Form 1 RWHAP Core Medical Services Waiver Attestation Form

OMB Number: 0906-0065

Expiration Date 09/30/2027

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 corresponding explanation. Include the proposed percentages of HIV service dollars allocated to core medical and support services in the Proposed Ratio for RWHAP Core Medical and Support Services section.

Name of recipient RWHAP Part A recipient RWHAP Part B recipient RWHAP Part C recipient

Initial request ^{Renewal request}

Year of request

REQUIREMENT	EXPLANATION
No ADAP waiting lists	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 within 30 days to core medical services for all HRSA RWHAP eligible individuals in the service area. Such access is without regard to funding source, and without the need to spend at least 75 percent of funds remaining from your RWHAP award (after reserving statutory permissible amounts for administrative and clinical quality management costs). 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.
PROPOSED RATIO FOR RWHAP CORE MEDICAL AND SUPPORT SERVICES
RWHAP core medical services		RWHAP support services
%		%

SIGNATURE OF CHIEF ELECTED OFFICIAL OR CHIEF EXECUTIVE OFFICER (OR DESIGNEE)

PRINT NAME

TITLE

DATE

Public Burden Statement: HRSA uses the documentation submitted in core medical services waiver requests to determine if the applicant/grant recipient meets the statutory requirements for waiver eligibility including: (1) No waiting lists for AIDS Drug Assistance Program (ADAP) services; and (2) evidence of core medical services availability within the grant recipient’s jurisdiction, state, or service area to all people with HIV identified and eligible under Title XXVI of the PHS Act. 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 0906-0065 and it is valid until XX/XX/2027. This information collection is required to obtain or retain a benefit (Ryan White HIV/AIDS Treatment Extension Act of 2009, Part A section 2604(c), Part B section 2612(b), and Part C section 2651(c)). Data will be kept private to the extent required by law. Public reporting burden for this collection of information is estimated to average 0.49 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.