Forms

Eligibility Forms


Ryan White Part A / AIDS Drug Assistance Program (ADAP) Enrollment Application

This application is completed when a new individual is seeking Ryan White Part A (RWPA) services for the first time. Income and residency verification documents and proof of diagnosis is required. The application is reviewed and forwarded to the AIDS Drug Assistance Program (ADAP).

Ryan White Part A / AIDS Drug Assistance Program Renewal

This application is completed during the birthday month of a current Ryan White Part A (RWPA) client. Income and residency verification documents are required. The application is reviewed and forwarded to the AIDS Drug Assistance Program (ADAP)



Ryan White Part A / AIDS Drug Assistance Program Half Birthday Attestation

This application is completed during the half birthday month of a current Ryan White Part A (RWPA) client. The client is able to attest that there is no income, residency or insurance changes. If a client does have changes in income, residency or insurance, they will need to provide current verification documents. The application is reviewed and forwarded to the AIDS Drug Assistance program (ADAP).



Ryan White Part A / AIDS Drug Assistance Program Change Form

This form is used when a client has a change in name, residency or income outside of their renewal month. This must be submitted to the Central Eligibility (CE) Office for follow up.



Supplemental Forms

Supplemental Forms are required to be completed at each agency and filed in all Ryan White Part A client charts. Please contact specific agencies or providers for more information.

Privacy Practices

Standard Privacy Practices notices should be given to clients at initial visit. Each agency must include in the client file a signed statement of Notice of Privacy Practices or an annotation referencing client's refusal to sign a statement. These forms are developed by the agency.



Client Rights & Responsibilities


Each agency must include in the client file a signed statement of Client Rights and Responsibilities or an annotation referencing client's refusal to sign a statement. These forms are developed by the agency.



Learn more about client rights and responsibilities by viewing:

Arizona Health Care Cost Containment System (AHCCCS) / Medicaid Providers


The goal of Arizona Health Care Cost Containment System (AHCCCS) providers is to provide clients with the highest quality healthcare. Many Ryan White clients are also enrolled in AHCCCS. View our Community Providers Brochure (PDF) for a sampling of HIV friendly providers that accept AHCCCS.