Case Management Verification
(Clinical Setting)
I, _____________________________________, certify that I am not currently receiving medical or nonPrint 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
Charlotte TGA Ryan White Program
Date
May 2015