Part C Application and Release Form - siouxfalls.org (File)

For individuals without Medicare/Medicaid or private insurance, Ryan White Part C may be able to assist with the cost of office visits, outpatient labs, and/or immunizations. Individuals with insurance of Medicare/Medicaid who need assistance with a bill not covered by those sources may contact the Ryan White Part C representatives. Those bills will be assessed on an individual basis, based on federal guidelines. Please do not ask a physician’s office to list us as a secondary insurance or to bill us. To apply for this benefit, please fill out this application and sign the enclosed release of information...