Ryan White Part B Program

Policies and Procedures:

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

Forms:

• Eligibility Forms

  • Enrollment Application (rev. 07/2021)
  • Reenrollment (rev. 07/2021)
  • Recertification (rev. 07/2021)

• Client Forms

  • Client Acuity Scale (rev. 07/2021)
  • Care Plan 1 (rev. 07/2021)
  • Care Plan 2 (rev. 07/2021)
  • Client Satisfaction Survey (annual)
  • Release of Information (annual, rev. 07/2021)
• Client Rights and Responsibilities (part of enrollment or as needed; rev. 07/2021)
• Health Coverage Screening and Attestation (rev. 07/2021)
• Marketplace Employer Coverage Tool

• Ryan White Services Reimbursement Forms

  • Request for Marketplace Insurance Premium Assistance  (rev. 11/2021)
  • Request for Emergency Assistance
  • Request for Medical Health Care
  • Request for Oral Health Care (rev. 07/2021)
  • Request for Out of State Treatment
  • Request for Vision Care
  • Transportation Reimbursement Request

• AIDS Drug Assistance Program (ADAP)

  • ADAP Formulary
  • ADAP Pharmacies
• Request for Trogarzo^TM
• 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.