Form NHSCUDS-2 National Health Service Corps UDS

BUREAU OF CLINICIAN
RECRUITMENT AND SERVICE

NATIONAL HEALTH SERVICE CORPS

UNIFORM DATA SYSTEM
REPORTING INSTRUCTIONS

CALENDAR YEAR 2 0 0 7

PUBLIC BURDEN STATEMENT

Public reporting burden for this collection of information is estimate to average 36 hours per response including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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; Paperwork Reduction Project
(0915-0232); Room10-33, 5600 Fishers Lane, Rockville, MD. 20857.

PREFACE

This is the Uniform Data System (UDS) Reporting Instructions for NHSC sites which do not receive
grant support from the Health Resources and Services Administration, Bureau of Primary Health
Care (HRSA/BPHC). Entities receiving grants from HRSA/BPHC file a different version of the UDS
report for which there are separate reporting instructions.
If you have questions about the UDS, please contact the help line at either, 1-888-459-1080 or
[email protected]. Frequently asked NHSC UDS questions and answers will be posted on the
NHSC web site at http://nhsc.bhpr.hrsa.gov/resources/uds/ . Other material will be posted on the
web site including a copy of this manual, copies of the tables, a summary of the changes made to
the NHSC UDS each year, the user survey form, the aggregate data for each reporting year and a
brief slide show providing an update of the changes made, an overview of the reporting
requirements, and a list of scheduled UDS training events. The latest version of the Microsoft
Access reporting software developed for the NHSC UDS will be mailed near the end of the reporting
year. If not received by mid January, copies may be requested by contacting the help line.

CONTENTS
Page
INTRODUCTION ..................................................................................................................... 1
GENERAL INSTRUCTIONS .................................................................................................... 3
INSTRUCTIONS AND COVER SHEET:
NHSC SITE PROFILE ..................................................................................................... 13
INSTRUCTIONS AND TABLE 1:
SERVICES OFFERED AND DELIVERY METHOD ......................................................... 17
INSTRUCTIONS AND TABLE 2:
PART A: USERS BY AGE AND GENDER
PRENATAL USERS BY AGE ........................................................................... 23
PART B: USERS BY RACE/ETHNICITY/LANGUAGE ..................................................... 24
PART C: USERS BY INCOME LEVELS .......................................................................... 24
PART D: USERS BY PAYMENT SOURCE ..................................................................... 25
INSTRUCTIONS AND TABLE 3:
STAFFING AND UTILIZATION ........................................................................................ 30
INSTRUCTIONS AND TABLE 4:
CHARGES, COLLECTIONS, AND SELF-PAY ADJUSTMENTS ..................................... 38
INSTRUCTIONS AND TABLE 5:
INCOME AND EXPENSES ............................................................................................. 44
INSTRUCTIONS AND TABLE 6:
MANAGED CARE ENROLLMENT .................................................................................. 50

APPENDIX A: PERSONNEL LISTING BY SERVICE CATEGORY ......................................A-1

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OMB No. 0915-0232 Expiration: 10/31/2008

INTRODUCTION
The National Health Service Corps (NHSC) is committed to improving the health of the nation’s
underserved by uniting communities in need with the healthcare professions and by supporting
communities’ efforts to build better systems of care. The NHSC is administered by the Bureau of
Health Professions within the Health Resources and Services Administration (HRSA). The NHSC
Uniform Data System (UDS) is an annual calendar year report prepared by all sites with NHSC
obligated clinicians which do not receive grant support from the any of the federal HRSA programs
identified in Sections 330 (e),(g), (h), and (i) of the Public Health Service Act. These include: the
Community Health Center Program, the Migrant Health Center Program, the Health Care for the
Homeless Program, and the Public Housing Primary Care Program. Sites with NHSC obligated
clinicians which receive grants from these programs file the Bureau of Primary Health Care UDS
report.
Approximately half of NHSC scholarship and loan repayment clinicians serve in sites which do not
receive grant support from the HRSA programs shown above. The NHSC UDS was designed
specifically for these sites. Data reported in other places such as the site application, the health
professional shortage area (HPSA) designation request, the provider application, or other sources
are not duplicated in the NHSC UDS.
The NHSC UDS is a valuable information management system, which gives the program a good
understanding of the services, users, staffing, production, finances, and managed care enrollment at
the sites receiving NHSC support. This information will enable the HRSA to respond more fully to
questions about the NHSC program and the populations served.
The NHSC has offered training each year since the UDS began in 1998 to explain how to complete
the UDS. On-site and web based training is offered again this year, please check the NHSC web
site or call 1-888-459-1080 if you are interested in participating. A brief slide show presentation
which reviews the tables and the changes for this year is also available on the software installation
CD and on the NHSC web site. See http://nhsc.bhpr.hrsa.gov/resources/uds/ .
There are no significant changes for the CY 2007 reporting year.
The sections of the manual which follow give general instructions and detailed instructions for each
table.

GENERAL INSTRUCTIONS
This section provides instructions applicable to all tables in the NHSC UDS. Instructions for each
table are presented together with the table in subsequent sections of these reporting instructions.
REPORTING PERIOD
The reporting period is the calendar year. All activity for the full calendar year is to be reported
even if the first NHSC assignment starts or last assignment ends during the calendar year. In
those cases where the site begins or terminates operations during the year, only part year data
will be reported, but the reporting period is still the full calendar year. The calendar year reported
is specified in the header and is the same for each table.
SCOPE OF ACTIVITY REPORTED
The UDS report is site specific. Clinicians fulfilling National Health Service Corps obligations
are assigned to a specific site or in rare cases more than one site. The scope of activity to be
reported in the UDS includes all activity at the site to which the NHSC clinician is assigned.
Activity at other sites owned or operated by the sponsoring organization is to be excluded.
All related activity of all providers at the site is to be reported, including activity of all NHSC and
non-NHSC providers at the site.
Related activity includes all primary care services and related supplemental services which
support the primary health care activity. These services are an integral part of the primary care
delivery system, under general direction and control of the sponsoring organization, and
provided by the site’s providers to the sponsoring organization’s patients at the approved site
location or by the site’s providers to the sponsoring organization’s patients at approved off-site
locations such as the patient’s home, nursing home, emergency room or hospital.
Sites may elect to include or exclude all or some portion of referred care services paid by the
sponsoring organization which are rendered to the site’s patients at off-site locations. This
election may be based upon the ability or ease of reporting this information on a site specific
basis. The same scope of off-site referred care should be used to complete the encounter,
user, charge, and cost tables.
Institutional or large provider organizations may opt to limit the scope of reportable activity to the
smallest set of common primary care services that can readily be reported at the site.
WHO SUBMITS REPORTS
The UDS reports for NHSC sites are to be filed by those parties which enter into an agreement
with Secretary of the Department of Health and Human Services for a NHSC provider placement
and which are not currently receiving HRSA/BPHC grant support for the site where the NHSC
placement is made. This may be the sponsoring organization which signs the Private Practice
Assignment (PPA) agreement, the obligated clinician who signs the Private Practice Option
(PPO) agreement or the sponsoring organization which signs the memorandum of agreement
(MOA) for a federally employed clinician.

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All sites with a NHSC obligated clinician in place at any point between April 1st and September
30th of the calendar year are to file a report. Those sites whose first NHSC clinician
assignment begins after September 30 th or whose last NHSC clinician assignment ends
before April 1st are not required to file for that calendar year.
All sites meeting the criteria above are to file a complete UDS report except for Federal Bureau
of Prison (BOP), nonfederal prison, Indian Health Service (IHS), Section 638, and Immigration
and Naturalization Service (INS) sites which are only to file the cover sheet, and tables 1, 2A,
2B, and 3.
Only one report per site is to be filed in those cases where more than one NHSC clinician is
working at the same site for the same organization.
A single sponsoring organization is to file separate reports for each site with NHSC clinicians.
If an individual NHSC clinician is assigned to more than one site, a separate UDS report is to be
filed by the sponsoring organization for each site.
Those entities which receive HRSA/BPHC grant support for the site where the NHSC
assignment is made are to file the standard HRSA/BPHC UDS report.
TABLE HEADER INFORMATION
The following information is reported in the header on all UDS Tables:
Date of Submission: the date the initial or revised report is submitted.

Initial Submission or Revision: an initial report is the first report for the reporting period.
Revisions are subsequent, corrected submissions.
Reporting Period: The reporting period is the calendar year. All activity for the full calendar
year is to be reported even if the first NHSC assignment starts or last assignment ends
during the calendar year. Not all sites whose first assignment starts or last assignment
ends during the year are required to file. See the discussion in this section defining which
sites are to submit reports. In those cases where the site begins or terminates operations
during the year, only part year data will be reported, but the reporting period is still the full
calendar year. The calendar year reported is specified in the header and is the same for
each table.
UDS Number: the number assigned to the site by the NHSC. The UDS numbers are site
specific and are permanently assigned at the time an NHSC vacancy is approved. A list of
UDS numbers is included in the UDS training notebooks. If you do not have the number, it
may be obtained by contacting UDS help line at either, 1-888-459-1080 or
[email protected].
REPORT DUE DATE
Reports are typically due on February 15th or approximately 45 days following the close of the
reporting year; however, this year reports are due on March 14th.
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General Instructions

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ELECTRONIC PREPARATION AND SUBMISSION
Sites are strongly encouraged to prepare and submit the UDS report using the NHSC Microsoft
Access software product introduced in CY 1999 and revised each year. The software is
designed to ease the reporting burden, help ensure reports are completed correctly, allow sites
to file electronically, and make data management more efficient. A toll free number, 1-888-4591080, is available for software support. The minimum computer system requirements are a CD
drive, Windows 2000 and approximately 100 MB of free disk space. The Microsoft Access
software is not required. The product includes a routine which will compile and summarize
sample user data and automatically produce a report summarizing the site’s data. The software
and be distributed to all sites near the end of the calendar year.
NUMBER OF COPIES TO SUBMIT
Sites filing electronically file once and sites filing manually submit one copy of the UDS report.
WHERE TO SUBMIT REPORTS
Sites filing electronically follow the instructions included in the software. Sites filing manually
send one copy to the NHSC UDS Data Center at the address shown below.
NHSC UDS Data Center
P.O. Box 666
Concord, NH 03302-0666
SUBMITTING REVISED REPORTS
Each site will be assigned a UDS editor. After the due date, revised reports should only be
submitted as instructed by the site’s editor. Sites filing electronically can only do so once for
each site unless given an unlock code by an editor. Prior to the due date, sites may inquire
about filing revised reports by contacting UDS help line at either, 1-888-459-1080 or
[email protected].
REPORT DOCUMENTATION AND RETENTION
Copies of the original and revised submissions, related source documents, and supporting
worksheets which substantiate the UDS data reported to the source data are to be kept on file
and available for review for a minimum of three years from the submission date.
DEFINITION OF ENCOUNTERS
An encounter is a face-to-face contact between a user and a provider who exercises
independent judgment in the provision of services to the individual and where the services
rendered are recorded in the patient’s record.
A listing of health personnel is presented in Appendix A which identifies those who are considered
providers and able to generate encounters and those who are considered nonproviders and not able
to generate encounters for UDS reporting purposes.

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The criteria used to define reportable encounters for the UDS resemble criteria often used by payers
to define a billable patient visit.
The criteria for encounters are as follows:
1. To meet the encounter criterion for independent judgment, the provider must be acting
independently and not assisting another provider. For example, a nurse assisting a
physician during a physical examination by taking vital signs, taking a history, or drawing a
blood sample is not credited with a separate encounter. A nurse using standing orders or
protocols, who sees a patient to monitor physiological signs, etc., without the patient also
seeing the physician during the same visit, is credited with a medical encounter.
Encounters also include provider contacts with patients who are in a hospital, nursing home,
or other inpatient facility. A provider may not generate more than one inpatient encounter per
patient per day.
2. Services such as drawing blood, collecting urine specimens, performing laboratory tests,
taking x-rays, immunizations, filling or dispensing prescriptions do not constitute encounters.
However, these procedures may be accompanied by services performed by medical, dental,
or other health providers that do constitute encounters.
3. The patient record does not have to be a full and complete health record in order to meet the
encounter criteria if a patient receives only minimal services and is not likely to return to the
site. For example, if an individual receives services on an emergency basis and these
services are documented, the encounter criteria are met even though a complete health
record is not created. Provision of HIV counseling and testing meets these encounter
criteria if documented. The same is true for services, such as employment physicals,
sports physicals, etc., which are rendered to persons who do not regularly use the practice
site. However, the services rendered must be documented. Mass screenings at health
fairs do not result in encounters in part because they are not fully
documented.
4. A patient may have more than one encounter at the site per day. The number of
encounters per site per day is limited as follows:
•

One medical encounter (physician, nurse practitioner, physicians assistant,
certified nurse midwife, or nurse);

•

One dental encounter (dentist or hygienist); and

•

One encounter for each other type of health provider (family planning or HIV
counselor, nutritionist, psychologist, podiatrist, speech therapist, etc.)

The limitation of one encounter per provider per site per day allows for another encounter at
an approved off-site location such as the hospital.
5. A provider may be credited with no more than one encounter with a given patient during that
patient's visit to the site in a single day, regardless of the type or number of services
provided. For example, a physician providing health education services during a physical
exam is credited with a medical encounter only. If a student provider sees patients in
conjunction with a nonstudent provider, only one encounter, credited to the nonstudent

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provider, is counted.
6. A reportable encounter by the NHSC and other staff providers may only take place at the
NHSC approved site or at any other NHSC approved off-site location such as the patient’s
home, the hospital, an extended care facility, or the emergency room. Encounters by staff
providers at other sites of the sponsoring organization, at another provider’s office,
or any location not approved for the NHSC provider to practice, are not to be reported.
Encounters supplied by paid nonstaff contractors or referral providers for services rendered
to the site’s patients at off-site locations, many of which may not be approved for the NHSC
clinician to practice, such as the referral provider’s office, may either be wholly or partly
included or excluded. The same scope of activity chosen to report off-site paid referral
provider encounters is also to be applied to the user, charge, and cost tables.
7. When a provider renders services to several patients simultaneously, the provider can be
credited with an encounter for each person if the provision of services is noted in each
person's health record. Examples of "group encounters" include: family therapy or
counseling sessions and group mental health counseling during which several people
receive services and the services are noted in each person's health record. Group medical
visits are not reported as encounters. Health education classes such as smoking cessation
classes are not credited as encounters.
8. The encounter criteria are not met in the following circumstances:
•

When a provider participates in a community meeting or group session that
is not designed to provide health services. Examples of such activities
include information sessions for prospective users, health presentations to
community groups (high school classes, PTA, etc.), and information
presentations about available health services at the practice site;

•

When the only health service provided is part of a large-scale effort, such
as a mass immunization program, screening program, or community-wide
service program such as a health fair;

•

When a provider is primarily conducting outreach or group education
sessions, not providing direct services;

•

When the only services provided are lab tests, x-rays, immunizations, TB tests, and
prescription refills; and

•

When the provider and patient are not physically present together as in a phone or
telemedicine consultation.

Definitions of encounters for different provider types follow:
Physician Encounter: an encounter between a physician and a patient during which medical
services are provided for the prevention, diagnosis, treatment, and rehabilitation of illness or
injury.
Nurse Practitioner/Physicians Assistant Encounter: an encounter between a nurse practitioner

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or physician assistant and a patient during which medical services are provided and where the
practitioner acts independently.
Certified Nurse Midwife Encounter: an encounter between a certified nurse midwife and a patient
during which medical services are provided and where the practitioner acts independently.
Nurse Encounter (Medical): an encounter between an R.N., L.V.N. or L.P.N., and a patient in
which the nurse acts as an independent provider of medical services and exercises independent
judgment. The service may be provided under standing orders of a physician, under specific
instructions from a previous visit, or under the general supervision of a physician, nurse
practitioner, or physician’s assistant who has no direct contact with the patient during the visit.
Services provided by Medical Assistants are not reportable encounters.
Dentist Encounter: an encounter between a dentist and a patient during which dental services are
provided for the purpose of prevention, assessment, or treatment of a dental problem, including
restoration.
Dental Hygienist: an encounter between a dental hygienist and a patient during which dental
services are provided and where the hygienist provides the service independently, not jointly with
a dentist. Only one encounter is generated when the patient sees both the hygienist and the
dentist in one day.
Mental Health Encounter: an encounter between a mental health provider and a patient during
which mental health services are provided.
Substance Abuse Encounter: an encounter between a substance abuse provider (e.g.,
rehabilitation therapist, psychologist, social worker, counselor, etc.) and a patient during which
alcohol or drug abuse services (i.e., assessment and diagnosis, treatment, aftercare) are
provided.
Other Professional Encounters: encounters between an other professional provider (e.g.
podiatrist, physical therapist, optometrist, audiologist, etc.) and a patient during which other
professional services are provided.
Other Service Encounter: encounters between other service personnel (e.g. case managers and
education specialists) and patients are not reported in the NHSC UDS.

DEFINITION OF A PROVIDER
A provider is a clinician who assumes primary responsibility for assessing the patient and
documenting services in the patient's record. Providers include only individuals who exercise
independent judgment as to the services rendered to the patient during an encounter. The provider
who exercises independent judgment is credited with the encounter, even when two or more
providers are present and participate. See Appendix A for a listing of personnel which identifies
those who are considered providers and who can generate encounters for UDS reporting purposes.
Ancillary services personnel including laboratory, x-ray, and pharmacy staff are defined as
nonproviders and do not generate encounters. Also, other service personnel including case
managers and education specialists are defined as nonproviders and do not generate encounters.

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Contract and paid referred care providers who serve the site’s patients at approved on or off-site
locations who document their services in the site’s records are considered providers and may
generate encounters for UDS reporting purposes.

DEFINITION OF A USER
Users are individuals with one or more encounters, as defined above, during the calendar
year. An individual can be counted only once in each of the following user service
categories each calendar year.
Medical User: an individual who has one or more medical encounters during the reporting period.
Prenatal User: an individual who has one or more prenatal medical encounters during the reporting
period.
Dental User: an individual who has one or more dental encounters during the reporting period.
Mental Health & Substance Abuse User: an individual who has one or more mental health or
substance abuse encounters during the reporting period.
Other Professional Service User: an individual who has one or more encounters with an other
professional service provider. See Appendix A for a list of other professional service providers.
Total Users: unduplicated number of individuals who have one or more encounters during the
reporting period.
The exhibit which follows illustrates that each calendar year an individual may only be counted as a
user once within each service category and once in the count of total users regardless of the
number of encounters the individual has in the reporting period.

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Exhibit 1
Patient X Encounters for the Calendar Year

Service Category

Encounter
Date

Medical
Dental
Prenatal

Other
1

Jan 15

Total

Mental
Health/
Substance
Abuse

Other
Professional

1

Total

1
1

Mar 10

1

Jun 12

1

1

Aug 01

1

1

Sep 21

1

1

Oct 03

1

1

1

Nov 30

1

1

Dec 18

1

Total
Encounters

1

2

3

2

1

NR

1

1

Service
Users

1

1

2

1

3

9

1

1
1

Total Users
Note: NR means “other medical service” users are not reported in the NHSC UDS

As shown, patient X had a total of nine visits during the year, was a user of each type of service, and
is counted once in the site’s total user count for the year. The table also illustrates that prenatal
encounters are a subset or type of medical encounter. Please note that prenatal users and total
medical users are reported but “other medical service” users are not reported in the NHSC UDS.
Total users and prenatal users are reported on Table 2. Users by service category are reported on
Table 3.
It should be noted that Table 2 asks for an actual count of the site’s total unduplicated users
and prenatal users in the reporting period. An actual count of total users for each of the four major
service categories shown above and reported on Table 3 is preferred but may be estimated based
upon a sample of patient records. One method for estimating users by service class is to divide
actual encounters for that service class by the encounters per user for that service class determined
from a random sample of patient records. See the illustration which follows.

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Estima tin g Med ical Us ers
Total medical visits for the calendar year (actual)

4,400

Medical patient records in the sample (user records)

200

Medical visits in the sample

800

Visits per patient per year in the sample (800/200)

4.0

Estimated Medical Users:
Total medical visits / Visits per patient per year
(4,400/4.0)

1,100

Estimates of users in the other service classes may be done in the same way as illustrated above.
This requires that there be an actual count of encounters in those service classes.
Other methods for estimating users by service class are acceptable. Inquire with the help line or the
assigned UDS editor.
All other user information requested in Table 2 may be estimated based upon a sample of patient
records. The minimum sample size is 200 records. The NHSC software includes a routine, which will
compile and summarize sample user data collected from patient records.

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INSTRUCTIONS FOR COMPLETING
NHSC SITE PROFILE
COVER SHEET

The cover sheet identifies the practice site name and address, the sponsor name and address, the
site contacts, and the site type.
(Lines 1 through 7) Practice Site Name and Address: name of the approved practice site,
address, and 9-digit zip code. The US Postal Service web site has a zip+4 look up directory.
See http://www.framed.usps.com/ncsc/lookups/lookup_zip+4.html
(Lines 8 through 13) Sponsoring Agency Name and Address: name, address, and 9-digit zip
code of the organization which signed the Private Practice Assignment (PPA) or Memorandum of
Agreement (MOA) or the organization where the obligated clinician who signed the Private
Practice Option (PPO) agreement works.
(Line 14 and 15) CEO/Executive Director and Phone: name, business phone, and phone
extension of the CEO, Executive Director, or Project Director of the sponsoring organization.
(Line 16) Clinical Director: name of the Clinical Director of the sponsoring organization.
(Line 17) Governing Board Chair: if there is a governing board, the name of the Chairman of the
sponsoring organization's governing board. If there is no board record N/A.
(Line 18) UDS Report Preparer/Site Contact: name of the staff person with primary responsibility
for preparing the UDS report. Do not include contractors.
(Line 19, 20 and 21) UDS Report Preparer/Site Contact Phone, Fax and E-mail Numbers:
business phone, and fax numbers, including area code and phone extension, plus the e-mail
address for the UDS preparer/site contact identified on line 18.
(Line 22 and 23) Reimbursement Status: check yes or no if the site is or is not a certified rural
health clinic or a federally qualified health center look-alike. A site can not be both. Count the
reimbursement status as of the end of the calendar year.
(Line 24) Location Code: the code noted on the bottom of the cover sheet which best describes the
approved site location. The codes are not intended to identify the specific services offered at the
site.
(Line 25) Sponsor Code: the code noted on the bottom of the cover sheet which best describes the
sponsoring organization. If appropriate, use the same code for location and sponsor.
Some examples are shown below.
• A solo private practice should be coded
location: (2. Private practice) and sponsor: (2. Private practice).
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A remote site operated by a group practice should be coded
location: (2. Private practice) and sponsor: (2. Private practice).
A community-based primary care site run by a nonprofit board of directors should be coded
location: (1. Community clinic) and sponsor: (1. Community clinic).
A freestanding community based primary care site operated by the health department
should be coded
location: (1. Community clinic) and sponsor: (4. Health department).
A primary care site located in a substance abuse clinic should be coded
location: (6. Substance abuse treatment center) and sponsor: (6. Substance abuse
treatment center).
A freestanding community based primary care site operated by a hospital should be coded
location: (1. Community clinic) and sponsor: (3. Hospital based clinic/hospital sponsor).
A primary care clinic located within the hospital should be coded
location: (3. Hospital based clinic/hospital sponsor) and sponsor: (3. Hospital based
clinic/hospital sponsor).
A primary care unit within a university hospital based outpatient facility should be coded
location: (3. Hospital based clinic/hospital sponsor) and sponsor: (7. University).
A program targeting the homeless located in a Mental health clinic/department operated by
a local mental health department should be coded
location: (5. Mental health clinic/department) and sponsor: (5 . Mental health
clinic/department).
A mobile clinic serving the migrant farm worker population operated by the local health
department should be coded
location: (20. Mobile clinic) and sponsor: (4. Health department).
A school clinic run by a nonprofit community based clinic organization should be coded
location: (18. School clinic) and sponsor: (1. Community clinic).
A freestanding primary care clinic operated by a university medical center should be coded
location: (1. Community clinic) and sponsor: (7. University).
A primary care unit located in and sponsored by the health department should be coded
location: (4. Health Department) and sponsor: (4. Health Department).

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Site Profile Cover Sheet

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UDS Number: ________________________________
For Period: January 1, 2007 to December 31, 2007

OMB No. 0915-0232
Date Submitted:

Expiration Date: 10/31/2008

COVER SHEET
NHSC SITE PROFILE
NHSC Site

Site Profile Data

(a)

Practice Site Name and Address
1.) Site Name
2.) Street Address
3.) Other Address/P.O. Box
4.) City
5.) County
6.) State
7.) Zip Code (Nine digits)
Sponsoring Agency Name and Address
8.)

Sponsor Name

9.)

Street Address

10.) Other Address/P.O. Box
11.) City
12.) State
13.) Zip Code
Contacts
14.) CEO/Executive Director
15.) CEO/Executive Director Phone

Extension:

16.) Clinical Director
17.) Governing Board Chair
18.) UDS Report Preparer/Site Contact
19.) Preparer/Site Contact Phone

Extension:

20.) Preparer/Site Contact Fax
21.) Preparer/Site Contact E-mail
Site Reimbursement Status (Check Yes or No)
22.) Certified Rural Health Clinic (P.L. 95-210)

Yes

No

23.) Federally Qualified Health Center Look-Alike

Yes

No

Site Description (Use Codes Listed Below to Complete Lines 24 & 25)
24.) Location Code
25.) Sponsor Code

Site Description Codes
1.
2.
3.
4.
5.
6.
7.

Community Clinic
Private Practice
Hospital Based Clinic/Hospital Sponsor
Health Department
Mental Health Clinic/ Department
Substance Abuse Treatment Center
University

8.
9.
10.
11.
12.
13.
14.

Federal Prison
INS Facility
Non-Federal Prison
Indian Health Service
Section 638 Tribal Contract
Section 638 Tribal Compact
Community Social Service Center

15.
16.
17.
18.
19.
20.
21.

HIV/AIDS Treatment Center
Public Housing Clinic
Migrant Camp or Worksite
School Clinic
Homeless Shelter
Mobile Clinic
Other-Identify

Note: Select the location code which best describes the site location and the sponsor code which best describes the organization sponsoring the
site. If appropriate, use the same code for location and sponsoring organization.

UDS 18.pdf

Revised 11/07

INSTRUCTIONS FOR TABLE 1:
SERVICES OFFERED AND DELIVERY METHOD
This table identifies those types of services provided directly by the site at any point during the
calendar year (column a), by paid referrals (column b), by unpaid referrals (column c) or by some
combination of these arrangements. If none of these arrangements are in place as defined below, the
service is not provided (column d).
Report the same scope of service activity as is to be reported for all other encounter, user, charge, and
cost tables. Individual sites will rarely provide or refer for all of the services listed in this table. The
inclusion of services on this list is not meant to imply that these services should be offered.
Delivery Method: Mark each cell that applies for each type of service with a check (Τ) or (X). Up to
three cells per service line may be checked if applicable.
(Column a) Provided by NHSC Site: includes services rendered by all paid and volunteer providers
and others such as out stationed eligibility workers who render services at the site or to the site’s
patients at approved off-site locations such as the patient’s home, the hospital, or the nursing home.
(Column b) By Referral - Site Pays: a formal arrangement with a referral provider for services to the
site’s patients under which the site pays the referral provider or bills reimbursement sources for the
service or both. These services are generally provided off-site. This type of arrangement is not often
present in NHSC sites operating without grant support. Sites may elect to include or exclude all or
some portion of the encounter, user, charge, and cost of purchased off-site referred care based
upon the ability or ease of reporting this information on a site-specific basis. Regardless of the
election made, record those referral services paid by the site on this table.
(Column c) By Referral - No Payment: a formal arrangement with a referral provider for services to the
site’s patients where the site does not pay the referral provider or bill reimbursement sources for the
service. A formal referral arrangement means either a written agreement or the expectation that
documentation from the referral provider will be returned for the patient record.
(Column d) Not Provided: the absence of any of the service arrangements defined above. Services
are considered not provided if the only arrangement is an informal referral where there is no written
agreement with the referral provider or where there is no ability to document the service in the patient
record.
(Lines 1 through 53) Service Type: these are types of services which may be provided by sites.
Service definitions appear below.
(Line 1) General Primary Medical Care: primary medical care services other than those identified
below.
(Line 2) Diagnostic Laboratory (technical component): technical component of laboratory
procedures. Does not include physician analysis or interpretation of procedure results. This service
refers exclusively to medical care services not dental care services.

Revised November 2007

Table 1: Services

Page 17

(Line 3) Diagnostic X-ray Procedures (technical component): technical component of diagnostic x-ray
procedures. Does not include physician analysis or interpretation of procedure results. Refers
exclusively to medical care services not dental care services.
(Line 4) Diagnostic Tests/Screening (professional component): professional services for the analysis
and interpretation of results from diagnostic tests and screening. Refers exclusively to medical care
services not dental care services. Virtually all medical clinicians have this capability.
(Line 5) Emergency Medical Services: provision of emergency services on a regular basis to meet life
threatening and other health conditions needing immediate attention.
(Line 6) Urgent Medical Care: provision of medical care of an urgent or immediate nature on a regular
basis.
(Line 7) 24-Hour Coverage: patient access to the site’s or shared call clinicians on a 24-hour basis.
(Line 8) Family Planning Services (Contraceptive Management): contraception, birth control and
infertility treatment. Includes medical provider counseling and education. Report under other services
when provided by other service providers.
(Line 9) HIV Testing: testing for HIV: includes medical provider counseling and education. Report
under other services when provided by other service providers.
(Line 10) Immunizations: provision of preventive vaccines such as diphtheria, tetanus, pertussis, polio
virus, measles, mumps, rubella, influenza b, hepatitis b, and influenza virus.
(Line 11) Following hospitalized patients: contacts with the site’s patients during hospitalizations.
(Line 12) Gynecological Care: gynecological services provided by a nurse, nurse practitioner, nurse
midwife or physician, including annual pelvic exams and pap smears, follow-up of abnormal findings,
and diagnosis and treatment of sexually transmitted diseases. This does not include family planning
services as defined for line 8.
(Lines 13 through 19) Obstetrical Care: services related to pregnancy, delivery and postpartum care
including: prenatal care, antepartum fetal assessment, ultrasound, genetic counseling and testing,
amniocentesis, labor and delivery professional care and postpartum care.
(Line 20) Directly Observed TB Therapy: delivery of therapeutic TB medication under direct
observation by site staff.
(Line 21) Other specialty care: medical services provided by medical professionals trained in any of the
following specialty areas: allergy, dermatology, gastroenterology, general surgery, neurology,
optometry, ophthalmology, otolaryngology, pediatric specialties, therapeutic radiology, psychiatry, and
anesthesiology.
(Line 22) Dental Care - Preventive: services of a dentist or hygienist including cleaning, prophylaxis,
sealants, and fluoride treatments.
(Line 23) Dental Care - Restorative: dentist services including fillings, crowns, extractions, dentures
and similar treatment.

Revised November 2007

Table 1: Services

Page 18

(Line 24) Dental Care - Emergency: dental services of an urgent or immediate nature provided on a
regular basis.
(Line 25) Mental Health Treatment/Counseling: mental health therapy, counseling, or other treatment
provided by a mental health professional.
(Line 26) Developmental Screening: development screening provided by a mental health professional.
(Line 27) 24-hour Crisis Intervention/Counseling: crisis counseling with access 24 hours per day to a
mental health professional.
(Line 28) Other Mental Health Services: other treatment provided by a mental health professional.
(Line 30) Substance Abuse Services: includes treatment for abuse of alcohol or other drugs.
Counseling and other medical or psycho social treatment services provided to individuals with
substance abuse problems. May include screening and diagnosis, detoxification, individual and group
counseling, self-help support groups, alcohol and drug education, rehabilitation, remedial education,
vocational training services, and aftercare.
(Line 31) Hearing Screening: diagnostic services to identify potential hearing problems.
(Line 32) Nutrition Services Other than WIC: advice and consultation appropriate to individual health
needs.
(Line 33) Occupational or Vocational Therapy: therapy designed to improve or maintain an individual's
employment or career skills.
(Line 34) Physical Therapy: assistance designed to improve or maintain an individual's physical
capabilities.
(Line 35) Pharmacy: dispensing of prescription drugs and other pharmaceutical products. Pharmacy
services are considered provided even in those situations where the only drugs offered are samples
dispensed by the clinician if the following criteria are met: the inventory is predefined, controlled, and
stocked; and drugs are dispensed to all patients or made available on a limited basis under a written
policy.
(Line 36) Vision Screening: diagnostic services to identify potential vision problems.
(Line 37) WIC Services: nutrition and health counseling services provided through the Special
Supplemental Food Program for Women, Infants and Children
(Line 38) Case management: coordination of patients’ primary care and related health and social
service needs. Key activities include: 1) assessment of the client's needs and personal support
systems; 2) development of a comprehensive, individualized service plan; 3) coordination and
monitoring of services required to implement the plan; and 4) periodic re-evaluation and adaptation of
the plan as necessary. Includes risk assessment, eligibility assistance, coordination and referral,
follow-up, tracking, and documentation.
(Line 39) Child Care: assistance in caring for young children accompanying the patient during medical
and other health care visits.

Revised November 2007

Table 1: Services

Page 19

(Line 40) Discharge Planning: case management services related to an individual's discharge from the
hospital.
(Line 41) Eligibility Assistance: help to get access to health, social service and other assistance
programs, including Medicaid, WIC, SSI, Food stamps, pharmacy assistance and similar programs.
May be provided by out-stationed eligibility workers.
(Line 42) Employment/Educational Counseling: counseling services to assist individuals define
career, employment, and educational interests and opportunities.
(Line 43) Environmental Health Risk Reduction: the detection and alleviation of unhealthy conditions
associated with water, sewage, solid waste, rodents, parasites, field sanitation, housing, lead paint,
pesticides, and other environmental factors related to public health.
(Line 44) Food Bank/Delivered Meals: provision of actual food or meals. Does not include financial
assistance for food or meals.
(Line 45) Health Education: personal assistance provided to promote knowledge regarding health and
healthy behaviors, including knowledge concerning sexually transmitted diseases, family planning,
prevention of fetal alcohol syndrome, smoking cessation, reduction in misuse of alcohol and drugs,
improvement in physical fitness, control of stress, nutrition, and others. Included are services
provided to the client's family and/or friends by non-licensed mental health staff which may include
psycho social, care giver support, bereavement counseling, drop-in counseling, and other support
groups activities.
(Line 46) Housing Assistance: assistance in locating and obtaining suitable temporary or permanent
shelter. May include locating costs, moving costs, and rent subsidies.
(Line 47) Interpretation/Translation Services: services to assist individuals with language or
communication barriers to receive and understand needed services.
(Line 48) Nursing Home and Assisted-Living Placement: assistance in locating a n d obtaining nursing
home and assisted-living placements.
(Line 49) Outreach: case finding, education or other services to identify potential clients and facilitate
access or make client referrals to available services.
(Line 50) Transportation: transportation provided for the site’s patients.
(Line 51) Home Visiting: health and other enabling services delivered to patients in the home.
(Line 52) Parenting Education: services to teach individuals child rearing and related skills.
(Line 53) Other (Specify): other services not identified above.

Revised November 2007

Table 1: Services

Page 20

UDS Number: ____________________________
For Period: January 1, 2007 to December 31, 2007

TABLE 1
SERVICES OFFERED AND DELIVERY
METHOD

OMB No. 0915-0232
Expiration Date: 10/31/2008
Date Submitted: _____________________________________

Delivery Method
Service Type
(See Instructions for Definition)

Delivery Method

Provided
by
Site

By
Referral
Site Pays

By
Referral
No Pymt

Not
Provided

(a)

(b)

(c)

(d)

Service Type
(See Instructions for Definition)

By
Referral
Site Pays

By
Referral
No Pymt

Not
Provided

(a)

(b)

(c)

(d)

26.) Developmental Screening

Medical Care Services
1.) General Primary Medical Care

(other than below)

27.) 24-hour Crisis Intervention/Counseling

2.) Diagnostic Laboratory

(technical component)

28.) Other Mental Health Services

3.) Diagnostic X-Ray Procedures

(technical component)

29.) Substance Abuse Treatment/Counseling

4.) Diagnostic Tests/Screenings (professional component)

30.) Other Substance Abuse Services

5.) Emergency Medical Services

Other Professional Services

6.) Urgent Medical Care

31.) Hearing Screening

7.) 24 Hour Coverage

32.) Nutrition Services other than WIC

8.) Family Planning

33.) Occupational or Vocational Therapy

9.) HIV Testing

34.) Physical Therapy

10.) Immunizations

35.) Pharmacy

11.) Following Hospitalized Patients

36.) Vision Screening

Obstetrical and Gynecological Care

37.) WIC Services

12.) Gynecological Care

Other Services

13.) Prenatal Care

38.) Case Management

14.) Antepartum Fetal Assessment

39.) Child Care

15.) Ultrasound

40.) Discharge Planning

16.) Genetic Counseling and Testing

41.) Eligibility Assistance

17.) Amniocentesis

42.) Employment/Education Counseling

18.) Labor and Delivery Professional Care

43.) Environmental Hlth Risk Redctn (via detectn/allevtn)

19.) Postpartum Care

44.) Food Bank/ Delivered Meals

Specialty Medical Care

45.) Health Education

20.) Directly Observed TB Therapy

46.) Housing Assistance

21.) Other Specialty Care

47.) Interpretation/Translation Services

Dental Care Services

48.) Nursing Home & Assisted Living Placement

22.) Dental Care - Preventive

49.) Outreach

23.) Dental Care - Restorative

50.) Transportation

24.) Dental Care – Emergency

51.) Home Visiting

Mental Health/Substance Abuse Services

52.) Parenting Education

25.) Mental Health Treatment/Counseling

53.) Other

UDS 18.pdf

Provided
by
Site

(Specify:

(during visit to Site)

)

Revised 11/07

INSTRUCTIONS FOR TABLE 2

Table 2 has four parts A through D. Users are all individuals receiving at least one face-to-face
encounter within the reporting period. Users and encounters are defined in the General Instructions
section beginning on page eight.
The total number of users and the total prenatal users are to be based upon actual data. The total
users reported on parts A, B, C, and D should be equal. The user distributions called for in parts A
through D may be actual or estimated. Estimates are to be based upon a sample of patient
records. The minimum sample size is 200 records of randomly selected users. Samples may be
drawn from patient records. The UDS software includes a routine which will compile and
summarize sampled user data. Mark the boxes in the header of each table to indicate whether the
distribution is based upon actual or estimated data. “Estimated from Sample” is automatically
recorded in the header when the UDS software routine is used.
The user software routine is the easiest way to get table 2 data that is not collected by an automated
patient accounting system. For additional advice about using the software routine to compile and
summarize data, please call the toll free support line at, 888-459-1080 or send an e-mail to
[email protected].
Federal Bureau of Prison, nonfederal prison, Indian Health Service (IHS), Section 638, and
Immigration and Naturalization Service (INS) sites are only to complete parts 2A and 2B of table 2.

TABLE 2 PART A:
USERS BY AGE AND GENDER AND PRENATAL USERS BY AGE

The number of users by age and gender may be actual or estimated. Estimates are to be based
upon a sample of patient records. The minimum sample size is 200 records of randomly selected
users. Samples may be drawn from patient records. Total users and total prenatal users are to be
based upon actual data.
(Column a and b) Male and Female Users: report the number of male and female users by age.
Use the individual's age on June 30th of the reporting period to identify the user’s age.
(Column c) Prenatal Users: complete only if site provides or assumes primary responsibility for a
patient’s prenatal care services. Report total prenatal care users in the year by age group.

Revised November 2007

Table 2: Users

Page 23

TABLE 2 PART B:
USERS BY RACE, ETHNICITY, AND LANGUAGE
The number of users by race, ethnicity, and the number of users requiring interpretation services
may be actual or estimated. Race and ethnicity classifications are to be determined by the user
records. Report the number of users where the race or ethnicity is unreported or where the patient
refuses to report as “Unreported/Refused to Report” on line 8. Unreported/ Refused to Report is to be
used to report missing data from actual or sampled records. It is not to be used to report that the
data is not collected. Estimates are to be based upon a sample. The minimum sample size is 200
records of randomly selected users. Samples may be drawn from patient records.
(Column a) Users by Race (Lines 1 through 5, 7 and 8 ): report the number of users in each race
category on lines 1 through 5. Report users selecting more than one race on line 7. Do not
report Hispanic or Latino users as a race category in Column (a) on line 7. Report the number of
users where the race is unknown as “Unreported/Refused to Report” on line 8.
Unreported/Refused to Report is to be used to report missing data from actual or sampled
records. It is not to be used to report that the data is not collected. The total users on line 9
column (a) equal total users on line 9 column (b).
(Column b) Users by Ethnicity (Lines 6 through 8): report the number of users in each ethnic
category on lines 6 and 7. Report “Hispanic or Latino” users on line 6 and all others as “Not
Hispanic or Latino” on line 7. Report the number of users where the ethnicity is unknown as
“Unreported/Refused to Report” on line 8. Unreported/ Refused to Report is to be used to report
missing data from actual or sampled records or surveys. It is not to be used to report that the
data is not collected. If data is not collected, it is to be estimated from a sample. The total users
on line 9 column (b) equals total users on line 9 column (a).
(Line 10) Users Needing Interpretation Services: the number of total users who would be better
served in a language other than English. This is an estimate of all users needing interpretation
services. Include in the estimate those users who needed but did not get interpretation services
and those who needed and received interpretation services from a bilingual provider, other
staff, their own interpreter, or another source. In a predominately Spanish speaking community
and clinic, report the number of users who would require interpretation services if served in
English. Include deaf patients as well as non-English speaking users. The definition is meant
to be inclusive rather than exclusive.

TABLE 2 PART C:
USERS BY INCOME LEVELS
The number of users by income level may be actual or estimated. Estimates are to be based upon
a sample. The minimum sample size is 200 records of randomly selected users. Samples may be
drawn from patient records. The total number of users is to be based upon actual data.
(Lines 1 through 5) Percent of Poverty Level: report the n um bers of users within the
income

Revised November 2007

Table 2: Users

Page 24

ranges identified. Income ranges are expressed as a proportion of the federal poverty
guidelines. The federal poverty guidelines are updated annually in February or March and are
published in the Federal Register. Copies are available from the NHSC web site at
http://nhsc.bhpr.hrsa.gov/resources/uds/. Copies are also available by searching the Federal
Register online under “notices” for the “Annual Update of the HHS Poverty Guidelines” at
http://www.gpoaccess.gov/fr/index.html. NHSC sites are expected to make services available
through the use of a sliding fee discount schedule or other documented means of eliminating
financial barriers for those at or below 200 percent of the federal poverty income guideline. The
data reported here should be based upon the numbers of users making use of the discount
policy, the most current patient income information available, and the current federal poverty
guideline. Report the number of users where the actual or sampled income data is unknown
as “Unreported/Refused to report” on line 4. “Unreported/ Refused to report” is to be used to
report missing data from actual or sampled records. It is not to be used to report that the data
is not collected.

TABLE 2 PART D :
USERS BY PRIMARY INSURANCE TYPE
The number of users by primary insurance type may be actual or estimated. Estimates are to be
based upon a sample. The minimum sample size is 200 records of randomly selected users.
Samples may be drawn from patient records. The total number of users is to be based upon actual
data.
A user may have coverage under more than one insurance plan, different coverage for different
services and this coverage may change over the course of a year. When medical services are
provided, report the user’s primary health insurance covering primary medical care, if any, as of
the last visit during the reporting period. If medical services are not provided, report the user’s
primary insurance, if any, for the services offered. Report the user's primary health insurance even
though it may not have covered the services rendered during the user's last visit.
Primary insurance is defined as the insurance plan or program that the site would bill first for
services rendered. For example:
Report Medicare as the primary insurance if a user has both Medicare and Medicaid
because Medicare is billed before Medicaid.
Report the employer plan as the primary insurance if a user has both an employer plan and
Medicare because the employer plan is billed first.
(Line 1) Medicare: users whose primary insurance is a plan for Medicare beneficiaries including
Federally Qualified Health Center, Rural Health Clinic, managed care, and other reimbursement
arrangements administered by Medicare or by a fiscal intermediary.
(Line 2) Medicaid: users whose primary insurance is a plan for Medicaid beneficiaries including
Federally Qualified Health Center, Rural Health Clinic, managed care, EPSDT, State Child
Health Insurance program (SCHIP) and other reimbursement arrangements administered either
directly by the state agency or by a fiscal intermediary.

Revised November 2007

Table 2: Users

Page 25

(Line 3) Other Public Insurance: users whose primary insurance is provided by federal, state, or
local governments that is not reported elsewhere such as, state indigent care programs, city
welfare, and similar government plans. A State Children’s Health Insurance Program operated
independently from the Medicaid program is an example of other public insurance. Users with
health benefit plans offered to government employees, retirees and dependants such as
TRICARE, the federal employees health benefit program, state employee health insurance
benefit programs, teacher health insurance and similar plans are to be classified as private
insurance users. Private insurance is earned and other public insurance is unearned. Users
with no insurance but who have public categorical or other grant funds applied to their
accounts for services received are to be classified as self-pay. The National Breast and
Cervical Cancer Early Detection Program is an example of a categorical grant program which is
not insurance.
(Line 4) Private Insurance: users whose primary insurance is a private insurance plan, managed
care plan, or a contractual arrangement. This includes plans such as Blue Cross and Blue
Shield, commercial insurance, managed care plans, self-insured employer plans, group
contracts with unions and employers, and service contracts with employers and others. As
noted above, users with health benefit plans offered to government employees, retirees and
dependants such as TRICARE, the federal employees health benefit program, state employee
health insurance benefit programs, teacher health insurance and similar plans are to be
classified as private insurance users.
(Line 5) Self-Pay (no insurance): users without any health insurance. As noted above, users with
no insurance but who have categorical or other grant funds applied to their accounts for
services received are to be classified as self-pay.

Revised November 2007

Table 2: Users

Page 26

UDS Number: ________________________________
For Period: January 1, 2007 to December 31, 2007

OMB No. 0915-0232
Expiration Date: 10/31/2008
Date Submitted: ___________________________

TABLE 2- PART A
USERS BY AGE AND GENDER
AND PRENATAL USERS BY AGE
Enter an “A” (Actual) or an “E” (Estimated) in the boxes for the columns

Cols (a) & (b), Lines 1-11:

Col (c), Lines 3-8:

Male
Users

Female
Users

Prenatal
Users

(a)

(b)

(c)

Age Groups

1.) Under age 1
2.) Ages 1-4
3.) Ages 5-12
4.) Ages 13-14
5.) Ages 15-19
6.) Ages 20-24
7.) Ages 25-44
8.) Ages 45-64
9.) Ages 65-74
10.) Ages 75-84
11.) Ages 85 and over
12.) Total Users

TABLE 2- PART B
USERS BY RACE/ETHNICITY/LANGUAGE
Enter an “A” (Actual) or an “E” (Estimated) in the boxes for the columns

Col (b), Lines 6-8:

Col (a), Lines 1-5 + 7-8:
Users By
Ethnicity

Users by Ethnicity

(b)
Lines 1-5: Not used
6.) Hispanic or Latino
7.) Non-Hispanic
8.) Unreported/Refused to report
9.) Total Users

Users by Race

Users By
Race
(a)

1.) Asian
2.) American Indian or Alaska Native
3.) Black or African American
4.) Native Hawaiian or Other Pacific Islander
5.) White
6.) Line not used
7.) More than one race
8.) Unreported/refused to report
9.) Total Users
10.) Users needing interpretation Services
(This line is a subset of total users)

UDS18.pdf

Revised 11/07

UDS Number: ________________________________
For Period: January 1, 2007 to December 31, 2007

OMB No. 0915-0232
Expiration Date: 10/31/2008
Date Submitted: ___________________________

TABLE 2- PART C
USERS BY INCOME LEVEL
Enter an “A” (Actual) or an “E” (Estimated) in the box below

Col (a), Lines1-3:
(Not Completed by Prison, IHS, Section 638 or INS sites)

Number
of Users

Percent of Poverty Level

(a)
1.) 100% and below
2.) 101- 200%
3.) Above 200%
4.) Unreported/Refused to report
5.) Total Users

TABLE 2- PART D
USERS BY PRIMARY INSURANCE TYPE
Enter an “A” (Actual) or an “E” (Estimated) in the box below

Col (a), Lines1-5:
(Not Completed by Prison, IHS, Section 638 or INS sites)

Number
of Users

Primary Insurance

(a)
1.) Medicare
2.) Medicaid
3.) Other Public Insurance (specify:

)

4.) Private Insurance
5.) Self-Pay (No Insurance)
6.) Total Users

Note: Total users in Tables 2A Cols (a) + (b), 2B Col (a), 2B col (b), 2C, and 2D are equal and are to be based on actual data. User distributions may be
estimated. Use sample size of 200 records or more. 

UDS18.pdf

Revised 11/07

INSTRUCTIONS FOR TABLE 3:
STAFFING AND UTILIZATION

This table profiles the personnel, encounters, and users by function. See Appendix A for a listing of
personnel included in each major service category. The number of staff are reported in full time
equivalents (FTEs). Encounters and users are defined in the General Instructions section beginning
on page five. Encounters and users are reported in four major service classes including medical,
dental, mental health & substance abuse, and other professional & other services. Encounters are
separately reported for staff and nonstaff providers as defined below.
Staff: salaried full-time or part-time employees of the sponsoring organization who work on behalf of
the site and nonsalaried individuals paid by the sponsoring organization who work for the
sponsor on a regular schedule that is controlled by the sponsor under any of the following
compensation arrangements: contract, National Health Service Corps assignment, retainer,
capitation, block time, fee-for-service, and donated time. Provider staff work at the NHSC
approved site or at approved off-site locations. Support staff may work for the site at other
locations. Regularly scheduled means a preassigned number of work hours devoted to the site’s
activities.
Nonstaff: individuals paid by the sponsoring organization who work independently under their
own control on their own schedule providing or supporting primary care and related
supplemental services to the site’s patients under one of the following compensation
arrangements: fee-for-service, capitation, retainer, and donated time which the sponsoring
organization would otherwise have to pay for the services. The FTE value of the time worked by
nonstaff providers and other personnel is not reported but the encounters are recorded in
column (d).
Full time equivalents (FTEs) are reported for staff and are not reported for nonstaff individuals.
Some examples of staff and nonstaff personnel are noted below.
• NHSC providers are considered staff.
• Providers working onsite under contract on a scheduled basis are considered staff.
Referral providers who are paid by the site or sponsoring organization are considered
nonstaff when working independently at unapproved off-site locations such as the referral
provider’s office
Central office administrative personnel working directly for the site are considered site staff
who’s FTEs are counted. The FTEs of central office personnel who indirectly support
the site are not counted.
Contracted support staff working under a contract which replaces personnel the site would
otherwise have hired, who work directly for the site, who may work either on or off-site, and
who work for the site on a regularly scheduled basis are consider “staff” whose time or
FTE value is to be reported. This might include personnel employed by a practice
management company, a management services organization, billing service company, or
similar contractor. If individuals under these arrangements work on an irregular,
unscheduled or indirect basis, they are considered nonstaff and their FTEs are not counted.
Revised November 2007

Table 3: Staffing and Utilization

Page 30

Professionals working for the site under legal, audit, actuarial, management consulting, and
similar contracts for services provided on a one-time, sporadic, or unscheduled basis are
considered nonstaff.
Consulting pathologists, radiologists, and other consulting providers who provide services on
an unscheduled or sporadic basis are considered nonstaff.
(Column a) FTEs: Full Time Equivalents (FTEs) for all staff. Full time equivalents are computed on
an individual basis by dividing the total number of hours in the reporting period for which a
person was compensated by the total number of hours in the year considered by the site to be
full-time. The total number of hours for which an individual was compensated includes the
number of hours a person was present for work and paid for their time, as well as paid leave
time including vacation, sick leave, continuing education trips, etc. An annual hours pay base of
2,080 (40 hours/week x 52 weeks/year) is typical but the base may vary by organization and by
class of employee. Employees who work less than the annual hour’s base are normally
considered part time. An individual staff member is not to be reported as more than 1.00 full time
equivalents regardless of any overtime hours worked or compensation paid. Round FTEs to the
second decimal place.
Salaried provider staff FTEs are to be calculated based upon the number of paid hours, not
the number of scheduled hours. A provider who schedules 32 hours per week to see patients
but who is paid for a 40 hour week is considered full time or 1.00 FTE.
Contract provider and support staff FTEs are to be calculated by dividing the hours the staff
work by the hours a full time employee of that type would be expected to work. The time
worked in the numerator is to be taken from contracts, invoices, schedules or similar sources.
The denominator or base of hours considered full-time for these arrangements should not
include leave time unless leave is directly charged or the time salaried clinician’s of that type are
ordinarily not scheduled to see patients. For example, if full time salaried providers are expected
to schedule 32 hours of patient care per week, a contract provider who was paid for 16 hours
of scheduled patient care per week would be considered half time or 0.50 FTE. The annual
scheduled hour’s base considered full-time for contract providers is likely to vary by clinical
specialty.
Time for personnel performing more than one function should be allocated as appropriate
among the major personnel service categories. For example, the time of a physician who is
also a medical director should be allocated between medical care services and administration.
Time for nurses who also provide case management services should be allocated between
medical care and case management.
The FTEs of central office staff in a multi-site sponsoring organization who provide direct support
to the NHSC site are to be counted. The FTEs of central office personnel who indirectly
support the site are not counted.
(Column b) Users: the unduplicated number of users seen during the reporting period within each of
four major personnel service categories: medical care services; dental services; and mental
health and substance abuse services; and other professional services. Users are defined in the
General Instructions section of this manual. An actual count is of users by service type is
preferred but may be estimated based upon a sample of records. One method for estimating
users by service class is to divide actual encounters for that service class by the encounters
per user for that service class determined from a random sample of patient records. See the
illustration in the General Instructions section on page 11.
Revised November 2007

Table 3: Staffing and Utilization

Page 31

(Column c) Staff Encounters: encounters generated by “staff” providers whose time is reported in
column (a). Encounters are defined in the General Instructions section of this manual on page
five.
(Column d) Nonstaff Encounters: encounters generated by “nonstaff” or referred care providers
who work independently on their own schedule at the approved site or an off-site location. The
service must be documented in the patient’s record to be a reportable encounter.
As noted in the General Instructions section beginning on page two, sites may elect to include or
exclude all or some portion of paid referred care services rendered to the site’s patients at offsite locations. This election may be based upon the ability or ease of reporting this information
on a site specific basis. The same scope of off-site referred care should be used to complete
the encounter, user, charge, and cost tables.
Personnel by Major Service Category: staff are classified into four service categories. The
categories are: medical care services; dental services; mental health and substance abuse
services; other professional and other services; and administration and facility. See Appendix A
for a listing of personnel included in each major service category.
(Lines 1 through 7) Physicians: (M.D. or D.O.): separate FTE and encounter totals for family
practitioners, general practitioners, internists, obstetrician/gynecologists, pediatricians,
psychiatrists, and all other specialists. Use board certification to classify physicians by
specialty. Classify physicians with more than one board certification in the specialty
representing the service the physician provides most or allocate based upon time spent.
(Line 8) Total Physicians: FTE and encounter totals for medical services, lines 1 through 7.
(Line 9) Nurse Practitioners/Physician Assistants: FTE and encounter totals for physician
assistant and nurse practitioner staff performing medical services. Nurse practitioners include
psychiatric nurse practitioners.
(Line 10) Certified Nurse Midwives: FTE and encounter totals for nurse midwives performing
medical services
(Line 11) Nurses: FTE and encounter totals for nurses that are involved in provision of medical
services, including registered nurses, licensed practical nurses, home health and visiting
nurses, clinical nurse specialists, and public health nurses. If an individual's time is divided
between medical and nonmedical services, allocate the FTEs to reflect this division of time. For
example, nurses who provide case management or education/counseling services in addition to
medical care should be allocated between medical services and other services.
Given the unusual and important role of Alaska Community Health Aides, they are reported on
line 11 rather than on a nonprovider line so that their encounters and users are recognized.
(Line 12) Other Medical Support Personnel: FTE totals for medical assistants, nurses aides, and
all other personnel providing services together with or in direct support of services provided by a
physician, nurse practitioner, physician assistant, certified nurse midwife, or nurse. FTEs for
registration, reception, appointments, transcription, patient records, and other support
personnel are not reported here but are reported on line 32 as Patient Service Support
Personnel.

Revised November 2007

Table 3: Staffing and Utilization

Page 32

(Line 13) Total Medical Services: FTE, encounter, and user totals for medical services, lines 1
through 12.
(Line 14) Laboratory Services Personnel: FTE totals for pathologists, medical technologists,
laboratory technicians and assistants, phlebotomists. This refers exclusively to medical
personnel not dental personnel. Dental personnel performing laboratory services are
reported on lines 18-20. Lab encounters are not reported.
(Line 15) X-ray Personnel: FTE totals for radiologists, X-ray technologists, X-ray technicians and
ultrasound technicians. Only report medical personnel not dental personnel. Dental
personnel performing x-ray services are reported on lines 18-20. X-ray encounters are not
reported.
(Line 16) Pharmacy Personnel: FTE total for pharmacists and pharmacist assistants. Pharmacy
encounters are not reported.
(Line 17) Total Ancillary Services: FTE totals for ancillary services, lines 14 through 16.
(Line 18) Dentists: FTE and encounter totals for general practitioners and specialists including
oral surgeons, periodontists, and pedodontists.
(Line 19) Dental Hygienists: FTE and encounter totals for dental hygienists.
(Line 20) Dental Assistants, Aides & Technicians: FTE totals for other dental personnel
including dental assistants, aides, and technicians.
(Line 21) Total Dental Services: FTE, encounter, and user totals for dental services, lines 18
through 20.
(Line 22) Mental Health and Substance Abuse Specialists: FTE and encounter totals for
individuals providing counseling or treatment services related to mental health or substance
abuse including clinical psychologists, clinical social workers, psychiatric social workers,
psychiatric nurses, mental health nurses, and family therapists. Report psychiatrists on line 6
under physicians and psychiatric nurse practitioners on line 9 under nurse practitioners,
not in this category.
(Line 23) Mental Health and Substance Abuse Support Personnel: FTE totals for assistants,
aides, and all other personnel providing services in conjunction with or in direct support of
services provided by mental health and substance abuse specialists.
(Line 24) Total Mental Health and Substance Abuse Services: F T E , encounter, a n d user totals
for mental health and substance abuse services, lines 22 and 23.
(Line 25) Other Professionals: FTE and encounter totals for other staff professionals providing
health services, including occupational therapists, physical therapists, podiatrists, optometrists
and chiropractors.
(Line 26) Case Managers and Education Specialists: FTE totals for case managers and
education specialists. Case manager and education specialist encounters are not reported.

Revised November 2007

Table 3: Staffing and Utilization

Page 33

Case managers include nurses, social workers and other professional staff providing services to
aid patients in the management of their health and social needs. Services include need
assessments, maintenance of referral, tracking and follow-up systems and eligibility assistance
when provided by staff performing broader case management functions.
Education specialists include health educators, family planning counselors, HIV counselors, HIV
specialists and others who provide information about health conditions and guidance about
appropriate use of health services that are not otherwise classified under outreach.
(Line 27) Outreach Workers, Transportation Staff, and Other: FTE total for individuals
conducting outreach or case finding, drivers and other transportation staff, child care workers,
eligibility assistance workers, housing assistance workers, interpreter, translators, and others.
Outreach worker, transportation and other service encounters are not reported.
(Line 28) Other Professional and Other Service Support Personnel: FTE totals for assistants,
aides, and all other personnel providing services in conjunction with or in direct support of
services provided by other professional and other service providers.
(Line 29) Total Other Professional and Other Services: FTE totals for other professional and
other services, lines 25 through 28. The encounter total for other professional services is
reported on line 25 and line 29. The user total for other professional service encounters is
reported only on line 29. Case manager, education specialist, outreach worker, transportation,
and other service encounters and users are not reported.
(Line 30) Administration Staff: FTE total for administrative personnel, including the executive
director, medical director, physicians or nurses with administrative responsibilities, secretaries,
finance, billing, information service, communications, marketing, planning, program
development, and other support staff.
(Line 31) Facility Staff: FTE total for staff with facility support and maintenance responsibilities,
including custodians, housekeepers, groundskeepers, security, and other maintenance staff.
(Line 32) Patient Services Support Staff: FTE total for registration, reception, appointments,
transcription, patient records, and other support personnel who provide centralized or indirect
support to patient service activities.
(Line 33) Total Administration and Facility: FTE total for administration, facility, and patient
service support personnel, lines 30 through 32.
(Line 34) Total: FTE and encounter grand totals. The total of unduplicated users is reported on
Table 2.

Revised November 2007

Table 3: Staffing and Utilization

Page 34

UDS Number: ____________________________
For Period: January 1, 2007 to December 31, 2007

OMB No. 0915-0232
Expiration Date: 10/31/2008
Date Submitted: __________________________

TABLE 3
STAFFING AND UTILIZATION
Personnel by Major Service Categories

F.T.E.’s

Users

Staff
Encounter

Nonstaff
Encounter

(a)

(b)

(c)

(d)

Medical Services
1.)

Family Practitioners

2.)

General Practitioners

3.)

Internists

4.)

Obstetrician/Gynecologists

5.)

Pediatricians

6.)

Psychiatrists

7.)

Other Physician Specialists

8.)

Total Physicians

9.)

Nurse Practitioners/Physician Assistants

(Lines 1 Thru 7)

10.) Certified Nurse Midwives
11.) Nurses
12.) Other Medical Support Personnel
13.) Total Medical Services

(Lines 8 thru 12, except Col. b)

Ancillary Services
14.) Laboratory Services Personnel
15.) X-Ray Services Personnel
16.) Pharmacy Personnel
17.) Total Ancillary Services

(Lines 14 thru 16)

Dental Services
18.) Dentists
19.) Dental Hygienists
20.) Dental Assistants, Aides, Technicians, and Support
21.) Total Dental Services

(Lines 18 thru 20, except Col. b)

Mental Health & Substance Abuse Services
22.) Mental Health & Substance Abuse Specialists
23.) Mental Health & Substance Abuse Support Personnel
24.) Total MH & SA Services

(Lines 22 and 23, except Col. b)

Other Professional and Other Services
25.) Other Professionals (PT, OT, Podiatrists, Nutritionists & Other)
26.) Case Managers and Education Specialists
27.) Outreach Workers, Transportation Staff, & Other Service
28.) Other Professional and Other Service Support Personnel
29.) Total Other Professional and Other Services

(Lines 25 thru 28)

Administration and Facility
30.) Administration Personnel
31.) Facility Personnel
32.) Patient Services Support Personnel (Patient Records, etc.)
33.) Total Administration & Facility
34.) Total
UDS18.pdf

(Lines 30 thru 32)
(Lines 13, 17, 21, 24, 29, & 33)
Revised 11/07

INSTRUCTIONS FOR TABLE 4:
PATIENT SERVICE CHARGES, COLLECTIONS AND SELF-PAY ADJUSTMENTS
This table shows the patient service charges, receipts, and sliding fee discounts by payment source
for all related activity of all providers at the site to which the NHSC provider is assigned. See the
General Instructions for a definition of the scope of activity to be reported. Report in whole dollars.
Charges and collections are to be reported in five pay classes: Medicare, Medicaid, other public,
private insurance, and self-pay. Charges and receipts are to be identified with the payer which is
the responsible party. For instance, Medicare receipts are attributable to Medicare even though the
receipts were made by an intermediary such as Blue Shield. Similarly, charges and receipts for
which a Medicare beneficiary is personally responsible such as deductibles and copayments are
self-pay rather than Medicare charges and receipts.
Charges and receipts are further classified as either fee-for-service or capitated amounts. Fee-forservice means any payment arrangement other than a managed care capitation plan such as a
Resource Based Relative Value System (RBRVS) fee schedule, a prospective pricing system, a
fixed fee schedule, a contract rate, a cost related rate, a fee-for-service managed care plan, and
similar arrangements. Capitated means those managed care plans under which the site receives a
fixed payment per enrollee in exchange for an obligation to provide or arrange a defined set of
covered services for a specified period of time to an enrolled individual; where the enrollee is
assigned a primary care provider at the site as their principal care giver; and where the primary
care provider has responsibility for authorizing any covered referred care services for the enrollee,
where the patient is locked-in to the arrangement for some period and where the site assumes
some measure of financial risk. Under these arrangements payment is generally made in
advance on a monthly basis and the site may be fully or partially at risk to provide covered primary
care, referred care, and inpatient services to enrollees with the capitation paid.
The charges and collections from managed care plans that are part capitation and part fee-forservice are classified as either fee-for-service or capitated on the appropriate payer lines.
(Column a) Full Charges: the gross charges as established by the site for the services rendered
during the reporting period. Charges are reported at their full value for all services prior to any
adjustments. Fee-for-service charges are uniformly reported at the full charge rate from the
site’s fee schedule. Site’s with capitation contracts or who are reimbursed on a cost based flat
fee, such as a Rural Health Clinic rate or Federally Qualified Health Center rate are to report the
normal full charge from the site’s fee schedule rather than the negotiated visit, capitation, or
contract rate.
Charges are to reflect the amount for which the payer is responsible. Deductibles,
copayments, and uncovered services for which the patient is personally responsible
should be reclassified and reported as self-pay. Similarly, any charges not payable by a third
party payer that are due from the patient or another third party should be deducted from the
payer’s charges and added to the account of the secondary payer. The reclassification of
charges to secondary and subsequent payers may be estimated based upon a sample.
Sites may elect to include or exclude all or some portion of paid referred care services rendered
to the site’s patients at off-site locations. This election may be based upon the ability or ease of
reporting this information on a site specific basis. The same scope of off-site referred care
should be used to complete the encounter, user, charge, and cost tables.
Revised November 2007

Table 4: Charges, Collections, and Self-Pay Adjustments

Page 38

(Column b) Amount Collected: the actual cash received during the period for services rendered,
regardless of the date of service. This includes Rural Health Clinic and Federally Qualified
Health Center settlement receipts, case management fee receipts, incentive receipts from
managed care plans, and other similar receipts.
Amounts collected are the amounts collected from the payer. If there is more than one payer
involved in a given encounter, the charges due from the primary payer and the amount collected
from the primary payer are reported on the primary payer line. The charges due from the
secondary payer are reported on the secondary payer line along with any amounts collected
from the secondary payer. The reclassification of charges and collections to secondary and
subsequent payers may be estimated based upon a sample of accounts.
(Column c) Adjustments: the difference between the full charges and the amount actually
received or expected. The only adjustments to be reported here are self-pay adjustments.
(Line 1) Medicare (Title XVIII) Fee-for-Service: charges and receipts related to services
provided to Medicare beneficiaries payable by fee-for-service insurance plans operated under
Title 18 of the Social Security Act including Federally Qualified Health Center, Rural Health
Clinic, or any
other reimbursement arrangement excluding capitated managed care
administered by Medicare or its fiscal intermediaries.
(Line 2) Medicare (Title XVII) Capitated: charges and receipts related to services provided to
Medicare beneficiaries payable by capitated managed care plans operated under Title 18 of the
Social Security Act. This includes supplemental or incentive receipts by the plan such as
hospital or referred care pool distributions, withhold receipts, and similar amounts.
(Line 3) Total Medicare: The sum of lines 1 and 2.
(Line 4) Medicaid (Title XIX) Fee-for-Service: charges and receipts related to services provided
to Medicaid beneficiaries and payable by fee-for-service insurance plans operated under Title 19
of the Social Security Act, including Federally Qualified Health Center, Rural Health Clinic, case
management, fee-for-service managed care, EPSDT, State Child Health Insurance Program
(SCHIP) and any other reimbursement arrangement, excluding capitated managed care,
administered either directly by the state agency or by its fiscal intermediaries.
(Line 5) Medicaid (Title XIX) Capitated: charges and receipts related to services provided to
Medicaid beneficiaries payable by capitated managed care plans operated under Title 19 of the
Social Security Act. This includes supplemental or incentive receipts by the plan or state such as
FQHC wrap-around receipts, incentive distributions, withhold receipts, and similar amounts.
(Line 6) Total Medicaid: The sum of lines 4 and 5.
(Line 7) Other Public Fee-for-Service: charges and receipts related to services provided to users
and payable by fee-for-service insurance plans operated by federal, state, or local governments
that are not reported elsewhere such as separately administered State Child Health Insurance
Programs (SCHIP), state or county indigent care programs, city welfare, and similar plans. This
may also include that portion of charges and receipts from public categorical service grants
which are directly applied to a self-pay or insured patient’s account. The National Breast and
Cervical Cancer Early Detection Program is one example of a public categorical service grant
program whose charges and receipts are classifiable as other public.

Revised November 2007

Table 4: Charges, Collections, and Self-Pay Adjustments

Page 39

(Line 8) Other Public Capitated: charges and receipts related to services provided to users and are
payable by capitated managed care plans operated by federal, state, or local governments that
are not reported elsewhere such as separately administered State Child Health Insurance
Programs (SCHIP), state or county indigent care programs, city welfare, and similar plans.
(Line 9) Total Other Public: The sum of lines 7 and 8.
(Line 10) Private Insurance Fee-for-Service: charges and receipts related to services provided to
users and payable by fee-for-service insurance plans other than those reported above such as a
private insurance plan, managed care plan, or a contractual arrangement. This includes plans
such as Blue Cross and Blue Shield, commercial insurance, managed care plans, self-insured
employer plans, group contracts with unions and employers, and service contracts with
employers, schools, health departments, and others. Health benefit plans offered to government
employees, retirees and dependants such as TRICARE, the federal employees health benefit
program, state employee health insurance benefit programs, teacher health insurance and
similar plans are to be classified as private insurance.
(Line 11) Private Insurance Capitated: charges and receipts related to services provided to users
and payable by capitated managed care plans other than those reported above such as
commercial, union, employer, and other managed care plans.
(Line 12) Total Private Insurance: The sum of lines 10 and 11.
(Line 13) Self-Pay: charges and receipts related to services provided to patients without any
principal health insurance or to patients with insurance but only that portion for which the patient
is personally liable such as deductible, copayments, and uncovered charges. Charges not paid
by a third party payer and due from the patient should be deducted from the full charges of the
third party payer and added to the full charges for the self-pay patients.
(Line 14) Total: the sum of lines 3, 6, 9, 12, and 13.
(Line 15) Self-Pay Sliding Fee Adjustments: the value of charge discounts granted to patients
prior to service and based upon financial hardship. It does not include professional courtesy,
staff, service incentive, or similar discounts. Also, it does not include bad debt adjustments
related to patients who were initially charged full fee but unable to pay because of financial
hardship or other reasons. If a hardship fund is used to pay for the referred lab, x-ray, pharmacy
or other care for sliding fee patients, report the charge value of those services in column (a) and
an off setting sliding fee adjustment in column (c). Sliding fee discounts reflect the site’s
compliance with its assurance to the NHSC that there are no financial barriers to care for those
at or below 200 percent of the current federal poverty income guideline.
(Line 16) Other Self-Pay Adjustments: the value of all self-pay adjustments other than sliding fee
adjustments. This includes bad debt and charity care adjustments taken or granted to self-pay
patients who were initially charged a full, discounted, or partial fee but who subsequently were
either unwilling or unable to pay the amounts charged. It does not include bad debt related to
other pay sources which may be caused by a failure to file timely claims, payer bankruptcy or
similar reasons.
(Line 17) Total Self-Pay Adjustments: the sum of lines 15 and 16.

Revised November 2007

Table 4: Charges, Collections, and Self-Pay Adjustments

Page 40

UDS Number: ____________________________
For Period: January 1, 2007 to December 31, 2007

OMB No. 0915-0232 Expiration Date: 10/31/2008
Date Submitted: ____________________________

TABLE 4
PATIENT SERVICE CHARGES, COLLECTIONS, AND SELF-PAY ADJUSTMENTS
(Not to be completed by Prison, IHS, Section 638 or INS sites)

Payment Source

Full Charges

Amount
Collected

(a)

(b)

Medicare
1.) Medicare Fee-for-Service
2.) Medicare Capitated
3.) Total Medicare

(Lines 1 and 2)

Medicaid
4.) Medicaid Fee-for-Service
5.) Medicaid Capitated
6.) Total Medicaid

(Lines 4 and 5)

Other Public Payers
7.) Other Public Fee-for-Service
8.) Other Public Capitated
9.) Total Other Public

(Lines 7 and 8)

Private Insurance
10.) Private Insurance Fee-for-Service
11.) Private Insurance Capitated
12.) Total Private Insurance

(Lines 10 and 11)

Self-Pay
13.) Self-Pay
14.) Total

(Lines 3, 6, 9, 12, and 13)

Adjustments
Self-Pay Adjustment Type

(c)

15.) Self-Pay Sliding Fee Adjustments
16.) Other Self-Pay Adjustments (Self-Pay Bad Debt and Charity Care)
17.) Total Self-Pay Adjustments

UDS18.pdf

(Lines 15 and 16)

Revised 11/07

INSTRUCTIONS FOR TABLE 5 :
INCOME AND E X PENSES
This table is to include the income and expense of all related activity of all providers at the site to
which the NHSC provider is assigned. See the general instructions for a definition of the scope of
activity to be reported. Include all direct income and expense attributable to the site. Report in whole
dollars, no cents.
(Line 14) Accounting Method: Reporting income and expenses on an accrual basis is preferred.
Check the box on line 14 at the bottom of the table to specify the method used.
(a) Cash: Income is recognized when cash is received and expenses are recorded when cash is
disbursed.
(b) Accrual: Income is recognized in the period it is earned and expenses are recorded in the
period they are incurred.
(c) Modified Accrual: Some combination of cash and accrual reporting such as when income is
recognized when earned and expenses are recorded when paid.
(Line 1) Federal Income: income directly attributable to the site from federal sources where the
sponsor is the grantee such as Title III of Ryan White Care Act. Federal programs funds
received by sites from states or other private nonprofit entities are reported as State, Local, or
Other income on line 3. Sites receiving federal grants from HRSA/BPHC programs are to file
the standard UDS report.
(Line 2) Patient Service Revenue: income directly earned by the site in exchange for and based
upon units of service rendered to patients. It may include fees-for-service, copayments,
premiums, fixed payment rates, capitations, service contracts, and other forms of payment.
Sources may include patients, Medicare, Medicaid, other public insurance, and other third
parties.
Sites reporting on a cash basis report all cash receipts from patient services on line 2. This will
equal the amount collected reported on Table 4 column (b) line 14. Sites reporting on an accrual
basis report net revenue which is gross charges minus contractual allowances, adjustments,
and bad debt. This is normally less than the gross charges reported on Table 4 column (a) line
14.
(Line 3) State, Local, and Other Income: all income directly attributable to the site that is not
federal and is not classifiable as patient service revenue. Include direct income and exclude
indirect income from the parent or sponsoring organization. This does not include NHSC loan
repayment proceeds. This may include grants, donations, and the value of donated goods
and services. Use generally accepted accounting principles when recognizing the value of
donated goods and services. Recognize the value of donated goods and services the
organization would otherwise be required to buy. Use conservative valuation methods. Do not
impute additional value to goods or services for which some payment is made. Offset the
recognition of any donated goods or service income with an equal amount donated goods
or service expense on the appropriate expense line.

Revised November 2007

Table 5: Income and Expenses

Page 44

(Line 4) Total Income: sum of lines 1 through 3.
(Line 5) Provider Compensation and Fringe: compensation and fringe earned by staff providers for
their services during the reporting period. Staff providers include all proprietor, partner,
shareholder, employed or contract physicians, NHSC providers, nurse practitioners, physician
assistants, certified nurse midwives, licensed nurses, dentists, dental hygienists, mental health
specialists, substance abuse specialists, and other professional staff. The providers whose
compensation is reported here should correspond to the provider FTEs reported on Table
3. This includes gross salaries and wages, including annual and sick leave, holiday pay,
overtime, bonuses, incentive payments, stipends, honoraria, partner/shareholder distributions,
profit distributions, contributions to a 401(k) or similar plan, and the cost of fringe benefits.
Fringe benefits include the employer’s share of life, health, disability, and other insurance, social
security (FICA), FUTA, state unemployment compensation, workers compensation, employer
retirement plan contributions, and deferred compensation paid or expensed during the period.
Fringe benefits do not include clinical liability insurance, membership dues, subscriptions,
continuing education expense, relocation expense, travel, automobile, entertainment and other
similar costs. Fringe benefits do not include NHSC loan repayment proceeds.
Do not include provider administrators or that share of provider salary and fringe spent as a site
administrator such as medical director. Report these amounts as nonprovider salaries and
fringe on line 6.
Payments to nonstaff providers such as consulting pathologists, consulting radiologists, other
provider consultants and payments to referred care providers are reported as other clinical
expenses on line 10.
(Line 6) Nonprovider Salaries and Fringe: gross salaries and wages and the cost of fringe
benefits, as defined for line 5 above, earned by all nonproviders. Nonproviders include all
employed staff not reported on line 5. This includes all other medical support, pharmacy
personnel, laboratory services personnel, x-ray personnel, dental assistants, dental aides,
mental health and substance abuse support staff, case managers, and education specialists,
outreach workers, transportation staff, other service staff, administrative staff, patient service
support staff, and facility staff. The nonproviders whose compensation and fringe is
reported here should correspond to the nonprovider FTEs reported on Table 3.
Payments to nonproviders or support staff under contract with the site such as independent
contractors, management service organizations, practice management companies, billing
services and similar arrangements are reported on line 11, administration, facility, and other
expenses.
(Line 7) Clinical Supplies: medical, dental, lab, x-ray, mental health, substance abuse, other
professional, pharmacy, and other service supplies. Exclude office, administration, and facility
supplies.
(Line 8) Clinical Equipment: depreciation, leases, and rent of medical, dental, lab, x-ray, mental

Revised November 2007

Table 5: Income and Expenses

Page 45

health, substance abuse, other professional, pharmacy, and other service equipment. Report
expenses for office equipment and furniture on line 11.
(Line 9) Clinical Liability Insurance: clinical liability or malpractice insurance premiums. Include
an allocable share of clinical liability insurance attributable to the site when paid centrally by the
sponsor.
(Line 10) Other Clinical Expenses: such as payments to nonstaff medical, dental, mental health
and other professional providers; purchased pharmacy, lab, and x-ray services; payments for
referred specialty, hospital, and other care under prepaid plans, including any expense
recognized for “incurred but not reported” (IBNR) claims; and other clinical expenses such as
membership dues, subscriptions, continuing education expense, provider relocation expense,
clinical travel, and provider automobile expense; provider recruitment and other similar clinical
expenses not reported elsewhere. Report bad debt expense as a deduction from patient service
revenue.
As noted in the General Instructions section, sites may elect to include or exclude all or some
portion of paid referred care services rendered to the site’s patients at off-site locations. This
election may be based upon the ability to report or the ease of reporting this information. The
same scope of off-site referred care should be used to complete the encounter, user, charge,
and cost tables.
(Line 11) Administration, Facility, and Other Expenses: administrative, marketing, telephone,
communications, management information, service bureau, interest, general management
expenses, and all expenses related to the use and maintenance of the facility including
depreciation, rent, housekeeping, maintenance, security, and utilities. Includes purchased
legal, accounting, management, and support services. Expenses exclude personal income
taxes for self employed sole proprietors. Report bad debt as a deduction from patient service
revenue on line 2 rather than as an expense on line 11.
(Line 12) Total Expenses: the sum of lines 1 through 11.
(Line 13) Surplus or (Deficit): line 4 minus line 12. The surplus or (deficit) is the amount after any
distributions to owners which are reported on line 5.
(Line 14) Accounting Method: check the method used. See the top of this section for an
explanation of the accounting methods.

Revised November 2007

Table 5: Income and Expenses

Page 46

UDS Number: ____________________________
For Period: January 1, 2007 to December 31, 2007

OMB No. 0915-0232 Expiration Date: 10/31/2008
Date Submitted: __________________________

TABLE 5
INCOME AND EXPENSES
(Not to be completed by Prison, IHS, Section 638 or INS sites)

Account Class

Total

Income
1.) Federal Income
2.) Patient Service Revenue
3.) State, Local, and Other Income
4.) Total Income

(Lines 1 thru 3)

Expense
5.) Provider Compensation and Fringe
6.) Nonprovider Salaries and Fringe
7.) Clinical Supplies
8.) Clinical Equipment
9.) Professional Liability Insurance (Malpractice)
10.) Other Clinical Expenses
11.) Administration, Facility and Other Expenses
12.) Total Expense

(Lines 5 thru 11)

13.) Surplus or (Deficit)

(Line 4 minus 12)

Accounting Method
14.)

UDS18.pdf

Cash (a)

(Check the box below that describes the method used)
Accrual (b)

Modified Accrual (c)

Revised 11/07

INSTRUCTIONS FOR TABLE 6:
MANAGED CARE ENROLLMENT
This table shows the end of period enrollment in prepaid and fee-for-service managed care plans.
Managed care plans are those insurance plans with the following characteristics: the site has an
obligation to provide or arrange a defined set of services for a specified period of time to an enrolled
individual; where the enrollee chooses or is assigned a primary care provider at the site as their
principal care giver; and where the primary care provider has responsibility for authorizing any
covered referred care services for the enrollee, where the patient is locked-in to the arrangement
for some period and where the site assumes some measure of financial risk. Sites may be paid by
the managed care entity with a prepaid capitation or on a fee-for-service basis or by some
combination of these methods.
It does not include individuals who are enrolled in managed care plans, assigned to a primary care
case manager provider at another location and are referred to the site for care. It does not include
members of Preferred Provider Organizations (PPOs) where the patient is free to go to other sites
or providers within a network without authorization from a case manager. It does include individuals
enrolled at the site in managed care plans that cover only medical services, only dental services,
only mental health services or some combination of health services.
A managed care enrollee is different from a user. A user is a patient with one or more reportable
encounters during the year. Managed care enrollees who do not use services during the year will
not be reported as a user. Typically some portion of the enrolled population does not use services
during the year. Even if all the patients in a payer class were enrolled in managed care, it would be
unlikely that the number of enrollees reported on table 6 would equal the users for that payer class
reported on table 2D.
(Line 1) Enrollees in Capitated Plans: the number of enrollees assigned to providers at the site
as of December 31 or the end of the NHSC reporting period in managed care plans under which
the site receives a fixed payment per enrollee in exchange for an obligation to provide or arrange
a defined set of covered services for a specified period of time. Under these arrangements
payment is generally made in advance on a monthly basis and the site assumes some
financial risk. The site may be fully or partially at risk to provide covered primary care, referred
care, and inpatient services to enrollees with the capitation paid.
Report members of managed care plans which reimburse in part on a capitated basis and in
part on a fee-for-service basis exclusively as enrollees in Capitated plans on line 1. Do not
report these individuals a second time as enrollees in fee-for-service plans on line 2.
(Line 2) Enrollees in Fee-for-Service Managed Care Plans: the number of enrollees assigned to
providers at the site as of December 31 in managed care plans under which the site receives
fee-for-service payments in exchange for providing covered services to enrollees. Under these
arrangements the site is not receiving advance payments in exchange for future service
obligations and is not at risk. Often some portion of the fee is withheld and returned based on
performance. Providers may also receive case management fees or a fixed amount per
enrollee per month for managing their care. These case management plans are classified as
fee-for-service managed care.

Revised November 2007

Table 6: Managed Care Enrollment

Page 50

(Line 3) Total Managed Care Enrollees: the sum of lines 1 and 2.
(Column a) Medicaid: enrollees in managed care plans operated under Title 19 of the Social
Security Act including plans administered directly by the state agency, a fiscal intermediary, an
HMO, or other contractor.
(Column b) Medicare: enrollees in managed care plans operated under Title 18 of the Social
Security Act including plans administered by Medicare, a fiscal intermediary, an HMO, or
other contractor.
(Column c) Other Public: enrollees in managed care plans operated by federal, state, or local
governments that are not reported elsewhere such as separately administered State Child
Health Insurance Programs (SCHIP), state, county, or city indigent care programs, and similar
plans.
(Column d) Private: enrollees in managed care plans operated by private entities such as
insurance companies, Blue Cross, Blue Shield, employer plans, union plans, and others.
(Column e) Total: the total of columns (a) through (d).

Revised November 2007

Table 6: Managed Care Enrollment

Page 51

UDS Number: ____________________________
For Period: January 1, 2007 to December 31, 2007

OMB No. 0915-0232 Expiration Date: 10/31/2008
Date Submitted: ___________________________

TABLE 6
MANAGED CARE ENROLLMENT
AS OF THE END OF THE REPORTING PERIOD
(Not to be completed by Prison, IHS, Section 638 or INS sites)

Payment Source
Enrollee Type

1.)

Enrollees in Capitated Plans

2.)

Enrollees in Fee-for-Service Plans

3.)

Total Managed Care Enrollees

UDS18.pdf

Medicaid

Medicare

(a)

(b)

Other

Public
(c)

Total

Private
(d)

(e)

Revised 11/07

APPENDIX A
LISTING OF PERSONNEL BY TABLE 3 LINE NUMBER AND SERVICE CATEGORY
WITH PROVIDER AND NONPROVIDER DESIGNATIONS

LINE

PERSONNEL BY MAJOR SERVICE CATEGORY

PROVIDER

NONPROVIDER

MEDICAL SERVICES

1

Family Practitioner

X

2

General Practitioner

X

3

Internist

X

4

Obstetrician/Gynecologist

X

5

Pediatrician

X

6

Psychiatrist

X

7

Other Specialist Physician

X

7

Allergist

X

7

Cardiologist

X

7

Dermatologist

X

7

Orthopedist

X

7

Surgeon

X

7

Urologist

X

7

Ophthalmologist

X

7

Other specialist and subspecialist

X

9

Nurse Practitioner/Physician Assistant

X

9

Psychiatric Nurse Practitioner

X

10

Certified Nurse Midwife

X

11

Nurses

X

11

Clinical Nurse Specialist

X

11

Public Health Nurse

X

11

Home Health Nurse

X

11

Visiting Nurse

X

11

Registered Nurse

X

11

Licensed Practical Nurse

X

11

Alaska Community Health Aide

X

Revised November 2007

Page A-1

APPENDIX A (continued)
LINE

12

PERSONNEL BY MAJOR SERVICE CATEGORY

PROVIDER

Other Medical Support Personnel

NONPROVIDER

X

12

Nurse Aide/Assistant (Certified and Uncertified)

X

12

Clinic Aide (Certified and Uncertified)

X

12

Medical Technologist (Certified and Uncertified)

X

12

Medical Assistant (Certified and Uncertified)

X

ANCILLARY SERVICES

14

Laboratory Services Personnel

X

14

Pathologist

X

14

Medical Technologist

X

14

Laboratory Technician

X

14

Laboratory Assistant

X

14

Phlebotomist

X

15

X-ray Personnel

X

15

Radiologist

X

15

X-ray Technologist

X

15

X-ray Technician

X

15

Ultrasound Technician

X

16

Pharmacy Personnel

X

16

Pharmacist

X

16

Pharmacy Technician or Assistant

X

DENTAL SERVICES STAFF

18

Dentist

X

18

General Practitioner

X

18

Oral Surgeon

X

18

Periodontist

X

18

Pedodontist

X

19

Dental Hygienist

X

20

Dental Assistant

X

20

Dental Technician

X

20

Dental Aide

X

Revised November 2007

Page A-2

APPENDIX A (continued)
LINE

PERSONNEL BY MAJOR SERVICE CATEGORY

PROVIDER

NONPROVIDER

MENTAL HEALTH AND SUBSTANCE ABUSE STAFF

22

Mental Health and Substance Abuse Specialists

X

22

Psychologist

X

22

Social Worker - Clinical or Psychiatric

X

22

Nurse - Psychiatric or Mental Health

X

22

Alcohol and Drug Abuse Counselor

X

22

Nurse Counselor

X

22

Family Therapist

X

23

Aide or Assistant

X
OTHER PROFESSIONAL STAFF

25

Other Professional Personnel

X

25

Audiologist

X

25

Occupational Therapist

X

25

Optometrist

X

25

Podiatrist

X

25

Chiropractor

X

25

Physical Therapist

X

25

Respiratory Therapist

X

25

Speech Pathologist

X

25

Nutritionists/Dietitian

X
OTHER SERVICE STAFF

26

Case Manager

X

26

Social Worker

X

26

Public Health Nurse

X

26

Home Health Nurse

X

26

Visiting Nurse

X

26

Registered Nurse

X

26

Licensed Practical Nurse

X

Revised November 2007

Page A-3

APPENDIX A (continued)
LINE

PERSONNEL BY MAJOR SERVICE CATEGORY

PROVIDER

NONPROVIDER

26

Education Specialist

X

26

Family Planning

X

26

Health Educator

X

26

Social Worker

X

26

Public Health Nurse

X

26

Home Health Nurse

X

26

Visiting Nurse

X

26

Registered Nurse

X

26

Licensed Practical Nurse

X

26

HIV Counselor or Specialist

X

27

Outreach Worker

X

27

Patient Transportation Worker

X

27

Patient Transportation Coordinator

X

27

Driver

X

27

Child Care Worker

X

27

Eligibility Assistance Worker

X

27

Interpreter/Translator

X

28

Aide or Assistant

X

ADMINISTRATION AND FACILITY STAFF

30

Administration Staff

X

30

Executive Director

X

30

Administrator

X

30

Finance Director

X

30

Accountant

X

30

Bookkeeper

X

30

Secretary

X

30

Director of Planning and Evaluation

X

30

Clerk Typist

X

30

Billing Clerk

X

Revised November 2007

Page A-4

APPENDIX A (continued)
LINE

PERSONNEL BY MAJOR SERVICE CATEGORY

PROVIDER

NONPROVIDER

30

Cashier

X

30

Director of Information Services

X

30

Data Processing Operator

X

30

Personnel Director

X

30

Director of Marketing

X

30

Marketing Representative

X

30

Enrollment/Service Representative

X

31

Facility Staff

X

31

Janitor/Custodian

X

31

Security Guard

X

31

Groundskeeper

X

31

Equipment Maintenance Personnel

X

31

Housekeeper

X

32

Patient Services Support Staff

X

32

Registration Clerk

X

32

Receptionist

X

32

Unit Clerk

X

32

Unit Secretary

X

32

Appointment Clerk

X

32

Patient Records Supervisor

X

32

Patient Records Technician

X

32

Patient Records Clerk

X

32

Patient Records Transcriptionist

X

Note:
• All line numbers refer to Table 3 and only providers generate reportable encounters.

Revised November 2007

Page A-5