Texas HIV Medication Program – Documents

THMP Application

• Application for new clients or former clients reapplying for assistance - English (PDF)
• Application for new clients or former clients reapplying for assistance - Spanish (PDF)
• Application for current THMP clients updating or renewing their application - English (PDF)
• Application for current THMP clients updating or renewing their application - Spanish (PDF)
• Application for current THMP clients self-reporting - English (PDF)
• Application for current THMP clients self-reporting - Spanish (PDF)

Other Documentation

• TIAP Application - English (PDF)
• TIAP Application - Spanish (PDF)
• Income Calculation Worksheet - English (XLS)
• Income Calculation Worksheet - Spanish (XLS)
• Recertification/Self Attestation Fax Cover Sheet (DOC)
• ADAP ARIES Upload Cover Sheet (DOC)

Medical Certification Form - Word (DOC) | Medical Certification Form - PDF (PDF) – allows physicians to request any and all medications currently available through the THMP. See Medical Certification Form Quick Facts to learn more. Please note that a separate form for the drug Fuzeon (enfuvirtide) is no longer required. (updated November 2021)

It is recommended that patients initiating Fuzeon treatment receive additional training and support through Nurse Connections. This service is provided free to new and existing patients. For information or to enroll a patient, please call 1-877-4Fuzeon (1-877-438-9366).

Trogarzo Medical Certification Form - Word (DOC) | Trogarzo Medical Certification Form - PDF (PDF) – allows physicians to request Trogarzo through the THMP. (updated June 2020)

THMP Acceptable Documentation - English (PDF) | THMP Acceptable Documentation - Spanish (PDF) (updated September 2021)

Guidelines (PDF) – program guidelines for THMP applicants. (updated February 2021)

THMP Medication Formulary and Maximum Quantities Table (PDF) – the list of drugs currently available through the THMP. (updated January 2021)

Out of State Texas Residents Medication Guidelines (PDF) (updated May 2019)

THMP Extra Medication Request Form (PDF) – complete to request extra refill or a 2-month supply of medication. (updated June 2020)

ADAP Enrollment Worker Training Manual (PDF) – manual from enrollment worker training.

Training Request Form [Survey Monkey]

Application Completeness Fact Sheet (PDF) – worksheet that explains the difference between an incomplete application and an application with verification issues.

THMP Eligibility Due Date Calendar (PDF) – monthly reminder of documentation due dates for THMP clients.

To view and download documents related to the HIV SPAP (State Pharmaceutical Assistance Program), please visit the TEXAS HIV SPAP page.

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