Ryan White | Early Intervention Services Notice of Eligibility

Name

Address

It has been determined that you comply with the eligibility requirements to receive allowable services from the Ryan White Part C Early Intervention Services (EIS) program. Allowable services are based on the adherence of all requirements established by the EIS and its affiliates.

Your eligibility status for receiving services from the Ryan White Part C EIS program is valid for 1 year from the date of this correspondence. You must have a new determination for eligibility no later than the expiration date provided below in order to continue services. You must advise the eligibility staff when there are changes which affect your eligibility status.

Household Size

FPL

Income

Other Programs (list all that apply)

Re-determination Is Due No Later Than

Your signature below acknowledges your understanding of the following:

I have received a copy and verbal explanation of this notice.
I understand the requirements for receiving HIV/AIDS services.
I verify that I have complied with all of the Rights and Responsibilities in the application as verified by my signature on the application.

Electronic Signature

Date

EIS Staff Signature

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