Fillable Ryan White Part A Request for Client Assistance (ACT)

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Ryan White Part A Request for Client Assistance (ACT)

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The Ryan White Part A Request for Client Assistance (ACT) form is 2 pages long and contains:

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Ryan White Part A Request for Client Assistance
Funds Fiscal Year 2020 - 2021
Client URN: _________________________________
Case Manager: _______________________________ Email: ________________________________
Agency: _____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: _____________________________________ Fax: __________________________________
Reason for Request (Ple
ase be specific):
List the other funding sources you have attempted to access to get this request paid. If you received
a payment, please indicate the amount(s). That amount will be deducted from the request.
Has the client applied for any of the following assistance programs? If so, please indicate date of
application and outcomes.
Veyo _________________ First Transit _________________
Basic Needs Program _________________
Amount of Request: ________
___
_________
Send bus pass / tokens to:
Case Manager Signature: ________________________________________ Date: ______________
Case Manager Supervisor Signature: _______________________________ Date: ______________
TRANSPORTATION
FOR OFFICE USE ONLY Funds Used: RWA RWB
Transportation Arrangement Form
(Request for Bus Pass/Tokens)
Please fill out form in its entirety and return it via fax to 860-761-6711.
Client ID: Date:
Client Name: Age:
Address: Apt:
City: State: CT Zip:
Agency: MCM Email:
Case Manager: Phone:
Race: Ethnic: Gender: HIV Status: Transmission:
For each of the following service types, please provide the total number of appointments for the
month.
Service Type Place
# of
Appointments
Date
Methadone Program
Medical Appointment
Mental Health
Substance Abuse
Counseling
Lab Tests
Support Group
Other
For ACT Transportation Program Use Only
Number of Bus Pass/Tokens for Client: _______ Last URS/CareWare Update: ______________
Case Manager Contact Log:
Date: _______________ Issue: ____________________________________________________
Date: _______________ Issue: ____________________________________________________
Date: _______________ Issue: ____________________________________________________
Date: _______________ Issue: ____________________________________________________
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Ryan White Part A Request for Client Assistance (ACT)

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Completed 8 February 2021

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