Skip to main content

Per Ryan White federal and state requirements, it is now required that all patients complete financial eligibility information 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)
We are currently in the process of updating the forms below.
If you need help or have questions regarding these, please call our clinic at 919-966-7198.
  • Financial Eligibility Application
  • Patient Caps on Charges Form
  • Acknowledgment of receipt of Bridge Counseling and Health Information Reporting forms
  • Health Information Reporting Form
  • Bridge Counseling Form