Enrollment Must-Haves

Paperwork, documents and forms you will need when you meet with your case manager

  • 1. Proof of HIV infection (must be provided only on initial intake)

    All clients must provide medical/legal documentation of HIV Infection. This documentation must be verified at the initial eligibility assessment only. One of the following acceptable documents is required:

    • LAB TEST
      • A computer-generated HIV+ laboratory test (with confirmatory testing, i.e. Western Blot or detectable viral load) with the individual’s name pre-printed.)
    • AN ANONYMOUS HIV TEST RESULT containing identifying information sufficient to ensure a reasonable certainty as to the identity of the test subject, e.g. gender and date of birth (valid for only 30 days from the start of services at the agency). Documentation submitted form the healthcare provider
      • A statement or letter signed by a medical professional (acceptable signatories listed below) indicating that the individual is HIV+, including the individual’s name and the phone number of the medical professional. Confirming documentation must be in the client’s medical record.
    • PREVIOUSLY OBTAINED DIAGNOSIS
      • A medical progress note, hospital discharge paperwork, or other document signed by a medical professional (acceptable signatories listed below) indicating that the individual is HIV+, including the individual’s name and the phone number of the medical professional.

     

    Acceptable signatories:

    • A licensed physician
    • A licensed physician assistant
    • A licensed nurse practitioner
    • A registered nurse working under the supervision of a physician
    • A licensed Master’s level social worker (LMSW, LCSW) working under the supervision of a physician
  • 2. Proof of Residency (minimum of two items)/or the “Dependent Support Form” or the “Homeless Declaration Form”

    Ryan White Part A Residency Requirements

    Clients must provide current documentation as proof of residency, current meaning all documentation must be within 12 months of preprinted date on document. Residency documentation for minors is required for a parent or guardian with whom the minor resides.

     

    Acceptable residency documentation includes:

    • Valid driver’s license or ID
    • Current utility/phone/cable bill in the name of the client
    • Current lease, rental agreement or mortgage in the name of the client or listing the client as an occupant
    • Current Property tax documents
    • Current credit card bill in the name of the client
    • Current letter on company letterhead signed by the director of a recognized group home, care home or transitional living facility
    • Any type of current business correspondence with the client’s name and address pre-printed, e.g. auto registration, insurance, bank/brokerage statement, food stamp letter, Social Security letter, Medicaid letter
    • Current pay stub with address
    • Post Office Boxes as long as there is another means to verify the address (i.e. current utility bill) (HIV/AIDS Policy Notice 13-02)
    • Client Residency Statement

     

    The following documentation is acceptable for undocumented and/or homeless clients or clients that cannot initially verify:

    • Agency temporary residency affidavit signed and dated by the client (valid for only 30 days from the start of services at the agency)
    • Letter on company letterhead from a case manager, social worker, counselor or other professional from another agency who has personally provided services to the client.

     

     

  • 3. Proof of Identification (Photo ID)

    Verification of identity must be included in all client charts. Verification of identity, like HIV Status, does not require additional documentation once it has been established, as long as the document is not expired.

     

    Acceptable documentation for identity:

    • Virginia Driver’s License
    • Tribal ID
    • Virginia Identification Card
    • Military ID
    • Virginia Department of Corrections identification card
    • Employment badge with picture
    • Student ID with picture
    • U.S. immigration documents with picture
    • Credit card with picture
    • U.S. naturalization, citizenship, passport or other Federal documents with picture
    • Driver’s license or identification card issued by another US state
    • A government-issued ID from a country other than the U.S.
    • Birth certificate (cannot be used by married women)
    • Social Security card
    • Medicaid/Medicare card
    • VA ID Card
  • 4. Proof of Income Level

    Documentation of income must be provided for all members of the client’s household. Income documentation for minors is required for the parent(s) or guardian(s) with whom the minor resides.

     

    Acceptable income documentation:

    • a current payroll stub/copy of payroll check/bank statement showing direct payroll deposit
    • Letter from employer on company letterhead indicating weekly or monthly wages
    • Proof of self-employment to include tax returns or business records or the like
    • Unemployment benefits letter/copy of check
    • Private disability/pension letter on company letterhead
    •  Alimony/child support/foster care payments
    • IRS 1040 form (tax return)/W2 form/1099 form
    • Social Security award letter or proof of application for Social Security (valid for 6 months only)
    • VA benefits letter
    • Medicaid letter
    • Child or spousal support order with judge’s signature and date
    • Food Stamp award letter (TANF)
    • Client living off savings: bank/investment account statements from 3 consecutive months showing withdrawals for living expenses
    • Agency income affidavit signed and dated by the client (valid for only 30 days from initial service date if client reports income greater than $0.)
    • Supporter Statement signed and dated by the supporter, which includes the amount and type of support (room only, room and board, cash assistance, etc.) and the supporter’s phone number and address for verification (must be updated/verified semi-annually from the first date of service.)
    • No Income Statement (page 5 of MCM forms is acceptable)
    • Homeless client: letter on company letterhead from a case manager, social worker, counselor or other professional from another agency who has personally provided services to the client.
  • 5. Verification of Insurance or Other Payer Sources

    Ryan White Part A is the payer of last resort for those services that are reimbursable by other payer sources and for services which payment has been made or can reasonably be expected. Client files must document, on a semi-annual basis, the agency’s efforts to verify client eligibility for other payer sources.

     

    Medical Case Managers, Referral for Health Care and Supportive Services Staff and/or Eligibility Specialist must vigorously pursue eligibility of other funding sources e.g. Medicaid, CHIP, Medicare, state-funded HIV/AIDS programs, employer-sponsored health insurance coverage and other private health insurance.

     

    Providers must assure that individual clients are enrolled in health care coverage whenever possible.  All clients who meet the eligibility requirements (In lieu of maintaining the information in individual client files, the agency may employ a tractable mechanism that assures verification at least semi-annually.)

     

    Services rendered under Ryan White Part A for days on which a client was eligible for Medicaid, Medicare, or another third-party payer will be recouped by the City of Norfolk. The agency however, will not be cited for failing to use Ryan White as the payer of last resort if the above documentation showing the client is ineligible for Medicaid or Medicare is in the client file at the time of the site visit.

     

    1. Acceptable to demonstrate client enrollment or attempt to enroll in ACA:
      1. Marketplace eligibility notice
      2. Marketplace notice of ineligibility
      3. Marketplace Certificate of Exemption
      4. Federal Tax Form 1040 and accompanying schedules
    2. For clients with insurance coverage, copies of the insurance card must be maintained in the client record along with other pertinent information such as co-pay amounts, deductibles, caps on coverage.
    3. Acceptable documentation to verify Medicaid/Medicare eligibility status:
      1. Verification of employment, i.e. payroll stub, copy of payroll check, bank statement showing direct payroll deposit, letter from employer on company letterhead indicating weekly or monthly wages no greater than 6 months old (to demonstrate Medicaid/Medicare eligibility status)
      2. Medicaid/Medicare rejection letter covering the dates of service
      3. Signed note in patient record showing date and time of call to Medicaid/Medicare
      4. Medicaid Referral Assessment form.
      5. Marketplace eligibility notice
      6. For undocumented or homeless clients, Letter on company letterhead from a case manager, social worker, counselor or other professional from another agency who has personally provided services to the client

     

    NOTE: The Grantee’s Office may during site visits to agencies providing Medicaid/Medicare reimbursable services, record the social security numbers of “reviewed” client records only. This measure is intended for the sole purpose of assuring that Ryan White Part A is the payor of last resort, as directed/dictated by The Health Resources & Services Administration (HRSA).

     

    After the Medicaid/Medicare eligibility status has been verified/established, all records of the Social Security Number are destroyed. All references to a client will be made by the use of the established Unique Record Identifier (URN).

     

     

HRSA DISCLAIMER

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87) via grant H89HA00007.

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