Forms

Per Ryan White federal and state requirements, it is now required that all patients complete financial eligibility information every 6 months to receive services from our medical team (medical care, nursing, case management, financial counseling, social work services, therapy and medical case management). The following items are required and if not received you will be billed for all clinic visits until documentation is received.

Required items:

  1. Proof of NC Residency (valid NC drivers licenses, NC ID or utility bill in your name)
  2. Verification of income (disability or social security award letter, check stubs, W2 or tax returns)
  3. Proof of insurance if insured (private, Medicaid, Medicare, Medicare Part D)

Please download and complete these forms, and bring them with you to your visit.
If you need help with these forms, call our clinic at 919-966-7198.