Ryan White Annual Pay Cap Form

West County Health Centers

Form for clients explaining the maximum annual amount of costs they will incur for RWHAP services they receive. Once this payment cap is reached in a given year, Ryan White providers will not charge any more for the rest of the year. The payment cap is calculated as a percentage of the client's annual income, as described in the Ryan White legislation.

The form includes a signature line for clients to attest their understanding of the payment cap concept and a place for patients to track out-of-pocket expenses they incur for all providers and services during the year.

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