Form 0285 compliance 0285 compliance 0285 compliance

OMB No. 0915-0285

Expiration Date:

COMPLIANCE MATRIX

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 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 30 minutes 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.

		YES	NO
	Is the applicant organization a public or non-profit private entity?
	Does the applicant organization demonstrate the need for primary health care services in the community(ies) that make up its service area based on geographic, demographic, and economic factors?
	Does the applicant organization serve, in whole or in part, a designated MUA or MUP? (Requested, not required for HCH, PHPC or MHC applicants)
	Does the applicant organization have a system of care that contributes to the availability, accessibility, quality, comprehensiveness and coordination of health services in the service area?
	Does the applicant organization provide ready access for all persons to all of the required primary, preventive and supplemental health services, including oral health care, mental health care and substance abuse services without regard to ability to pay either directly on-site or through established arrangements?
	Does the applicant organization provide all additional health services as appropriate and necessary?
	Does the applicant organization have patient case management services (including counseling, referral and follow-up services) designed to assist health center patients in establishing eligibility for and gaining access to Federal, State and local programs that provide or financially support the provision of medical, social, educational or other related services?
	Does the applicant organization collaborate appropriately with other health and social service providers in their area?
	Are all contracted services (including management agreements, administrative services contracts, etc.) under the governance, administration, quality assurance and clinical management policies of the applicant organization?
	Does the applicant organization arrange referrals to providers as may be appropriate to assure ready access for all persons to all of the required primary, preventive and supplemental health services without regard to ability to pay?
	Are all services available to all persons in the service area or target population regardless of age, gender, or the patient’s ability to pay?
	Does the applicant organization maintain a core staff of primary care providers appropriate for the population served?
	Are the primary care providers working at the health center licensed to practice in the State where the center is located?
	Have all providers been properly credentialed and privileged according to PINs 99-08 and 2001-11?
	Do the applicant organization’s physicians have admitting privileges at their referral hospital(s), or other such arrangement to ensure continuity of care?
	Does the applicant organization use a charge schedule with a corresponding discount schedule based on income for persons between 100 percent and 200 percent of the Federal poverty level?
	Is/will the new access point be open to provide services at the times that meet the needs of the majority of potential users?

		YES	NO
	Does the applicant organization provide professional coverage during hours when the center is closed?
	Does the applicant organization have clear lines of authority from the Board to a chief executive (President, Chief Executive Officer or Executive Director) who delegates, as appropriate, to other management and professional staff?
	Does the applicant organization have systems which accurately collect and organize data for reporting and which support management decision-making and which integrate clinical, utilization and financial information to reflect the operations and status of the organization as a whole?
	Does the applicant organization have accounting and internal control systems appropriate to the size and complexity of the organization reflecting Generally Accepted Accounting Principles (GAAP) and separating functions appropriate to organizational size to safeguard assets?
	Does the applicant organization maximize revenue from third party payers and from patients to the extent they are able to pay?
	Does the applicant organization have written billing, credit and collection policies and procedures?
	Does the applicant organization assure that an annual independent financial audit is performed in accordance with Federal audit requirements?
	Does the applicant organization have a governing board that is composed of individuals, a majority of whom are being served by the organization and, who as a group, represent the individuals being serviced by the center? (May waived for HCH or PHPC applicants. See Form 6, Part B)
	Does the governing board have at least 9 but no more than 25 members?
	Do the corporate bylaws require the governing board to meet at least one per month? (May be waived for HCH, MHC or PHPC applicants. See Form 6 – Part B)
	Does the applicant organization’s corporate bylaws demonstrate that the governing board has the required authority and responsibility to oversee the operation of the center?
	Do the corporate bylaws include provisions that prohibit conflict of interest or the appearance of conflict of interest by board members, employees, consultants and those who provide services or furnish goods to the center?

I certify that the information contained herein is accurate to the best of my knowledge.

Signature of Governing Board Chairperson Date

Printed Name