and transmit copies of the health information to an entity
or person designated by you, provided that any such choice is clear, conspicuous, and specific
.
• Request amendment: You may request in writing that MDH correct or add to your health record. MDH will respond to your
request within 60 days, with up to a 30-day extension, if needed. MDH may deny the request if MDH determines that t
he
health information is: (1) correct and complete; (2) not created by us and/or not part of our records; (3) not permitted to be
disclosed. If MDH approves the request for amendment, MDH will change !the health information and inform you, and MDH w
ill
tell others that need to know about the change in the health information.
• Require authorization: You have the right to require your authorization for most uses and disclosures of psychotherapy
notes, for receiving marketing communication and for the sale of your PHI.
• Receive accounting of disclosures: You have a right to request a list of the disclosures made of your health information
after April 14, 2003, and in the six years prior to the date on which the accounting is requested. Exceptions are health
information that has been used for treatment, payment, and health care operations. In addition, MDH does not have to list
disclosures made to you, based on your written authorization, provided for national security, to law enforcement officers, or
correctional facilities. There will be no charge for up to one such list each year. Additionally, MDH will provide an accounting
for disclosures made through an electronic health record for treatment, payment, and health care operations, but information is
limited to three years prior to date of reques
t.
• Opt-Out: You have the right to receive fundraising communication and the right to request to opt-out of fundraising
communication. You also have a right to opt-out of a MDH facility’s patient directory, and you have the right to opt-out of
Maryland’s Health Information Exchange (HIE), which is the Chesapeake Regional Information System for our Patients
(CRISP).
• Receive notice: You have the right to receive a paper copy of this Notice and/or an electronic copy by mail upon request.
• Receive breach notification: You have the right to receive notification whenever a breach of your unsecured PHI occurs.
• Receive protection of genetic information: If any of MDH’s health care components is considered a health plan, the health
plan is prohibited from using or disclosing your genetic information for certain underwriting purposes.
• Receive protection of mental health records: If a medical record that is developed in connection with you receiving menta
l
health services is disclosed without your authorization, MDH will only release the information in your record that is relevant to
the purpose for which the disclosure is sought. !For More information: !This document is available in other languages
and
alternative formats that meet the guidelines for the Americans with Disabilities Act. If you have questions and would like more
information, you may contact: Client Services at 410-767-6535.
• To Report a Problem about our Privacy Practices: !If you believe that your privacy rights have been violated, you may file a
complaint.
• You can file a complaint with the Maryland Department of Health, Division of Corporate Compliance at !1-866-770-7175.
You can file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office of Civil !Rights. You may call
the Maryland Department of Health for the contact information.
MDH will take no retaliatory action against you if you make such complaints. !
Effective Date: This notice is effective on August 19, 2013
NOTICE TO THE PUBLIC
NON-DISCRIMINATION STATEMENT AND ACCESSIBILITY REQUIREMENTS
MADAP, as a unit of the Department of Health and Mental Hygiene (the Department)
complies with applicable Federal civil rights laws and does not discriminate, exclude people,
or treat them differently on the basis of race, color, national origin, age, disability, or sex.
The Department, upon request:
Provides free aids and services to people with disabilities to communicate effectively
with Department staff, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic
formats, other formats)
Provides free language services to people whose primary language is not English,
such as:
Qualified interpreters
Information written in other languages
If you need any of the services listed above, please contact
MADAP directly at 410-767-6535 or fax MADAP at 410-333-2608.
*********************************************************************************************************
If you believe that the Department has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Delinda Johnson, Equal Access Compliance Unit
Office of Equal Opportunity Programs
Maryland Department of Health and Mental Hygiene
201 West Preston Street, Room 514, Baltimore, Maryland 21201
410-767-6600 (voice),1-800-735-2258 (TTY)
410-333-5337 (Fax), or delinda.johnson@maryland.gov (email).
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Delinda Johnson
is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-
1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Interpreter Services Are Available for Free
Help is available in your language:1-800-205-6308 (TTY:1-800-735 -2258).
These services are available for free.
Español/Spanish
Hay ayuda disponible en su idioma: 1-800-205-6308 (TTY: 1-800-735 -2258)). Estos servicios están disponibles gratis.
አማርኛ/Amharic
እገዛ በ ቋንቋዎ ማግኘት ይችላሉ፦:1-800-205-6308 (TTY: 1-800-735-2258) ።
እነዚህ አገልግሎቶች ያለክፍያ የሚገኙ ነጻ ናቸው
 /Arabic

1-800-205-6 308
)800 (2258-735.
中文/Chinese
用您的语言为您提供帮助：1-800-205-6308 (TTY: 1-800-735-2258)。 这些服务都是免费的
ی /Farsi
800800(8036

Français/French
Vous pouvez disposer d’une assistance dans votre langue :1-800-205-6308 (TTY: 1-800-735-2258). Ces services sont
disponibles pour gratuitement.
/Gujarati
 1-800-205-6308 ( (TTY: 1-800-735-2258). 
kreyòl ayisyen/Haitian Creole
Gen èd ki disponib nan lang ou: 1-800-205-6308 (TTY: 1-800-735-2258). Sèvis sa yo disponib gratis.
Igbo
Enyemaka di na asusu gi: 1-800-205-6308
(TTY: 1-800-735-2258). Ọrụ ndị a dị na enweghi ugwo i ga akwu maka ya.
한국어/Korean
사용하시는 언어로 지원해드립니다: 1-800-205-6308 (TTY: 1-800-735-2258). 무료로 제공 됩니다
Português/Portuguese
A ajuda está disponível em seu idioma: 1-800-205-6308 (TTY: 1-800-735-2258). Estes serviços são oferecidos de graça.
Русский/Russian
Помощь доступна на вашем языке: 1-800-205-6308 (TTY: 1-800-735-2258). Эти услуги предоставляются бесплатно.
Tagalog
Makakakuha kayo ng tulong sa iyong wika: 1-800-205-6308 (TTY: 1-800-735-2258). Ang mga serbisyong ito ay libre.
ودرا/Urdu).

1-800-205-6308 (TTY: 1-800-735-2258). 
Tiếng Việt/Vietnamese
Hỗ trợ là có sẵn trong ngôn ngữ của quí vị 1-800-205-6308 (TTY: 1-800-735-2258). Những dịch vụ này có sẵn miễn phí.
Yorùbá/Yoruba
rànlọ
́
wọ
́
wà ní àrọ
́
wọ
́
tó ní d rẹ: 1-800-205-6308 (TTY: 1-800-735-2258). Awon ise yi wa fun o free.
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Completed 23 February 2022

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