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.