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It also gathers proof of income and proof of residency documentation options, plus household financial information with income sources and amounts. The form includes a certification statement authorizing release of information for billing, audits, monitoring, reporting, and needs assessment. 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It also includes other income documentation and proof of insurance or lack of coverage.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What documents qualify as proof of residency?",{"text":113,"@type":109},"The form lists utility bills, lease or rental agreements, a valid MS driver’s license/ID, statements from a homeless shelter, bank statements, federal IRS transcripts, and income verification showing a physical address with no PO box. It also requires verification of HIV status.",{"name":115,"@type":106,"acceptedAnswer":116},"What is the purpose of the patient and staff certification sections?",{"text":117,"@type":109},"The certification confirms the information provided is accurate and explains that false information may disqualify the applicant. 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I realize that providing false information may disqualify me from Ryan White Part C Program services. The Ryan White Part C Program cannot pay for services that have been paid or can reasonably be paid by any State, Federal, or private entity that provides health benefits.  \nI understand that my records are protected under State and Federal regulations and cannot be disclosed without my written consent. I understand that information can be released for billing, chart audits, program monitoring/quality improvement, data reporting, and needs assessment purposes. This document serves as my release of information. I also understand that I may revoke this consent at any time, in writing, except to the extent that action has been taken in reliance on it.  \nPatient’s Name______________________________________ Date______________________  \nStaff’s Name________________________________________ Date______________________  \nRevised June 2016","cbCair7plVNWwzxj","https://ap.wps.com/l/cbCair7plVNWwzxj","pdf",93453,"English","# Proof of Income\n# Proof of Residency\n# Applicant Information\n# Housing and Health Insurance\n# HIV Medication Status\n# Race, Ethnicity, and Gender\n# Language Spoken in Home\n# Household Financial Information\n# Certification and Signatures","[{\"question\":\"What documents are listed for proof of income?\",\"answer\":\"The form lists items such as pay stubs or earnings statements, Social Security/Disability Award Letters, unemployment statements, TANF/SNAP benefit statements, VA benefit statements, an affidavit of zero income, and tax form information for self-employment. It also includes other income documentation and proof of insurance or lack of coverage.\"},{\"question\":\"What documents qualify as proof of residency?\",\"answer\":\"The form lists utility bills, lease or rental agreements, a valid MS driver’s license/ID, statements from a homeless shelter, bank statements, federal IRS transcripts, and income verification showing a physical address with no PO box. It also requires verification of HIV status.\"},{\"question\":\"What is the purpose of the patient and staff certification sections?\",\"answer\":\"The certification confirms the information provided is accurate and explains that false information may disqualify the applicant. It also authorizes release of records under state and federal regulations for billing, chart audits, program monitoring/quality improvement, data reporting, and needs assessment, and includes patient and staff signature/date lines.\"}]","Ryan White Program Eligibility Form | PDF",1789800897]