Mending Communities, One Man, Woman and Child at a Time
Ryan White HIV/AIDS Program · Appendix 7
This form creates a PDF in your browser. Answers and supporting files are not sent to or saved by TM2K or this website. The completed PDF may contain sensitive health, insurance, income, address, and contact information; store and share it carefully.
The supplied statement and instructions are kept in the PDF.
Has there been a change in your change in your medical insurance, income, household size or address in the past 6 months?
If no: “There has been no change in my medical insurance, income, household size or address in the future, should there be a change with any of the criteria, I understand that I must notify the program immediately.” If your answer is no, you have completed this form. Please sign at the bottom.
If yes: complete the details that apply. You can attach proof documents and both sides of an insurance card; the files are appended to the downloaded PDF in this browser.
Enter the name as it should appear on the statement.
Choose Yes or No. If Yes, select each type of change and complete the matching section.
The source form asks for the new insurance information and both sides of the insurance card.
Attach a PDF, JPG, or PNG. Files are read locally and appended to the completed PDF; they are not uploaded.
Enter the new monthly household income and attach proof.
Attach a PDF, JPG, or PNG. The selected file is appended to the completed PDF in this browser.
Include everyone in the household and the number under age 18.
Enter the new address and attach proof of address.
Answer both questions as they appear on the supplied statement.
The original statement remains in the PDF. A patient or authorized witness must sign.
I understand I will be notified if any changes affect my eligibility for the cap on charges or sliding fee discount.