- The Department of Health's application form must be completed:
- for each applicant upon initial application and recertification; and
- when there is a change in status affecting eligibility.
- The signature of the individual applying for assistance is required on the application form. In any case where the applicant is incapable of signing the application because of physical incapability, or mental incompetency, application shall be signed on behalf of such a person by his/her authorized representative.
- The form shall contain the following information, in addition to any other information which the Department of Health may require for the proper administration of the program:
- name, gender, date of birth, social security number, address and telephone number of the applicant;
- income information for the applicant; and
- information regarding any other health benefits or insurance coverage that is available to the applicant.
2. Medical Condition
An applicant must have a confirmed medical diagnosis of HIV/AIDS to participate in the program.
3. Financial Status
Financial eligibility for the VMAP program is limited to applicants where the adjusted gross income of applicant does not exceed 500% of the Federal Poverty Level (FPL). The Federal Poverty Guidelines are published on the U.S. Department of Health and Human Services website at http://aspe.hhs.gov/poverty/12poverty.shtml#guidelines and are hereby incorporated by reference.
Applicants must be domiciled within the State of Vermont and be able to provide proof of such domicile.
5. Other Application
If the applicant may be eligible for other programs offering assistance with the cost of medications, such as Medicaid, the applicant will be required to apply for such assistance.
Complete the application and mail it to:VT Medication Assistance Program Coordinator
VT Dept of Health
P.O. Box 70, Drawer 41 IDEPI
Burlington, VT 05402