Client Eligibility Forms

This webpage provides eligibility forms for new clients, as well as current clients who are recertifying for the God’s Love service. Please use the appropriate link below to access and fill out the electronic version of each form.

For all clients:

• Referral and Medical Form: click here to access the form
• Client Policies and Procedures: click here to access the form
• HIPAA Confidentiality Form: click here to access the form

Clients living with HIV, or their referrers, should complete the above forms, AND submit the following documents:

• Proof of Income and Residence: click here to access the form
• Grievance Form: click here to access the form

When filling out the form, please be sure to click “submit” to ensure your information is saved and sent to us. FormDr, the online tool for completing these forms, is HIPAA compliant.

If you submit these forms electronically, you do not need to send paper copies to God’s Love We Deliver.