Form B-1 S B-1 S Part B X08 Supplemental Allocations Report clean

OMB Number (0915-0318)

Expiration date (09/30/2023)

Part B X08 Allocations Report

FYXXXX RWHAP Part B Supplemental Program Award Allocations Report
Recipient Name
Preparer Name
Preparer Phone Number
FY XXXX RWHAP Part B Supplemental Program Award
Section A: Planned Funding by Program Component	Total FY XXXX RWHAP Part B Supplemental Program Award
	Amount	Percent
1. RWHAP Part B Supplemental AIDS Drug Assistance Program Subtotal	$0	- -
a. ADAP Services		- -
b. Health Insurance to Provide Medications		- -
c. ADAP Access/Adherence/Monitoring Services		- -
2. RWHAP Part B Supplemental Health Insurance Premium & Cost Sharing Assistance for Low Income Individuals		- -
3. RWHAP Part B Supplemental Home and Community-based Health Services		- -
4 RWHAP Part B Supplemental HIV Care Consortia (Provide detail in Section B)	$0	- -
5. RWHAP Part B Supplemental State Direct Services (Provide detail in Section B)	$0	- -
6. RWHAP Part B Supplemental Clinical Quality Management 1		- -
7. RWHAP Part B Supplemental Recipient Planning & Evaluation Activities2		- -
8. Recipient Administration2		- -
9. Total RWHAP Part B Supplemental Program Funding Amounts	$0	0.00%
Section B: Breakdown for Consortia and State Direct Services Final Funding	Consortia3		Direct Services
	Amount	Percent	Amount	Percent
10. Core Medical Services Sub-total	$0	- -	$0	- -
a. AIDS Drug Assistance Program (ADAP) Treatments
b. AIDS Pharmaceutical Assistance		- -		- -
c. Early Intervention Services		- -		- -
d. Health Insurance Premium & Cost Sharing Assistance for Low Income Individuals		- -
e. Home and Community-based Health Services		- -
f. Home Health Care		- -		- -
g. Hospice		- -		- -
h. Medical Case Management (including Treatment Adherence Services)		- -		- -
i. Medical Nutrition Therapy		- -		- -
j. Mental Health Services		- -		- -
k. Oral Health Care		- -		- -
l. Outpatient /Ambulatory Health Services		- -		- -
m. Substance Abuse Outpatient Care		- -		- -
11. Support Services Sub-total	$0	- -	$0	- -
a. Child Care Services		- -		- -
b. Emergency Financial Assistance		- -		- -
c. Food Bank/Home Delivered Meals		- -		- -
d. Health Education/Risk Reduction		- -		- -
e. Housing		- -		- -
f. Linguistics Services		- -		- -
g. Medical Transportation Services		- -		- -
h. Non-Medical Case Management Services		- -		- -
i. Other Professional Services		- -		- -
j. Outreach Services		- -		- -
k. Psychosocial Support Services		- -		- -
l. Referral for Health Care and Support Services		- -		- -
m. Rehabilitation Services		- -		- -
n. Respite Care		- -		- -
o. Substance Abuse Services (Residential)		- -		- -
12. Total Funding Amounts	$0	- -	$0	- -
(1) May not exceed 5% of the FY XXXX RWHAP Part B Supplemental Program award, or $3 million, whichever amount is smaller.
(2) May not use more than 10% of the FY XXXX RWHAP Part B Supplemental Program award for either Planning and Evaluation or Recipient Administration; additionally, the combined costs for these two categories may not exceed 15% of the FY XXXX RWHAP Part B Supplemental award.
(3) All services in this column are considered Support Services.