• HIV/AIDS
  • Chlamydia
  • Gonorrhea
  • Syphilis
  • Hepatitis B
  • Hepatitis C
  • Tuberculosis
  • Program Areas

  • About
  • Data
  • Vaccine Information
  • Protect Yourself, Get Tested
  • Patients Resources
  • Reporting
  • Educational Materials
  • Events and Trainings
  • Supplies Order Form
  • Contact Us
  • Information for Contracted Partners

  • Counseling, Testing, and Referral (CTR) Sites
  • Ryan White Case Management Agencies
  • TB Case Managers
  • Syringe Service Program
  • Community Planning Group

Ryan White Part B Program

 

Policies and Procedures:

 

  • North Dakota Ryan White Part B Program Manual
  • MAVEN User Guide for RW Case Managers
  • Case Management Agencies

Forms:

 

  • Eligibility Forms

    • Enrollment Application
    • Reenrollment
    • Recertification

 

  • Client Forms

    • Client Acuity Scale
    • Care Plan 1
    • Care Plan 2
    • Client Satisfaction Survey (annual)
    • Release of Information (annual)
    • Client Rights and Responsibilities (part of enrollment; as needed)
    • Statement of No Health Coverage
    • Marketplace Employer Coverage Tool

 

  • Ryan White Services Reimbursement Forms

    • Request for Marketplace Insurance Premium Assistance 
    • Request for Emergency Assistance
    • Request for Medical Health Care
    • Request for Oral Health Care
    • Request for Out of State Treatment
    • Request for Vision Care
    • Transportation Reimbursement Request

 

  • AIDS Drug Assistance Program (ADAP)

    • ADAP Formulary
    • ADAP Pharmacies
    • Request for TrogarzoTM
    • Request for Prescription Not on RW Drug Formulary

 

  • Other

    • Grievance Resolution
    • Request for Reimbursement

 

For any questions, please contact the Ryan White Part B Program.

Risk Assessment

Take an HIV/STD/viral hepatitis risk assessment survey.

About Disease
HIV/AIDS
Chlamydia
Gonorrhea
Syphilis
Hepatitis B
Hepatitis C
Tuberculosis
Data
Vaccine
Resources for Positives
HIV/AIDS
Chlamydia
Gonorrhea
Syphilis
Hepatitis B
Hepatitis C
Tuberculosis
Reporting
Events & Trainings
Educational Materials
Healthcare Providers
Educators
Parents
Supplies
Contact Us

2635 E Main Ave, Bismarck, ND 58505 | 800.472.2180