ATTACHMENT 11 CORE MEDICAL SERVICES WAIVER REQUEST ATTESTATION FORM (UNSIGNED).PDF

OMB Number: 0906-0065 
Expiration Date 09/30/2024 
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 
           
RWHAP Part C recipient  
                         
Renewal request 
Year of request _GY 25: 03/01/2025 to 02/28/2026
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 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 0906-0065 and is valid until 09/30/2024. 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.          
Maricopa County- Phoenix Eligible Metropolitan Area
X
Initial request   
X