PrEP Initial Questionnaire

PrEP Initial Questionnaire

Get started on PrEP today!
PrEP Clinic Location*
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security Number
Height*
ex. 5'9" or 69in
Weight*
ex. 160 lbs
What are your preferred Pronouns (Select all that apply)*

He/Him/HisShe/Her/HersThey/Them/TheirsOther
What is your sexual orientation?*

Gay MaleLesbianHeterosexualBisexualNon-BinaryUnsurePrefer not to answer
What is your Current Relationship status?*

SingleMarried/Partnered, Monogamous RelationshipMarried/Partnered, Open RelationshipWidowedSeparatedDomestic PartnerOther
Who are your preferred sexual partners? (select all that apply)*

Male PartnersFemale PartnersTransgender Partners (Male to Female)Transgender Partners (Female to MalePrefer not to answer
In the last 12 months, how many sexual partners have you had?*
Percent of anonymous sexual partners*

0%Less than 25%50%75%100%
What Sexual Practices do you engage in? (Select all that apply.)*

Give OralReceive OralAnal Receptive (Bottom)Anal Insertive (Top)VaginalPrefer not to answer
Percent of oral sex encounters using condoms:*

0%Less than 25%50%75%100%
Percent of anal sex encounters using condoms:*

0%Less than 25%50%75%100%
Percent of vaginal sex encounters using condoms:*

0%Less than 25%50%75%100%
In the last 12 months, have you had any HIV positive sexual partners?*

YesNoI'm not sure
In the last 12 months, have you been diagnosed with any of the following? (Select all that apply.)*

ChlamydiaGonorrheaHIV/AIDSSyphilisHepatitisHerpesHPVNone of the Above
Due to your reported history of HIV/AIDS; You are currently not eligible for PrEP. Please consult with your health care provider.
Have you ever injected drugs or have a history of any injectable drugs for recreation?*

YesNoPreferred not to Answer
In the last 4 weeks, have you experienced any diarrhea, headache, fever, fatigue, sore throat, night sweats, and/or rash?*

YesNoI'm not sure
In the past 72 hours, have you been exposed to the blood or semen of someone that is HIV positive or of unknown HIV status?*

YesNoI'm not sure
Please consult with the Pharmacist before doing labs.
Have you been on PrEP before?*

YesNoI'm not sure
Which PrEP medication were you on? (Select all that apply)*

TruvadaDescovyApretude
For how long were you on PrEP?*
Are you still taking PrEP?*

YesNo
Why did you stop taking PrEP?*
Did you experience any issues or complications on PrEP?*
How long do you plan on being on PrEP?*

Intermittently3-12 months1-5 yearsIndefinitely
* Once you start taking your pills, if you decide to stop taking PrEP please make sure that you notify us immediately so that we can update your chart.
Are you available to return in 10 weeks (about two and a half months) for labs and a follow-up with a provider?

YesNo
o Please keep your appt even though you may still have pills. If you miss your appt, you might have delays in getting your prescription renewed.

o If you need to change your appt, you can always reschedule by using your Healthvana
app.
For PrEP to work at its maximum potential, you will need to take this pill every day. Are you ready to take this pill daily, 7 days per week?*

YesNo
What are your concerns for not taking this pill every day?*
Would you be interested in the injectable form of PrEP in the future?*

YesNoMaybe
What are your concerns about being on Injectable PrEP?*

Side EffectsFear of NeedlesCost/CoverageShowing up every 2-6 months for the InjectionEffectiveness Compared to the Pills (Truvada/Descovy)Not sure/Need More Information
What are your concerns about being on injectable PrEP?*
Do you have any known allergies to any medication or food?*

YesNo Known Allergies
Please list your Allergies:*
Are you currently taking any other medications or supplements?*

YesNo
Please list the current medications/supplements you are taking:*
Do you have any health conditions? (ex. liver or kidney disease, high cholesterol, bone problems)*

YesNo
Please list your health conditions:*
Do you have a current medical provider/Primary care doctor?*

YesNo, not at this time.
Current Medical provider/Primary care Doctor:*
What questions/concerns you would like addressed during the consultation? *
Do you have Health/Prescription Insurance?*

YesNo
Name of Insurance*
Unfortunately we are unable to accept Kaiser for payment of your PrEP medication. But we do offer the Generic form of Truvada for $25 per bottle of #30.
Please Upload an image of your insurance or enter in the information manually below

Cancelof
ID number on Card
rx BIN #
rx PCN#
rx GROUP#
I give permission to bill my insurance for the PrEP Medication at AHF Pharmacy.*

YesNo
Since we are not billing your insurance, the Cost of Brand name PrEP medication can be very costly.

Truvada: $1989.65

Descovy: $2201.95

But we do offer the Generic form of Truvada for only $25 for a bottle of #30
Since you have no health insurance, you have the option to sign up for insurance through our Benefits Counselor.

We also offer the Generic form of Truvada for $25 per bottle of #30 if you prefer not to use insurance or if no insurance is approved.
Income Affidavit

To whom it may concern,

I am providing this affidavit to verify my income, as I have no other income documentation available to me.

I receive $ gross amount* and the frequency is *. I last received this on Date* .

I understand that this information is subject to verification by the State of * . I certify that the information present in this letter is true and correct to the best of my knowledge and belief.

Sincerely,
How are you being supported with $0 income?*

Living with Family/SpouseLiving with FriendsLiving off SavingsOther
Signature of the person receiving the income.*

Clear
Patient Care Coordination Service Agreement
*In case we can't reach you, we may communicate with the Alternate person you have designated.
Emergency/Alternate Contact Name*

First NameLast Name
Relationship to Emergency/Alternate Contact*
Phone number of Emergency/Alternate Contact*
Please enter a valid phone number.
Refill Management Program

We will contact you on a periodic basis to remind you that we are refilling all of your maintenance medications and to check to see if there are changes in your information and medications. Please note that most insurance plans require that we be in contact with you on a regular basis and could result in a delay if we cannot reach you. AHF Pharmacy utilizes a central refill facility to process refills for AHF Pharmacy Locations. These are located in Ft. Lauderdale, FL and Gardena, CA. You may “Opt-Out” of our Auto-Refill Management Program by talking with your AHF Pharmacy Team.
Please Select your preference Regarding Auto refill authorization*

I wish to enroll in this Auto-Refill programI decline participation in automated medication refills
What is your preferred method of contact?*

Telephone CallText MessagingEmailTelepharmacy
What is the best time to contact you?*

Morning (8AM- 12Noon)Afternoon (12Noon - 5PM)Evening (After 5PM)
Preferred Language
Other Language
Which Medication cap do you prefer?*

Safety CapNon-Safety Cap
In accordance with the Poison Prevention Packaging Act of 1970, we are required to package and dispense medications with child-resistant caps or “safety caps.” The purpose of this legislation is to prevent children’s accidental ingestion of medication.

AUTHORIZATION

By selecting Non-Safety Cap and signing below, I request and acknowledge that ALL of my prescriptions dispensed by AHF Pharmacy, on and after the date of signature, will NOT be packaged with child-resistant cap packaging when available. This request is valid for 1 year from the date of signature, or until rescinded, whichever comes first.
Complimentary Delivery Options
You may wish to pick-up your medications each month from the pharmacy, have them delivered by an AHF Pharmacy Services Liaison or have them mailed or shipped. You may change at any time.*

Delivery by AHF Pharmacy Services LiaisonUSPSPick Up at the Pharmacy (must pick up within 14 days of fill date)
Delivery Location*

Deliver to Home AddressDeliver to an Alternate Address
Alternate Address for Delivery, Mail or Shipping*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Delivery Instructions*

Ok to Leave at the DoorSignature Required*
Special Delivery Instructions and Gate codes if applicable
*controlled substance prescriptions require a signature and any packages requiring a signature will NOT be left at the door.
Optional

Authorize someone else receive or pick up.
Name of Person Authorized to receive or Pick up*

First NameLast Name
Relationship of the Person Authorized to receive or Pick up.*
Relationship
Phone Number of the Person Authorized to receive or Pick up*
Please enter a valid phone number.
Credit Card on File

No, I will provide you with payment at time of purchase.Yes, keep my credit card on file for prescription cost not payable by my insurance plan.Yes, keep my credit card on file, obtain my authorization before charging to my card.
Disclosures and Notice of Privacy Practices
1. The AIDS Healthcare Foundation (“AHF”) is the sole member of Pharmacy4Humanity (“P4H”). Both AHF and P4H operate pharmacies under the business name AHF Pharmacy. Your prescription may be filled by any AHF Pharmacy.

2. AHF cannot ensure the security of messages sent by email or text, as these messages travel over the internet, and we have no control over the security of the device that receives the messages. Upon request, we may be able to arrange for the transmission of encrypted emails. Please contact your AHF Pharmacy team if you prefer this option.

3. AHF will exhaust all available means and resources to avoid you paying “out of pocket” for medications that your insurance plan does not pay for or that require a co-payment of one kind or another. Please contact your AHF Pharmacy Team if you wish to “opt-out” of this service.

4. By completing and signing this form, you authorize AHF Pharmacy and staff to send protected healthcare information to you and receive that information from you by email, messaging apps, other electronic tools and/or text messaging that could include, for example, information about prescriptions, test results, diagnoses, appointments details and reminders. By signing this authorization, you accept any risk involved in sending your health information by email, messaging apps, other electronic tools, and/or text messaging. Even if you opt to communicate with us by email, messenger apps, other electronic tools, or text messaging, you will always be able to communicate with us by phone and U.S. mail.

5. By completing and signing this form, you authorize AHF Pharmacy and staff to send you information regarding the medications you are taking and receiving from AHF Pharmacy, in an electronic format. If you wish to receive hard copy (paper) forms, please notify your AHF Pharmacist.

6. If you authorize AHF Pharmacy to leave packages delivered to your stated address and you are not at the address to receive them, you must sign via an electronic method that AHF Pharmacy will provide to you. Not completing this signed document in a timely manner may result in a delay in you receiving your next refill.

7. There are certain medications that will require a signature (“proof of delivery”), at the time of delivery. The package cannot be left without the signature. We will inform you of a package being shipped that you or your designated person must sign for. In this instance, an electronic signature method may not be used. For example: Signatures are required for Class II controlled substances, narcotics, and medications valued at $5,000.00 and above. Signature-required orders are shipped “Signature Confirmation.”

8. If we cannot reach you to continue providing service to you, AHF Pharmacy may have an AHF Pharmacy employee (usually a Pharmacy Services Liaison) to see if you have moved or changed provider, or we may communicate with the “Alternate Contact Person” you have designated in this document.

9. The law requires AHF Pharmacy, from time to time, to send you certain types of regulatory notices. If you elect to place a “do not contact” request on your file, you must specify an alternate address to receive these notices. That address may be the pharmacy itself, your doctor’s office, or another address of your choice. If you do not specify an alternate address, we will be required to send these notifications to your mailing address on record.

10. “I acknowledge that from time to time, the Pharmacy is required to send certain legal and regulatory notices to me (each, a “Notice”). I further acknowledge that these Notices are mandatory, and the Pharmacy is required to send them even if I have indicated a “do-not=-contact” request. Accordingly, by checking the box below, I am designating Pharmacy as my address of record for receiving these Notices. I understand that if I decline to make this designation, then the Pharmacy will send the Notices to my regular address on file.”

11. I received and agree to the {Notice of Privacy Practices}. A copy of the Notice of Privacy Practices and welcome packet will be included in your confirmation email.
I Agree to the Disclosures and "Notice"
Date

MonthDayYear
Date
Signature*

Clear
Name of Pharmacy Representative
Should be Empty:

PrEP Initial Questionnaire

Due to your reported history of HIV/AIDS; You are currently not eligible for PrEP. Please consult with your health care provider.

Unfortunately we are unable to accept Kaiser for payment of your PrEP medication. But we do offer the Generic form of Truvada for $25 per bottle of #30.

Since we are not billing your insurance, the Cost of Brand name PrEP medication can be very costly.

But we do offer the Generic form of Truvada for only $25 for a bottle of #30

Since you have no health insurance, you have the option to sign up for insurance through our Benefits Counselor.

We also offer the Generic form of Truvada for $25 per bottle of #30 if you prefer not to use insurance or if no insurance is approved.

Income Affidavit

Patient Care Coordination Service Agreement

Refill Management Program

Complimentary Delivery Options

Disclosures and Notice of Privacy Practices