Form 0285-4 Documents on File

OMB No.: 0915-0285. Expiration Date: 08/31/2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 1 - PART C: DOCUMENTS ON FILE	FOR HRSA USE ONLY
	Grant Number		Application Tracking Number
MANAGEMENT AND FINANCE		DATE OF LATEST REVISION
Personnel Policies and Procedures
Conflict of Interest Policies and Procedures
Data Collection and Information Systems
Agreements with Medicaid and Medicare
Billing and Collection Policies and Procedures
Procurement Policies and Procedures
Emergency Preparedness and Management Plan
Travel Policies
Fee Schedule
Accounting Policies and Procedures Manual
Documentation of FQHC rates
Contracts with Agencies, Vendors, etc.
Legal Documents related to federal interest in real property
CLINICAL PROGRAM		DATE OF LATEST REVISION
Patient Confidentiality Policy and Procedures
Principles of Practice (As applicable)
List of Non-Physician Supervision Protocols
Health Maintenance Protocols by Age Group
Clinical Protocols
Continuing Professional Education Policies
Patient Flow
Sample Medical Record
Clinical Information and Tracking Systems
Patient Grievance Policy and Procedure
Quality Management and/or Assurance Plan 1
Malpractice Coverage and/or FTCA Deeming/Malpractice Coverage Provisions
OSHA Documents
CLIA Documents
Credentialing Policy and Procedures
OTHER DOCUMENTS		DATE OF LATEST REVISION
Current MUA or MUP designation
Current HPSA designation
Frontier Area Documentation

¹ This should include Incident Reporting System and Risk Management Plans/Policies

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.