Form 0285 income analys 0285 income analys 0285 income analysis

I

OMB No. 0915-0285 Expiration Date: 6/30/2007

NCOME ANALYSIS FORM

OMB No. 0915-0285

Expiration 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 0915-0285.  Public reporting burden for this collection of information is estimated to average 15 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 10-33, Rockville, Maryland, 20857.

YEAR 1 YEAR 2 YEAR 3

PAYOR CATEGORY	NUMBER OF VISITS	AVERAGE CHARGE PER VISIT	TOTAL CHARGES (a * b)	AVERAGE ADJUSTMENT PER VISIT	AMOUNT BILLED [c-(a*d)]	COLLECTION RATE (%)	PROJECTED INCOME (e * f)
	(a)	(b)	(c)	(d)	(e)	(f)	(g)
FEE FOR SERVICE
Medicaid: Medical
Medicaid: EPSDT (if different from Medical)
Medicaid: Dental
Medicaid: Behavioral
Medicaid: Other Fee for Services
Medicaid: Capitated
Subtotal: Medicaid
Medicare
Medicare: Other Fee for Services
Medicare: Capitated
Subtotal: Medicare
Private Insurance: Medical
Private Insurance: Dental
Private Insurance: Behavioral
Self-Pay: 100% of charge (no discount): Medical
Self-Pay: Sliding Fee Scale discounts: Medical
Self-Pay: 0% of charge, full discount: Medical
Self-Pay: 100% of charge (no discount): Dental
Self-Pay: Sliding Fee Scale discounts: Dental
Self-Pay: 0% of charge, full discount: Dental
Self-Pay: 100% of charge (no discount): Behavioral
Self-Pay: Sliding Fee Scale discounts: Behavioral
Self-Pay: 0% of charge, full discount: Behavioral
Other: Capitation
Other: Contracts
SUB-TOTAL
OTHER INCOME
Contributions/Donations
Fund Raising
Section 330 Grant
Other Federal Grants
State Grants
Local Support
Foundation Grants
Other
GRAND TOTAL