Pending / Clinic Name City / Concord / Yes No City / Boston / City/Town / /
Company
Federal Income Tax Bank Statement / /
Facility
Clinic Name City/Town / Clinic Address Phone pg. / /
IndustryTerm
health insurance policy / insurance continuation / mental health services / insurance premiums / substance use services / insurance status / /
MedicalCondition
TB / syphilis / HIV / HIV/hepatitis C / HIV/hepatitis B / Opportunistic Infection / AIDS / HIV/AIDS / /
MedicalTreatment
Counseling / /
Organization
AIDS Service Organization / Federal Government / office of Ombudsman / DEPARTMENT OF HEALTH / HUMAN SERVICES DIVISION OF PUBLIC HEALTH SERVICES NH RYAN WHITE CARE PROGRAM / MEDICARE / /
Person
Viral Load Lowest / / /
Position
Witness Signature Date Physician / care physician / pharmacist / case manager / x4502 CARE Manager / Section Director / case manager / physician / representative / NH CARE Program Manager / Controller / /
STATE OF NEW HAMPSHIRE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF PUBLIC HEALTH SERVICES NH RYAN WHITE CARE PROGRAM[removed][removed]x4502[removed]fax