Form 1 HRSA RWHAP Core Medical Services Waiver Request Attestat

[Insert OMB # here 0906‐XXXX] 

HRSA Ryan White HIV/AIDS Program (RWHAP)
Core Medical Services Waiver Request Attestation Form
This form is to be completed by the Chief Elected Official, Chief Executive Officer, or a designee of either.
Please initial to attest to meeting each requirement after reading and understanding the explanation.

Name of recipient _________________________________________________________________
RWHAP Part A recipient

RWHAP Part B recipient

Initial request

Renewal request

RWHAP Part C recipient

Year of request ___________________________ 

REQUIREMENT
No ADAP waiting lists

EXPLANATION
By initialing here and signing this document, you attest there are no
AIDS Drug Assistance Program (ADAP) waiting lists in the

service area.

Availability of, and
accessibility to core
medical services to
all eligible
individuals

By initialing here and signing this document, you attest to the
availability of and access to core medical services for all HRSA RWHAP
eligible individuals in the service area within 30 days. Such access is
without regard to funding source, and without the need to spend on
these services, at least 75 percent of funds remaining from your
RWHAP award after reserving statutory permissible amounts for
administrative and clinical quality management. You also
agree to provide HRSA HAB supportive evidence of meeting

this requirement upon request.

Evidence of a public
process

By initialing here and signing this document, you attest to having had a
public process during which input related to the availability of core
medical services and the decision to request this waiver was sought
from impacted communities, including clients and RWHAP
funded core medical services providers. You also agree to

provide supportive evidence of such process to HRSA HAB
upon request.

______________________________________________________________________
SIGNATURE OF CHIEF ELECTED OFFICIAL OR CHIEF EXECUTIVE OFFICER (OR DESIGNEE)
______________________________________________________
PRINT NAME
______________________________________________________
TITLE
_____________________________________________________________
DATE 
Public Burden Statement:  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 project is 0906‐XXXX.  Public reporting burden for this collection of information is 
estimated to average 4 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 14N39, Rockville, Maryland, 20857.                                  

                                                                                                                                                       Expires XX/XX/20XX