CAREAssist - Forms and applications

CAREAssist Application and Instructions

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

Once you have downloaded the application, 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.

If you need assistance with any part of the application, please call 971-673-0144 (from Portland) or 1-800-805-2313 (from outside Portland).

• Application and instructions
• Affidavit of Zero Income Form - you must complete this form and submit it with your application if you are reporting zero income.
• HIV Verification Form - you must ask your health care provider to sign this document and submit with your application.
  
  
• Solicitud confidencial de CAREAssist & Instrucciones
• Declaración de no ingresos
• Formulario de confirmación VIH/Sida

CAREAssist Eligibility Review

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

• CER Instructions
• CER Form
  
  
• Instrucciones completas para llenar la revision de elegibilidad del cliente de CAREAssist and Revision de elegibilidad de clientes de CAREAssist

Cost Share Adjustment Request

If you are a CAREAssist member and your income changes by 25% or more, you may be eligible to apply for a cost share adjustment. Please complete the form and submit to the CAREAssist Program.

• Cost Share Adjustment Request form
  
  
• Pedido de ajuste en la coparticipacion

CAREAssist Complaints and Grievances

It is the policy of the CAREAssist program to consistently respond with diligence to concerns voiced by clients about the administration of the CAREAssist program or policy issues regarding the program.

• CAREAssist Complaint and Grievance Policy - Concerns and complaints will be resolved in the least formal manner using a variety of approaches while grievances must regard decisions, which affect a client's eligibility, amount, or length of time of assistance, and/or termination of assistance for program violations.
  
• Grievance Policy and Form - Grievances may only be filed for (1) denial of eligibility to participate in the CAREAssist program (2) denial of a request for CAREAssist program assistance (3) denial of a request for exception (4) termination of assistance for program violations.
  
  
• Procesos de queja formal e informal
• Programa de cuidado y tratamiento del VIH Politica y formulario de queja formal de CAREAssist

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 medical providers, use the MTM clinical providers referral form

For Ryan White case managers, use the MTM case managers referral form