Out of Pocket Medical Expense
Tracking Form
Total Health Care’s Ryan White program is partly supported by grants from the Ryan White Care Act. Thanks to this funding, if your healthcare costs go over your annual payment cap (which is based on a percentage of your income), Total Health Care will not charge you for any additional services you receive. Please submit your healthcare costs for the year to date via the form below to allow proper tracking and documentation.
Should you have any questions or concerns, do not hesitate to contact your Ryan White case manager.
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