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

Note: The value in the Projected Income (d) column should equal the value in the Billable Visits (b) column multiplied by the value in the Income per Visit (c) column. If not, explain in the Comments/Explanatory Notes box. Refer to the Fiscal Year (FY) End Date selected in Form 1A of the application to provide the information in the Prior FY Income (e) column.

PART 1: NON FEDERAL SHAREPatient Service Revenue –, Program Income

Payor Category

Number Of
VisitsPatients by Primary Medical Insurance

Average
Charge
PerBillable Visits

Gross
Charges
(a*b)=(Income per Visitc)

Adjustment Rate (%)

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

Collection Rate (%)

Projected Income
(e*f)

Actual AccruedPrior FY Income Past 12 Months**

(a)

(b)

(c)

(d)

(e)

(f)

(dg)

(eh)

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 ServicePublic

3.	Subtotal: Private

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

54b. 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 (Lines 1-5)

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 – Other Federal, State, Local, and Other Income

Payor Category

Projected Income (d)Total Other Income by Source

Prior FY Income (e)

7. Other Federal10. Applicant Funds (Retained Earnings)

811. State FundsGovernment

912. Local FundsGovernment

Other Support10. Private Grants/Contracts

113a. ContributionsOther Federal Grants

123b. Contributions and FundraisingOther

13c. Applicant (Retained Earnings)Foundation Grants

1413d. Total Other ___________(please listLines 7-13)

13.	Subtotal Other Support

14.	TOTAL OTHER INCOME

15. Total Non-Federal SHARE(Non-Health Center Program) Income (Program Income Plus Other)
[line 6, column g + line 7, column e + line 14] matches line 5, column f, "Non- Federal Totals” of the SF-424A

15. Total Non-Federal (Lines 6 + 14)

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 2.51 hours 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 10-3314N-39, Rockville, Maryland, 20857.