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
  • Reenrollment Form
  • Recertification

• Client Forms

  • Client Acuity Scale
  • Care Plan
  • 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 Trogarzo^TM
• Request for Medication Not on RW Drug Formulary

• Other

• Grievance Resolution
• Request for Reimbursement

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