[AGENCY NAME]
ALL INFORMATION ON THIS FORM IS CONFIDENTIAL. CONFIDENTIAL CLIENT INFORMATION CIVIL CODE 56.10
RYAN WHITE REGISTRATION AND ELIGIBILITY FORM – Page 1 of 4 / [Chart/ARIES #]
Name: / No Middle Initial
Last / First / MI
Mother’s Maiden Name: / Date of Birth: / Last 4 SSN #: / ***-**-
Contact Information (ARIES Subtab DEMOGRAPHICS/Contact Information) – Reassess every six months. Update in ARIES as needed. Verify with proof of identification and residence.
Address:
Street / City / Zip (Do not leave blank)
Home Phone: / Cell Phone: / Check if allows calls / Check if allows mail
Demographic Information (ARIES Subtab DEMOGRAPHICS / Demographic Detail) – Assess at intake.
Gender / Hispanic / Race
Male / Yes / White
Female / No / Black
TG Male to Female / Unknown / Asian
TG Female to Male / Pacific Islander
Other / American Indian or Native Alaskan
Unknown / Unreported/Unknown
Refused to report / Other:
Current Living Situation (ARIES Subtab DEMOGRAPHICS / Living Situation) – Reassess every six months. Update in ARIES as needed.
Board care or assisted living / Jail/Prison / Rental housing
Homeless from emergency shelter / Living with relatives/friends / Rented room
Homeless from the streets / Participant-owned housing / Substance abuse treatment facility
Hospital or other medical facility / Psychiatric facility / Transitional housing
Other:
Living Situation since:
Client Income (ARIES Subtab ELIGIBILITY / Financial) – Reassess every six months. Update in ARIES as needed. Verify with proof of income.
Employment: / Full Time / Not Employed / Part Time / Student/Volunteer
Client Wages:
Employment/Wages / $ / Worker’s Compensation / $ / Social Security Retirement / $
State Disability Ins/SDI / $ / Gifts / $ / Alimony/Child Support / $
Retirement / $ / Veterans Benefits/VA / $ / Total Income / $
Social Security Insurance / $ / Unemployment/UI / $ / Client has no income
Monthly Household Income: / $ / Percentage of Federal Poverty Level:
# People in Household:
Medical Insurance Coverage (ARIES Subtab ELIGIBILITY / Insurance) – Check one box for each insurance type. Reassess every six months. Update in ARIES as needed. Check “No insurance” in ARIES if not eligible for any type of insurance. If “start date” is unknown, enter date of assessment. Verify with proof of medical insurance.
Not eligible for Ryan White Medical Care if enrolled in Medi-Cal, Medicare, or Private Insurance.
Not eligible for Ryan White Mental Health Services if enrolled in Medicare or Private Insurance, or able to access comparable Medi-Cal or MSI Mental Health services.
Medi-Cal / Not eligible / Meets criteria but not enrolled / Eligibility pending / Enrolled. Start date
Medicare / Not eligible / Meets criteria but not enrolled / Eligibility pending / Enrolled. Start date
MSI (Public 1) / Not eligible / Meets criteria but not enrolled / Eligibility pending / Enrolled. Start date
Veteran’s Affairs / Not eligible / Meets criteria but not enrolled / Eligibility pending / Enrolled. Start date
Private Insurance / Not eligible – Must complete statement of no private medical insurance to be eligible for Ryan White Medical or Mental Health Services or if client has no other insurance. / Enrolled. Start date
Eligible but not enrolled (please explain)
[AGENCY NAME]
ALL INFORMATION ON THIS FORM IS CONFIDENTIAL. CONFIDENTIAL CLIENT INFORMATION CIVIL CODE 56.10
RYAN WHITE REGISTRATION AND ELIGIBILITY FORM – Page 2 of 4 / [Chart/ARIES #]
CDC Disease Stage (ARIES Subtab MEDICAL / Basic Medical) – Reassess every six months. Update as needed.
HIV Positive / AIDS Diagnosis / Other
Date of HIV Positive Test: / Date of AIDS Diagnosis: / HIV negative
HIV positive, disease stage unknown / CDC-Defined AIDS / Pediatric indeterminate
HIV positive, asymptomatic / Disabling AIDS / Unreported
HIV positive, symptomatic, not AIDS / Unknown
HIV positive, symptomatic disabling
Pediatric, confirmed HIV positive
Client Risk Factors (ARIES Subtab RISK AND ASSESSMENTS / Risk Factors) – Assess at intake.
Pediatric
Sex Partner Risk Factors
Client Risk Factors / (Heterosexual Contact ONLY)
Sex with male / Intravenous/injection drug user
Sex with female / Bisexual male
Injected nonprescription drugs / Person with AIDS or documented HIV
Received clotting factor for hemophilia/coagulation disorder / Other
Received transfusion of blood/blood components (other than clotting factor), transplant of tissues/organs or artificial insemination / Unknown
Worked in healthcare or clinical lab setting
Mother HIV infected/Perinatal transmission (pediatric only)
Sexual abuse (pediatric only)
Other
Unknown
[AGENCY NAME]
ALL INFORMATION ON THIS FORM IS CONFIDENTIAL. CONFIDENTIAL CLIENT INFORMATION CIVIL CODE 56.10
RYAN WHITE REGISTRATION AND ELIGIBILITY FORM – Page 3 of 4 / [Chart/ARIES #]

VERIFICATION OF ELIGIBILITY

Proof of Identification (ID) (Recommended at initial screening and upon expiration of proof)
Driver's License. Exp. Date: / Permanent residency card. Exp. Date:
Other government issued ID. Exp. Date: / Passport/foreign country ID. Exp. Date:
Other: / Expiration Date:
Proof of Diagnosis (Verify at initial screening)
WB / IFA / Signed Verification from M.D. / Proof provided at initial eligibility
Proof of Residence in Orange County (Verify every six months)
Lease agreement (current year) / Rent/mortgage receipt (most recent) / Vehicle registration (current)
Letter from government agency (most recent) / Signed statement of living arrangement / Voter registration (current)
Prison release papers / Utility bill (most recent)
Other:
Proof of Income (Verify every six months) – Check all that apply
Bank statements with direct deposits (3 consecutive months) / Veteran's Affairs (VA) Benefits / Award letter of Unemployment
Pay stub (3 consecutive months) / SSDI / Benefits
Pension statement (3 consecutive months) / SSI/SSP / W2-Tax return (most recent)
Signed statement of cash assistance/income or no income
Proof of Medical Insurance (Verify every six months) – Check all that apply.
Proof of Medi-Cal application / Medicare card or Medicare HMO / Statement of COBRA insurance
Medi-Cal card / Private health insurance card / Veteran’s Affairs (VA) card
Proof of MSI application / MSI card
Mental Health Insurance Coverage. Please include justification if client is receiving Ryan White Mental Health Services and are enrolled in Medi-Cal or MSI. Verify every six months. / Not Applicable (Skip)
Proof of Disability. Only required for services with disability requirements for eligibility. Verify as needed. / Not Applicable (Skip)
Verification of disability signed by M.D. / Date of expiration/next assessment:
Other (please describe):
Proof of Need for Nutritional Supplements. Only required for Nutritional Supplements. Verify every three months. / Not Applicable (Skip)
Verification of need for Nutritional Supplements signed by M.D. / Date of reassessment:
Other (please describe):
Proof of Homebound due to Disability. Only required for Home Delivered Meals. Verify every three months. / Not Applicable (Skip)
Verification of disability signed by M.D. / Date of reassessment:
Other (please describe):
Proof of Impairment to Carry On Daily Activities. Only required for Home Health Care. Verify as needed. / Not Applicable (Skip)
Verification of impairment signed by nurse or M.D. / Date of reassessment:
Other (please describe):
[AGENCY NAME]
ALL INFORMATION ON THIS FORM IS CONFIDENTIAL. CONFIDENTIAL CLIENT INFORMATION CIVIL CODE 56.10
RYAN WHITE REGISTRATION AND ELIGIBILITY FORM – Page 4 of 4 / [Chart/ARIES #]

CLIENT SIGNED STATEMENTS

Statement of Living Arrangement / Not Applicable (Skip)
Please complete only if no other documentation of your residency within Orange County exists. Please include your address or location and a brief description of the living arrangement. If you have no stable address, please indicate the location in Orange County (for example, 4th and Civic Center in Anaheim) that you most often spend the night.
Statement of Cash Assistance/Income or No Income / Not Applicable (Skip)
Please complete only if no other documentation of your income can be obtained. Please indicate your current income status:
I currently do not receive cash assistance and have no income Or
I am currently receiving cash assistance or an income. (Please complete box below)
I, / , receive income in the following manner:
Client Name
Date / Description (type of work, support from family) / Amount
Statement of No Private Medical Insurance
Must complete to be eligible for Ryan White Medical or Mental Health Services or if client has no other insurance / Not Applicable (Skip)
I, / , attest that I do not currently have and am not eligible for private medical insurance.
Client Name
Statement of No Private Dental Insurance
Must complete to be eligible for Ryan White Dental Services / Not Applicable (Skip)
I, / , attest that I do not currently have and am not eligible for private dental insurance.
Client Name
My signature below indicates that the information provided is true and accurate to the best of my knowledge. I understand that providing false information may disqualify me from Ryan White-funded services. I agree to immediately notify my provider of any changes in my living, income, or insurance status. This document has been completed, and read by or to me, prior to my signature.
Client Signature / Date Signed
Staff Completing Registration/Eligibility / Date Completed / Eligibility Expiration

Revised 03/13/2012