Case Management Verification

(Clinical Setting)

I, _____________________________________, certify that I am not currently receiving medical or non-Print Client’s Name

medical case management services through the Ryan White Program or any other provider of HIV Case

Management services.

Client’s Signature Date

I hereby certify that prior to enrollment into the case management program, CAREWare was used to

verify that was not receiving medical or Print Client’s Name

non-medical case management services through the Ryan White Program.

Case Manager/Agency Representative Signature Date

Charlotte TGA Ryan White Program May 2015