B-4 Part B X08 Expenditures Report 4_9_2021_clean

Ryan White HIV/AIDS Program Allocation and Expenditure Forms

Part B X08 Expenditures Report 4_9_2021_clean

OMB: 0915-0318

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RWHAP Part B Supplemental Grant Award Amount


RWHAP Part B Supplemental Approved Carryover Amount


Total RWHAP Part B Supplemental Funds



OMB Number 0915-0318

Expiration date 09/30/2023








Total


Carryover

Award

Total

Percent

1. RWHAP Part B Supplemental AIDS Drug Assistance

Program Subtotal





a. ADAP Services





b. Health Insurance to Provide Medications





c. ADAP Access/Adherence/Monitoring Services





2. RWHAP Part B Supplemental Health Insurance

Premium & Cost Sharing Assistance





3. RWHAP Part B Supplemental Home and Community-

based Health Services





4a. RWHAP Part B Supplemental HIV Care Consortia





4b. RWHAP Part B Supplemental HIV Care Consortia/

Administration





5. RWHAP Part B Supplemental State Direct Services





6. RWHAP Part B Supplemental Clinical Quality

Management





7. RWHAP Part B Supplemental Recipient Planning &

Evaluation Activities





8. Recipient Administration





9. Column Totals








Consortia

Direct Services


Carryover

Amount

Total

Percent

Carryover

Amount

Total

Percent


Core Medical Services










a. AIDS Drug Assistance Program (ADAP)

Treatments










b. AIDS Pharmaceutical Assistance (LPAP)




- -




- -


c. Early Intervention Services




- -




- -


d. Health Insurance Premium & Cost Sharing

Assistance




- -






e. Home and Community-based Health Services




- -






f. Home Health Care




- -




- -


g. Hospice




- -




- -


h. Medical Case Management (including Treatment

Adherence Services)




- -




- -


i. Medical Nutrition Therapy




- -




- -


j. Mental Health Services




- -




- -


k. Oral Health Care




- -




- -


l. Outpatient /Ambulatory Health Services




- -




- -


m. Substance Abuse Outpatient Care




- -




- -


1. Core Medical Services Total










Support Services










a. Child Care Services










b. Emergency Financial Assistance










c. Food Bank/Home-Delivered Meals









d. Health Education/Risk Reduction









e. Housing









f. Linguistics Services









g. Medical Transportation Services









h. Non-Medical Case Management Services









i. Other Professional Services









j. Outreach Services









k. Psychosocial Support Services









l. Referral for Health Care and Support Services









m. Rehabilitation Services









n. Respite Care









o. Substance Abuse Residential Services









2. Support Services Total









3. Total Service Expenditures












Core Medical Services Expenditures


Amount

Percentage (Amount / Total

Service Expenditures)

ADAP



Health Insurance Premium & Cost Sharing Assistance



Home-and Community-based Health Services



State-Direct Services: Core Medical Services



Total Core Medical Services Expenditures



Support Services Expenditures

Amount

Percent

Consortia Services



State-Direct Services: Support Services



Total Support Services Expenditures



Total RWHAP Part B Supplemental Core Medical & Support Services Expenditures





Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of new and existing clients, and clients who have been out of care treated with RWHAP Part B supplemental funding. HAB will use these data to show the impact of the increased funding on reducing new HIV infections, identifying new HIV infections, engaging clients in care and treatment. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0318 and it is valid until 09/30/2023. This information collection is mandatory (through increased Authority under the Public Health Service Act, Section 311(c) (42 USC 243(c)) and title XXVI (42 U.S.C. §§ 300ff-11 et seq.). Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]


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AuthorRawimas Laohavanich (Wi)
File Modified0000-00-00
File Created2021-05-31

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