Member Wellness Update

Member Wellness Update

Aliveness members are asked to complete this form at least every six months. It allows us to offer help as needed and keep our services FREE for folks living with HIV!
Name *

First Name Last Name
Aliveness Member Number
Four digits - also called an Access Pass
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number
Email
example@example.com
Are you comfortable receiving mail from Aliveness?

Yes No
May Aliveness call you on the phone?

Yes No
My annual income is: *
If you have no personal income, how do you pay your expenses? Check all that apply.

My family member(s) are working or own a business. My family member(s) receive child support, SSI, SSDI, pension, etc. My family member(s) get money from a friend, relative, or organization. A relative, friend, or organization pays all my expenses. I pay my expenses from money in savings, checking, trust fund account, or the sale of personal items. Another source
Number of People in My Household:
Please include children, family, live-in partners if you share finances. If you live alone or support only yourself financially, you have a household of 1.
Please upload PROOF OF INCOME - examples: pay stubs, benefit letter, tax return, etc.
You are not required to provide proof if you have no income. You are also not required to provide proof if your income exceeds 400% of the Federal Poverty Guidelines (income over $51,040 for one person or over $68,960 for a two-person household). ALL members with income between 0 and $51,040 must upload a document to show your income.
Date of my last HIV/AIDS medical appointment *

Month Day Year
Date
How often do you see your HIV/AIDS doctor? *

Every 3-6 months Once a year (every 12 months) I am not currently receiving medical care and treatment for my HIV
What type of health insurance do you have? You can check more than one option. *

Medicaid (MA, MinnesotaCare): Medicare A/B: Medicare D: VA, Tricare, or other military health care: Private - employer: Private - individual: Indian Health Services: I have health insurance, but do not know what type: I do not have health insurance right now:
Please upload PROOF OF HEALTH INSURANCE - examples: a picture of your health insurance card, document showing active health insurance, etc.
What is your housing status? *

Stable/Permanent (rental, homeowner) Temporary (with friends/relatives, treatment facility, transitional housing) Unstable (homeless, staying in or out of shelter)
Please upload PROOF OF MINNESOTA RESIDENCY - examples: MN state ID, MN driver's license, picture of lease or utility bill
Signature (use your finger or mouse to sign) *

Clear
Date Submitted *

Month Day Year
Date
Should be Empty: