Ryan White Annual Pay Cap Form

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.

We'd like your feedback

Was this page helpful?
I found this page helpful because the content on the page:
Check all that apply
I did not find this page helpful because the content on the page:
Check all that apply
Please include an email address if you would like a response
Please include an email address if you would like a response
Did you use this approach in your work?
Not yet because
If no, why not?