Ryan White Part B Program

Policies and Procedures:

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

Forms:

• Eligibility Forms

  • Enrollment Application
  • Re-enrollment Form
  • Recertification

• Ryan White Services Reimbursement

  • 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 Brand Name Drug
  • Request for Medication Not on RW Drug Formulary
  • Trogarzo Prior Authorization (available soon)

• Other

  • Marketplace Insurance Enrollment - RW Premium Assistance
  • Grievance Resolution
  • Release of Information
  • Request for Reimbursement
  • Satisfaction Survey

For any questions, please contact the HIV/Ryan White Program.