Notice of Privacy Practices
PDF
Handed directly to applicant

Eligibility Application (Attachment D)
Fillable PDF
Completed at intake

(General) Authorization to Disclose Confidential Information (DH 3203)
Fillable PDF
Completed for external medical providers and emergency contacts

Initiation of Services (DH 3204)
Fillable PDF
Completed at intake

Self Employment Tracking Sheet (Attachment J)
Fillable PDF
Completed as proof of income for applicants who are self-employed

Case Closure Form
Microsoft Word document
Must have supervisory approval

Brevard County ADAP Referral & Enrollment Verification Form
Fillable PDF
To be completed by the case manager or referral specialist and faxed to Brevard ADAP. Completed form must be uploaded to client’s profile.

Florida HIV Care Patient Eligibility Manual
PDF
Revised November 2022

Florida Department of Health HIV Case Management Guidelines
PDF
Revised June 2019

2020-2021 Patient Care Programs Administrative Guidelines
PDF
Revised December 2019

ADAP Formulary
PDF
Revised March 2024

APA/LPAP Formulary
PDF
Revised July 2023

Part A Contact List
Excel
Updated September 2025
Refer to www.orangecountyfl.hiv for client services in Orange, Osceola, Seminole, and Lake Counties

Part B Contact List
Excel
Updated September 2025

CAREWare 2025-2026 Subservice Codes
PDF

CAREWare Access Request Form (CARF)
Word

Income Assessment Tool
Excel document
Used to calculate annual and monthly income for client + five household members

Zero-Income Affidavit (HFUW) 
Fillable PDF
Completed as proof of income for applicants with no income

Payer of Last Resort Form (HFUW) 
Fillable PDF
Completed annually

Client Rights, Responsibilities, and Grievance Procedures (HFUW) 
Fillable PDF
Completed annually

Client Grievance Form (HFUW)
Fillable PDF
Completed according to Grievance Policy

Proof of Residency (HFUW) 
Fillable PDF
Completed as applicable

Comprehensive Needs Assessment Form
Fillable PDF
January 2025
Completed within 30 days of intake/enrollment and updated at least annually or as changes occur

Acuity Assessment Tool
Excel document
Revised March 2025
Due at the completion of the Comprehensive Needs Assessment and updated annually (Low) or every six months (Moderate/High)
Completed by EIS for newly diagnosed and previously lost to care clients

Care Plan
Excel document
Revised April 2025
Due at the completion of the Comprehensive Needs Assessment and updated every six months (Low), three months (Moderate), or monthly (High)
Completed by EIS within 72 hours of first EIS encounter & updated as each goal is achieved

Mental Health Referral Forms (updated 05-2025)
Initial Referral – Fillable PDF
Follow-Up Referral – Fillable PDF

Food Bank & Home-Delivered Meals
Fillable PDF
Includes:
-Food Rights & Responsibilities form
-Supermarket Gift Card Distribution form
-List of Allowable Personal Hygiene Items
Revised July 2024

Medical Transportation
Fillable PDF
Includes:
-Transportation Rights & Responsibilities form
-Bus Pass Distribution form
-Transportation Services Checklist
Revised August 2023

Contract Deliverables Schedule FY 24-25
PDF
Updated April 2025

Subcontractor Invoicing Guide
PDF
Updated April 2025

Monthly Expenditure Report Packet
Excel document
Updated April 2025

Provider Monthly Narrative
Excel document
Updated March 2024

Quarterly CQM Report
Excel document
Updated April 2025

Quarterly RSR Report
Excel document
Updated April 2025

A3 Problem Solving Tool
PDF
Updated April 2022