Housing Opportunities for Persons With AIDS (HOPWA) assistance in Nebraska requires proof of HIV status, and this one-page Division of Public Health form provides it. The certifying provider states that the named applicant has tested positive for HIV and gives the test date, then adds identifying and licensing details. A notes area allows any additional information.
A physician, certified health care provider or certified HIV testing site must complete the certification, with printed name, signature, license number if applicable and issuing state, date and contact details. The applicant's name and Social Security number appear at the top.
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Statement of HIV Verification - HOPWA
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The form says it must be filled out by a physician, a certified health care provider or a certified HIV testing site. The person certifying prints their name, signs, dates the form and gives a license number and issuing state if applicable, plus contact details.
The applicant's name and Social Security number, a statement certifying that the applicant tested positive for Human Immunodeficiency Virus on a given date, and the certifier's printed name, signature, license number, date, phone and address. Free-text notes lines follow at the bottom.
The form is titled Statement of HIV Verification - HOPWA and is issued by the Nebraska DHHS Division of Public Health for the Housing Opportunities for Persons With AIDS program. It is not described as serving any other program.