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  1. New G-845 and G-845 Supplement Forms Required for Verification of Immigration Documents with Department of Homeland Security (DHS)

    The G-845 and G-845 Supplement Forms are used to confirm the immigration status of an individual applying for federal, state or local public benefits, including eligibility for benefits under Titles II, XVI, and XVIII. Typically, the G-845 and G-845 Suppl ...

    admin - 11/4/2015 5:43pm

  2. Patient's Acknowledgment of Counseling of Positive HIV Status, Arkansas Department of Health, Bureau of Public Health Programs, AIDS/STD Division (1998)

    This form was created and used by the Arkansas Department of Health, Bureau of Public Health Programs to document the warning of persons after they have tested positive for HIV that their HIV status can be the basis of felony and misdemeanor charges if th ...

    Anonymous (not verified) - 10/29/2018 3:57pm

  3. What You Need To Know About Missouri Laws On HIV, Missouri Department of Health and Senior Services (2008)

    The Missouri Department of Health and Senior Services requires that all individuals who test positive for HIV sign – and initial every paragraph of – a form in which HIV-positive individuals must acknowledge potential criminal liability, punishable by 10 ...

    Anonymous (not verified) - 10/29/2018 4:05pm

  4. HIV INTERVIEW FORM No. 917, Mississippi State Department of Health (2009)

    The six "requirements" which all HIV-positive individuals are directed to acknowledge in writing on this Mississippi State Department of Health form include the " n ecessity of not causing pregnancy or becoming pregnant, " and the nece ...

    Anonymous (not verified) - 11/15/2017 4:31pm

  5. Client Acknowledgment Form, Kalamazoo County Health and Community Services (2007)

    This form is presented to individuals who test positive for HIV in Kalamazoo, Michigan.  After testing positive, clients are asked to sign and date the form, in the presence of a witness, attesting to the fact that they have been informed of behaviors tha ...

    Anonymous (not verified) - 10/29/2018 4:19pm

  6. Model Informed Consent for HIV Testing, Massachusetts Department of Public Health, Bureau of Infectious Disease, Office of HIV/AIDS

    The Massachusetts Department of Public Health (MDPH) created this model informed consent form for HIV testing to facilitate the implementation of routine HIV testing in clinical settings. Under chapter 111, section 70F of the Massachusetts General Laws, n ...

    Anonymous (not verified) - 5/8/2013 1:46pm

  7. Physical Residual Functional Capacity Questionnaire

    This questionnaire, provided by attorney Leslie Kline-Capelle, formerly of Health Advocates, is intended to assist with a determination of disability for purposes of obtaining social security disability benefits. In order to be effective, the form must be ...

    Anonymous (not verified) - 5/8/2013 1:46pm

  8. Mental Residual Functional Capacity Questionnaire

    This questionnaire, provided by attorney Leslie Kline-Capelle, formerly of Health Advocates, is intended to assist with a determination of disability for purposes of obtaining social security disability benefits. In order to be effective, the form must be ...

    Anonymous (not verified) - 5/8/2013 1:46pm

  9. Form SSA 4815-F6, Medical Report on Child with Allegation of HIV Infection

    An essential form that is mysteriously unavailable on the Social Security Administration's website, this document is used by a child's health care provider to establish to the SSA field office processing the claim that manifestations of the appl ...

    Anonymous (not verified) - 5/8/2013 1:46pm

  10. Form SSA 4814-F5, Medical Report on Adult with Allegation of HIV Infection

    This essential form, unavailable on the Social Security Administration's website, is used by a disability applicant's health care provider to establish to the SSA field office processing the claim that manifestations of the applicant's HIV ...

    Anonymous (not verified) - 5/8/2013 1:46pm