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Referral

Ryan White Short Term COVID-19 Support

Preapproval Required through Ryan White Partner.

Step 1 of 5

20%

Preapproval required
Referral must be made by a professional employed by a Ryan White-funded agency, e.g. a medical case manager, Linkage to Care coordinator, etc. Eligible clients must have been financially impacted by loss of job, reduction of hours, or self-imposed short term suspension of work directly related to COVID-19.

NOTE: If a client needs access to meals/food, but is not part of this preapproved program, please visit our Online Referral Form and select Project OpenHand Columbus. Then use the “Emergency Meal” option.

Clients submitting for this program will be cross referenced with the funding source to confirm eligibility.
Acknowledgement*
- I confirm the client being referred to this program been preapproved to receive this service and I am a professionals employed by a Ryan White-funded agency, e.g. a medical case manager, Linkage to Care coordinator, etc. I understand my client will be cross checked by the funding party to confirm approval. This client has been financially impacted by loss of job, reduction of hours, or self-imposed short term suspension of work directly related to COVID 19.

Referring Agency Information
Name of HIV Care Provider or Agency*
Other (Please Specify)*
Name of Agency Representative Making Referral*
Agency/Representative Phone*
Agency/Representative Email*

Patient Information
Patient Name*
First Last
Patient Date of Birth*
Month
Day
Year
Patient Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient County of Residence*
Emergency Contact Name
First Last
Emergency Contact Relationship
Emergency Contact Phone

Patient Information
At the time of completing this application, has the client been confirmed or presumed positive for having COVID-19?*
- Yes
- No
Year Patient Tested Positive for HIV*
Client’s Ryan White Part A Eligibility Start Date*
Month
Day
Year
Client’s Ryan White Part A Eligibility Expiration Date*
Month
Day
Year
Household Composition*
- Lives alone
- Lives with other adults
- Lives with children
- Unknown
Marital Status*
- Single
- Married
- Divorced
- Widowed
Gender Identity*
Check all that apply.
- Male
- Female
- Transgender (MTF)
- Transgender (FTM)
- Other (Please Specify)
Gender Identity - Please Specify*
Ethnicity*
- Not Hispanic/Latino(a)
- Hispanic/Latino(a)
Race*
Check all that apply.
- White
- Black or African American
- American Indian or Alaskan Native
- Asian
- Native Hawaiian or Pacific Islander
If Asian, please specify:
Check all that apply.
- Indian
- Chinese
- Filipino
- Japanese
- Korean
- Vietnamese
- Native Hawaiian or Pacific Islander
- Unknown
- Other (Please specify)
Race - Asian/Other (Please Specify)
If Native Hawaiian or Pacific Islander, please specify:
- Native Hawaiian
- Samoan
- Guamanian or Chamorro
- Other (Please specify)
If Hispanic, please specify:
- Mexican, Mexican American, Chicano(a)
- Puerto Rican
- Cuban
- Unknown
- Other Hispanic, Latino(a) or Spanish Origin (Please specify)
Hispanic/Latino(a) - Other (Please Specify)
Estimated Monthly Income
Notes

Requested Services
Please select from the services offered through this program:
Check all that are requested by the client.

Note: Referrals received on Monday, Tuesday, or Wednesday will be delivered on Friday between 8am-4pm. Referrals received on Thursday, Friday, Saturday, or Sunday will be delivered on Tuesday between 8am-4pm. If any changes to these days or times are made, the client will be notified via phone. Please email Lbunck@lifecarealliance.org if you have any questions.
COVID-19 Cleaning Kit
This will be a bag of assorted items delivered one time to the client’s home. Check all the apply and are needed.
- Basic Bags (Will include hand sanitizer, soap, shampoo, toilet paper, disposable mask, antibiotic cleaner, etc.)
Shelf-Stable Food/Produce Box
This will be delivered two times a month. Assortment of shelf-stable items (such as macaroni and cheese, soups, cereal, beans, canned vegetables/fruits, peanut butter, etc.) and fresh produce from the Mid-Ohio Food Bank.
- Shelf-Stable Food/Produce Box
- Shelf-Stable Food/Produce Box — Vegetarian Option
Anything else we need to know or special requests:
By completing this referral, I verify that all client eligibility information has been properly reviewed and documented per Columbus Public Health policy and that the client is approved to access Columbus Ryan White Part A services.*
- Click here to confirm
Digital Signature of Referring Professional*
Please type your name below to serve as your digital signature

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