Form 5b Service Sites

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 5B: SERVICE SITES

FOR HRSA USE ONLY

Application Tracking Number

Grant Number

Site Qualification Criteria

1. Is the site an "admin-only" site?

[_] Yes [_] No

If ‘No’,

Are/will health center encounters generated by documenting in the patients’ records face-to-face contacts between patients and providers?

[_] Yes [_] No [_] Not Applicable

2. Do/will providers exercise independent judgment in the provision of services to the patient?

[_] Yes [_] No [_] Not Applicable

3. Are/will services be provided directly by or on behalf of the grantee, whose governing board retains control and authority over the provision of the services at the location?

[_] Yes [_] No [_] Not Applicable

4. Are/will services be provided on a regularly scheduled basis (e.g., daily, weekly, first Thursday of every month)?

[_] Yes [_] No [_] Not Applicable

Choose Site Location Setting

Is the Site a Domestic Violence (Confidential)?

[_] Yes [_] No [_] Not Applicable

Site Information

Name of Service Site

 

Service Site Type

 

Location Type

 

Location Setting

 

Number of Contract Service Delivery Locations
(Voucher Screening Only)

 

Number of Intermittent Sites (Intermittent Only)

 

Web URL

 

Site Operated by

[_] Grantee [_] Sub-Recipient [_] Contractor

If site is operated by sub-recipient or contractor, please provide the organization information below:
Organization
Organization Name
Address (Physical)
Address (Mailing)
EIN
Comments

Date Site was Opened

 

Date Site was Added to Scope

 

Site Operational By

 

Medicare Billing Number

 

Medicaid Billing Number

 

Medicaid Pharmacy Billing Number

Site Phone Number

 

Site Fax Number

 

Site Physical Address

   

Site Mailing Address (including Mailstop Code, Division/Department Name, Company, and Street/PO Box Address)

   

Administration Phone Number

Service Area Population Type

[_] Urban [_] Rural

[_] Sparsely Populated

Service Area Zip Codes (include only those from which the majority of the patient population will come)

Service Area Census Tracts (include only those from which the majority of the patient population will come)

Operational Schedule

[_] Full-Time

[_] Part-Time

Calendar Schedule

[_] Year-Round

[_] Seasonal

Total Hours of Operation when

Patients will be Served per Week (include extended hours)

Months of Operation (required for Permanent and Seasonal Locations)

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.