Form 0285 sites 0285 sites 0285 sites

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx
DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY
Application Tracking Number

Grant Number

SERVICE SITES
HRSA SITE ID #
Name of Service Site

Service Site Type

Location Type

Location Code

Site Entity Type

Site Classification
Type

Site Operated by

[_] Applicant

[_] Subrecipient

[_] Contractor

If Site is operated by Sub-recipient or Contractor please provide with the organization information
below:
Organization
Organization Name
Address
(Physical)
Address
(mailing)
EIN
View

Date Site was Added
to Scope

Date Site will be
Operational

(existing Grantees)

Date Site was
Opened (existing
grantees)

Medicare Billing
Number
Medicaid Billing
Number

Medicaid Pharmacy
Billing Number

Site Phone Number

Site Fax Number

Physical Site Address

Site Mailing Address

Congressional
District

County Name

Service Area
Zipcodes

Service Area Census
Tracts

Service Area
Population

[_] Urban [_] Rural

Operational Schedule
Total Hours of
Operation when
Patients will be
Served per Week
(include extended
hours)

[_] FullTime

[_] PartTime

Calendar Schedule

[_] YearRound

Months of Operation

From

[_] Seasonal

To

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 1 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.