Form 0285 certification 0285 certification 0285 certification

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 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.

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EALTH CENTER AFFILIATION CERTIFICATION

(MUST BE COMPLETED BY ALL CHC and/or MHC APPLICANTS)

Organization:       UDS #      

(where applicable)

Does your organization have any of the following arrangements with another organization? NOTE: You must complete a checklist for EACH organization with which you have any of the following arrangements.

NO (Submit only this page with application, no other documents necessary)

YES (Please check all that apply)

a) Contract or sub-award for a substantial portion of the proposed project

b) Memorandum of Understanding (MOU)/Agreement (MOA) for a substantial portion of the proposed project

c) Contract with another organization or individual contract for core primary care providers

d) Contract with another organization for staffing health center

e) Contract with another organization for the Chief Medical Officer (CMO) or Chief Financial Officer (CFO)

f) Merger with another organization

g) Parent Subsidiary Model arrangement

h) Acquisition by another organization

i) Establishment of a New Entity (e.g., Network corporation)

Name of Affiliating Organization:      

Address:      

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