Form 0285 services prov 0285 services prov 0285 services provided

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx
FOR HRSA USE ONLY

DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Health Resources and Services Administration

Application Tracking
Number

Grant Number

SERVICES PROVIDED
MODE OF SERVICE PROVISION
SERVICE TYPE

AGREEMENT
APPLICANT (Grantee pays
for service)

Required Services
Clinical Services
General Primary Medical Care
Diagnostic Laboratory
Diagnostic X-Ray
Screenings
●

Cancer

●

Communicable Diseases

●

Cholesterol

●

Blood lead test for elevated blood lead level

●

Pediatric vision,hearing and dental

Emergency Medical Services
Voluntary Family Planning
Immunizations
Well-Child Services
Gynecological Care
Obstetrical Care
Prenatal and Perinatal Services
Preventive Dental
Mental Health Services (referrals)1
Substance Abuse Services (referrals)1
Referral to Speciality Services
Pharmacy
Substance Abuse services (required for HCH programs):
●

Detoxification

REFERRAL
ARRANGEMENTS
(Grantee DOES NOT
pay)

●

Outpatient Treatment

●

Residential Treatment

●

Rehabilitation (non hospital settings)

Non - Clinical Services
Case Management
Counselling/Assessment
Referral
Follow-up/Discharge Planning
Eligibility Assistance
Health Education
Outreach
Transportation
Translation2
Substance abuse services (required for HCH programs):
●

Harm/Risk Reduction (e.g. educational
materials, nicotine gum/patches)

Additional Services (Optional)
Clinical Services
Urgent Medical Care
Dental Services
●

Restorative

●

Emergency

Mental Health Services
●

Treatment/Counseling

●

Developmental Screening

●

24-Hour Crisis

●

Other Mental Health

Substance Abuse Services
Recuperative Care
Enviornmental Health Services
Occupational-Related Health Services3
●

Screening for Infectious Diseases

●

Injury Prevention Programs

Occupational Therapy
Physical Therapy
HIV Testing
TB Therapy
Podiatry
Rehabilitation (Non-Hospital Settings)
Other: Dental Surgical Service
Non Clinical Services
WIC
Nutrition (not WIC)
Child Care
Housing Assistance
Employment/Education Counseling
Food Bank/Meals
Other: Unemployment Assistance
1. Applicants are required to provide mental health and substance abuse services by referral arrangement.
However, applicants may provide these services by applicant or agreement instead of by referral
arrangement.
2. Required for Health Centers serving a substantial number of patients with limited English-Proficiency.
3. Additional Services for Health Centers serving Migrant and seasonal farmworkers (MSFWs).
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 .5 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.