Texas HIV Medication Program – Documents

Client Application - the THMP application for assistance is available in English and Spanish in Word and PDF formats. The application includes the supplemental SPAP application page as part of the formal application process, for those clients with Medicare coverage.

• Emergency Application - English (Word : 44 kB)
  This application is only valid 3/13/2020 through 8/31/2020.  Please use it for New, Renewal (Recertification), and Self-Report (Self-Attestation) applications. For new applicants, we also need the Medical Certification Form (MCF) completed by the Doctor.
• Emergency Application - Spanish (Word : 56 kB)
  Esta aplicación sólo es válida del 3/13/2020 al 8/31/2020.  Utilícelo para aplicaciones Nuevas, de Renovación (Recertificación) y de Reporte Propio (Atestación). Para aplicantes nuevos, también necesitamos el formulario de certificación médica (MCF) completado por el Doctor.
• Client Application - English - Please use the Emergency Application above for Medication Assistance only
• Emergency Texas Insurance Assistance Program Application - English (Word : 30 kB)
• Emergency Texas Insurance Assistance Program Application - Spanish (Word : 36 kB)
  
• Client Application - Spanish - Por favor, utilice la Aplicación de Emergencia para Asistencia con Medicamentos solamente
• Six Month Self Attestation of Eligibility Changes - English - Please use the Emergency Application above for Medication Assistance only
• Six Month Self Attestation of Eligibility Changes - Spanish - Por favor, utilice la Aplicación de Emergencia para Asistencia con Medicamentos solamente
• Income Verification - English (PDF : 80 kB)
• Income Verification - Spanish (PDF : 26 kB)
• Supporter Statement - English (PDF : 79 kB)
• Supporter Statement - Spanish (PDF : 24 kB)
• Self-Employment Log - English (PDF : 56 kB)
• Self-Employment Log - Spanish (PDF : 69 kB)
• Income Calculation Worksheet - English (Excel : 20 kB)
• Income Calculation Worksheet - Spanish (Excel : 20 kB)
• Recertification/Self Attestation Fax Cover Sheet (Word : 33 kB)
• ADAP ARIES Upload Cover Sheet (Word : 44 kB)
  

Hepatitis C Pilot

• Hepatitis C Medical Certification Form (PDF : 266 kB)
• Eligibility and Enrollment for Hepatitis C-AIDS Drug Assistance Program (PDF : 180 kB)

Medical Certification Form (MCF) - Word (41 kB) | PDF (221 kB) - allows physicians to request any and all medications currently available through the THMP. Please note that a separate form for the drug Fuzeon (enfuvirtide) is no longer required. (updated April 2020)

It is recommended that patients initiating Fuzeon treatment receive additional training and support through Nurse Connections. This service is provided free to new and existing patients. For information or to enroll a patient, please call 1-877-4Fuzeon (1-877-438-9366).

Trogarzo Medical Certification Form - Word (36 kB) | PDF (403 kB) - allows physicians to request Trogarzo through the THMP. (updated October 2019)

THMP Acceptable Documentation - English (PDF : 341 kB) | Spanish (PDF : 302 kB) (updated February 2020)

Guidelines (PDF : 208 kB) - program guidelines for THMP applicants. (updated May 2019)

THMP Medication Formulary and Maximum Quantities Table (PDF : 283 kB) - the list of drugs currently available through the THMP. (updated April 2020)

Out of State Texas Residents Medication Guidelines (PDF : 250 kB) (updated May 2019)

THMP Extra Medication Request Form (PDF : 173 kB) - complete to request extra refill or a 2-month supply of medication. (updated April 2018)

ADAP Enrollment Worker Training Manual (PDF : 5,850 kB) - manual from enrollment worker training.

Training Request Form [Survey Monkey]

Application Completeness Fact Sheet (PDF : 75 kB) - worksheet that explains the difference between an incomplete application and an application with verification issues.

THMP Eligibility Due Date Calendar (PDF : 265 kB) - monthly reminder of documentation due dates for THMP clients.

To view and download documents related to the HIV SPAP (State Pharmaceutical Assistance Program), please visit the TEXAS HIV SPAP page.

THMP homepage | FAQ | Documents | Policies | Pharmacies
Advisory Committee | Medicare | SPAP | Contact Us