Ryan White Request for Client Assistance
Funds Fiscal Year 2020 - 2021
Client URN: _________________________________
Case Manager: _______________________________ Email: ________________________________
Agency: _____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: _____________________________________ Fax: __________________________________
Request:
Health Insurance Premium & Cost Sharing
EFA Medications
Reason for Request (Please be specific. “No other funding available” is not acceptable):
Identify all other funding sources you have applied to in order to get this request paid, and note
amount(s) received. That amount will be deducted from the requested amount, unless otherwise
indicated.
Medicaid/Husky _________ ACA _________ CADAP _________ CIPA _________
Medicare _________ Other (e.g. VA) _____________________________________________
Amount of Request: ________
___
_________ Check Payable to: _____________________________
Mail payment to:
Case Manager Signature: ________________________________________ Date: ______________
Case Manager Supervisor
Signature: _______________________________ Date: ______________
HEALTH INSURANCE PREMIUM AND COST
SHARING/EFA MEDICATIONS
FOR OFFICE USE ONLY Funds Used: RWA RWB
