RYAN WHITE CARE PROGRAM
[This is NOT an on-line form. Please print out and fill it in; bring it with you when you come to IEP Clinic.]

APPLICATION
* FILL IN COMPLETELY/PLEASE PRINT
Name_________________________________ Do you currently have Medi-Cal?   Yes  No
Street_________________________________ City/State_______________   Zip____________
Date of birth(mo/day/yr)_________________ Social Security Number___________________
Day phone  (           )_____________________ Evening phone (             )____________________
Any restrictions on phone messages? __________________________________________________
If a caseworker referred you, please specify agency _______________________________________

* TO QUALIFY FOR THE PROGRAM YOU MUST ATTACH THE FOLLOWING DOCUMENTS TO THIS FORM
 Proof of income (under $1,600 a month) Tax Return, 2 last paychecks, Disability Award Letter, GA award letter (photocopy) 
Proof of San Francisco residency
Letter of referral & diagnosis from primary care physician
*BRIEFLY DESCRIBE YOUR CURRENT STATE OF HEALTH
_________________________________________________________________________
_________________________________________________________________________
*PLEASE DESCRIBE YOUR PRIOR INVOLVEMENT, IF ANY, WITH CHINESE MEDICINE
_________________________________________________________________________
_________________________________________________________________________
*INDICATE WHICH SERVICES YOU WOULD LIKE TO RECEIVE
Acupuncture treatment Herbal medicine Massage therapy
CONTRACT


1. I agree to participate in the Chinese Herbal, Acupuncture and Massage Program sponsored by the Immune Enhancement Project in cooperation with the City of San Francisco Department of Public Health and the Ryan White CARE Program. I understand that the program will be paid for by the Ryan White CARE funding. I understand that funding is limited, and some services will not be covered by Ryan White CARE funding. I will be responsible for payment of such extras if I choose to take them.
2. I understand that there will be periodic program questionnaires needed for the funding agencies to gauge the effectiveness 		of the program, and that an evaluation appointment will take the place of an acupuncture treatment every 16 weeks.
3. If I choose to discontinue the program at any time, I will notify IEP's Program Director as soon as possible, and future reinstatement will be at IEP's discretion based on funding availability.
4. I authorize IEP to allow either persons conducting program audits (Department of Public Health employees) or persons conducting internal chart reviews to access my files. I further understand that these persons are required and have agreed to treat all information in my files confidentially.

My signature here indicates that I agree to abide by the agreements in this document.

Signature _________________________________________     Date________________


Client contact dates
[OFFICE USE ONLY]
3_______________
Interested? Yes/Enroll date ______
No/Reason__________________ __________________________
1_______________
 4_______________
2_______________
 5_______________


 


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