THMP – Documents
TakeChargeTexas (TCT) allows clients and agency workers to complete applications online for THMP and other Ryan White services. This can be completed from the comfort of home or through a local agency.
Call your local agency or THMP at 800-255-1090 with questions about how to apply for services.
Documentation Needed for TCT
THMP needs the following documents uploaded to TCT to apply for the program:
- Medical Certification Form - Word | Medical Certification Form - 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. 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 (877-438-9366).
- Documents for Proof of Support or Income – this includes documents THMP will accept for proof of income, support, residency, and insurance:
- THMP Acceptable Documentation - English | THMP Acceptable Documentation - Spanish
- Supporter Statement - English | Supporter Statement - Spanish – this form should be used only when an applicant has no income and is unable to provide any documentation showing how they manage.
- THMP Self-Employment Log - English | THMP Self-Employment Log - Spanish – this form should only be used by persons with self-employment income (money made working for yourself or as a subcontractor) who have no documentation showing this income.
- Income Verification - English | Income Verification - Spanish – this form should be used only when no supporting income documentation is available.
Information About Program Medications
- Guidelines – program guidelines for THMP applicants.
- THMP Medication Formulary and Maximum Quantities Table – the list of drugs currently available through the THMP.
- Out of State Texas Residents Medication Guidelines
- THMP Extra Medication Request Form – complete to request extra refill or a 2-month supply of medication.
- Trogarzo Medical Certification Form - Word | Trogarzo Medical Certification Form - PDF – allows physicians to request Trogarzo through the THMP.
- Training Request Form
- Application Completeness Fact Sheet – worksheet that explains the difference between an incomplete application and an application with verification issues.
- THMP Eligibility Due Date Calendar – 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.