Form 3 Income Analysis

OMB No.: 0915-0285. Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 3: INCOME ANALYSIS

YEAR 1  YEAR 2 

FOR HRSA USE ONLY

Applicant Name

Grant Number

Application Tracking Number

PART 1: NON FEDERAL SHARE, PROGRAM INCOME

Payor Category

Number Of
Visits

Average
Charge
Per Visit

Gross
Charges
(a*b)=(c)

Adjustment Rate (%)

Net Charges
(Amount Billed)
[c*(100-d)]

Collection Rate (%)

Projected Income
(e*f)

Actual Accrued Income Past 12 Months**

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

PROJECTED FEE FOR SERVICE INCOME

1a. Medicaid: Medical

1b. Medicaid: EPSDT (if different from medical rate)

1c. Medicaid: Dental

1d. Medicaid: BH/SA

1e. Medicaid: Other Fee for Service

1.	Subtotal: Medicaid

2a. Medicare: All Inclusive FQHC Rate

2b. Medicare: Other Fee for Service

2.	Subtotal: Medicare

3a. Private Insurance: Medical

3b. Private Insurance: Dental

3c. Private Insurance: BH/SA

3d. Private Insurance: Other Fee for Service

3.	Subtotal: Private

4a. Self-Pay: 100% Charge, No Discount (Medical)

4b. Self-Pay: 0-99% of Charge, Sliding Discounts Including Full Discount (Medical)

4c. Self-Pay: 100% Charge, No Discount (Dental)

4d. Self-Pay: 0-99% of Charge, Sliding Discounts Including Full Discount (Dental)

4e. Self-Pay: 100% Charge, No Discount (BH/SA)

4f. Self-Pay: 0-99% of Charge, Sliding Discount Including Full Discount (BH/SA)

4g. Self-Pay: 100% Charge, No Discount (Other)

4h. Self-Pay: 0-99% of Charge, Sliding Discount Including Full Discount (Other)

4.	Subtotal: Self Pay

5.	Subtotal: Other Public

6.	TOTAL FEE FOR SERVICE

** State the time period used for Actual Accrued Income Past 12 Months by listing the 12-month period end date (month and year):

PROJECTED CAPITATED MANAGED CARE INCOME

TYPE OF PAYOR

Number of Member Months
(a)

Rate Per Member Month
(b)

Risk Pool and Other Adjustments
(c)

FQHC Cost Settlement and Wrap Adjustments
(d)

Projected Gross Income
(e)

7a. Medicaid

7b. Medicare

7c. Commercial

7d. Other Public

7.	TOTAL CAPITATED MANAGED CARE

Visits
(a)

Average Charge Per Visit
(b)

Total Charges
(c)

8. Capitated Managed Care

9. TOTAL PROGRAM INCOME [line 6, column g + line 7, column e] matches line 7 "Program Income" of the SF‑424A

PART 2: NON-FEDERAL SHARE, OTHER INCOME

Total Other Income by Source

10. Applicant Funds (Retained Earnings)

11. State Funds

12. Local Funds

Other Support

13a. Other Federal Grants

13b. Contributions and Fundraising

13c. Foundation Grants

13d. Other___________(please list)

13.	Subtotal Other Support

14.	TOTAL OTHER INCOME

15. TOTAL NON-FEDERAL SHARE
[line 6, column g + line 7, column e + line 14] matches line 5, column f, "Non- Federal Totals” of the SF-424A

Comments/Explanatory Notes (if applicable):

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.