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DOH Form 150-103 Agreement, Release of Information & Assignment of Benefits - Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap) - Washington
What Is DOH Form 150-103?
This is a legal form that was released by the Washington State Department of Health - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is DOH Form 150-103?
A: DOH Form 150-103 is an agreement, release of information, and assignment of benefits form for the Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap) in Washington.
Q: What is the purpose of DOH Form 150-103?
A: The purpose of DOH Form 150-103 is to gather necessary information and obtain consent from individuals seeking assistance through the Prep Dap program in Washington.
Q: What is the Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap)?
A: The Pre-exposure Prophylaxis Drug Assistance Program (Prep Dap) is a program in Washington that provides access to comprehensive HIV prevention services, including provision of HIV pre-exposure prophylaxis (PrEP) medications.
Q: What does DOH Form 150-103 include?
A: DOH Form 150-103 includes an agreement, release of information, and assignment of benefits sections.
Q: What information is required in DOH Form 150-103?
A: DOH Form 150-103 requires personal information, insurance information, and signature of the individual seeking assistance through the Prep Dap program.
Form Details:
- Released on May 1, 2017;
- The latest edition provided by the Washington State Department of Health;
- Easy to use and ready to print;
- Available in Spanish;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of DOH Form 150-103 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.
