Form 1 Prelimnary Data Request

ARRA Section 3012 Supporting Statement for State Health Information Exchange Cooperative Agreement Program

3012 Preliminary Application

Preliminary Application Data Request

OMB: 0990-0340

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Address to Submit Preliminary Application

Application materials will be available for download at http://www.grants.gov. ONC is requiring preliminary and full applications for all announcements to be submitted via electronic mail to [email protected]. Applicants will be able to download a copy of the application packet, complete it off-line, and then submit the application electronically via email to: [email protected].

PRELIMINARY APPLICATIONS WILL NOT BE ACCEPTED THROUGH ANY WEBSITE, AND WILL NOT BE ACCEPTED THROUGH PAPER MAIL, COURIER, OR DELIVERY SERVICE.

APPLICANTS ARE STRONGLY ENCOURAGED TO COMPLETE AND SUBMIT APPLICATIONS AS FAR IN ADVANCE OF THE SUBMISSION DEADLINE AS POSSIBLE. THE APPLICATION INCLUDING ALL REQUIRED ATTACHMENTS AND INCLUDED FILES FOR POTENTIAL CONSIDERATION IN THE REVIEW PROCESS MUST BE RECEIVED BY 11:59 PM EASTERN TIME ON THE DATE SPECIFIED IN SECTION IV E, BELOW.



Preliminary applications procedures:

  • You must access the electronic application for this program via www.grants.gov.  You must search the downloadable application page by the Funding Opportunity Number (EP-HIT-09-003) or CFDA number (93.718).

  • All applicants should have a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number and register in the Central Contractor Registry (CCR).  You should allow a minimum of five days to complete the CCR registration. Although not required to process preliminary applications, applicants who do not already have a DUNS number and/or are not registered in CCR should do so as soon as possible. As there is no fee to complete these processes, applicants should not wait to receive the results of the preliminary application review before taking these steps.

  • You must submit all documents electronically, including all information included on the SF424 and all necessary assurances and certifications.

  • Your application must comply with any page limitation requirements described in this Funding Opportunity Announcement.

  • After you electronically submit your application, you will receive an automatic email notification from the email address that demonstrates the email was received.  This notification does not provide assurance that your application was complete, only that the email was received.

  • After ONC reviews your email submission, a return receipt will be emailed to the applicant contact indicating the files that were received and able to be successfully opened and read. Due to volume of applications received, this receipt may not be available for several days; applicants are strongly encouraged to submit applications as far in advance as possible if they wish to receive confirmation of receipt prior to the deadline. Organizations applying for federal grants will need to be registered with the Central Contractor Registry (CCR). You can register with the CCR online and it will take about 30 minutes (http://www.ccr.gov). If you have already registered with CCR but have not renewed your registration in the last 12 months, you will need to renew your registration at http://www.ccr.gov.



Key Contact for all Preliminary Application:

Inquiries should be addressed to:

U.S. Department of Health and Human Services

Office of the National Coordinator for Health Information Technology

Email: [email protected]

Preliminary Application Content Requirements

Applicants are required to submit a preliminary application to apply for this funding opportunity according to the dates specified in section IV D. This preliminary application requires the following:

  • A letter signed by the designated authorized representative of that organization committing to that application, which includes the organizational mission statement.

  • Proof of the applicant’s nonprofit status.

  • If the proposal is on behalf of a consortium, there must be letters of commitment from all members of the consortium which include their tax status.

  • Any letters of support.

  • A certification that there is no conflict of interest, real or perceived, with HIT vendors (See Appendix E, Conflict of Interest Certification Template).

  • A letter from the State Medicaid Director(s) is required for all full-state or multi-state application.

  • A table or spreadsheet that addresses all of the elements below (see Attachment I). All estimates provided in your spreadsheet will require justification in a full proposal.


  • Geographic Diversity, Service Area Participation and Collaboration:

    • Detailed service area proposed (please provide list of zip-three codes, or if smaller geographic units, zip-five)

    • Estimate of the total number of primary-care providers actively practicing in service area

    • Estimate the total number of priority primary-care providers in the service area

    • Presence of any practice networks in the service area that are supported by other federal agencies (VA, IHS, DOD, HRSA, CMS demonstrations, other) – specify names of the networks and who supports them.

    • Level of health information exchange capability in service area. (If there are health information organizations in the area, name them and specify whether they are in planning, pilot, or operational stage.)


  • Proposed Service Offerings including Proposed Center Capacity: Provide estimates for the minimum number of primary-care providers, and the minimum number of individual incorporated practices, that would receive each service below over the two-year budget period:

    • Group purchasing of EHR software

    • Onsite EHR Implementation Technical Assistance

    • Onsite Practice and Workflow Redesign

    • Functional Interoperability and Health Information Exchange

    • Technical Assistance around federal and State Privacy and Security requirements


  • Organizational Mission, Capability, and Experience as Reflected by Current Service Offerings: If the applicant (or any members of the applying consortium) is currently offering the services listed below, indicate whether the service is currently offered (Y/N), which organization is providing it, the number of Full-Time Equivalent (FTE) staff dedicated to each, and the number of practices and providers served in the 12 month interval: July 1, 2008 to June 30, 2009.

    • Group purchasing of EHR software

    • Onsite EHR Implementation Technical Assistance

    • Onsite Practice and Workflow Redesign

    • Functional Interoperability and Health Information Exchange



  • Multi-stakeholder, Community, and Provider Commitment: If the applicant includes letters of support or commitment from any of the stakeholder groups below, indicate the number of independent organizations and their names.

    • State Primary Care Association(s)

    • Health Professional Societies

    • Health Center Controlled Networks (HCCNs)

(for more information about HCCNs, go to: http://www.hrsa.gov/healthit/healthcenternetworks/default.htm)

    • State/ Local/ Tribal Public Health Agency

    • State Medicaid Director (if applicable)

    • Health Plans

    • Hospital Systems

    • Community Colleges

    • Medicare Quality Improvement Organization

    • Other: please specify




File Typeapplication/msword
AuthorDHHS
Last Modified BySeleda.Perryman
File Modified2009-08-19
File Created2009-08-19

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