Questions
for Addition of Service(s)
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In
this CIS request, you have added the following services to
scope:
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Service
has not been selected.
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*1.
Why do you want to add the
service(s)?
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Needs
assessment indicated a high need for services at this
location.
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Needs
assessment completed on (mm/dd/yyyy):
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Community
asked us to provide services at the site and provided
supporting needs data.
An
existing clinic is closing and we have an opportunity to
continue those services in the area.
Other
(Describe in the space provided below):
To
upload supporting attachments, visit the 'Supporting
Documents' section in this CIS Request.
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*2.
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Describe
how adding this service will benefit your total level or
quality of health services currently provided to the
patients you currently serve? (Please
provide a summary of one page or less.)
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(Maximum
3,000 Characters)
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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*3.
When do you plan to start providing
the service(s)?
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Effective
date for service (mm/dd/yyyy):
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*4.
Information about population to be served by the new service
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4a.
Number
of patients to be served
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(Format:
99)
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4b.
Percentage
of patients below 200% of Federal Poverty Level
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%
(Format: 9 or 9.99)
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4c.
Percentage
of uninsured patients
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%
(Format: 9 or 9.99)
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*5.
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Does
the budget include any special grant, foundation or other
funding that is time-limited, i.e., will only be
available for 1 or 2 years?
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Yes
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No
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5a.
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If
yes, how will you support the new service when these
funds are no longer available? Please provide an
explanation in the space provided below. (Provide
a summary of one page or less.)
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