Form 5A Services Provided

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 5A: SERVICES PROVIDED

(REQUIRED SERVICES)

FOR HRSA USE ONLY

Application Tracking Number

Grant Number

 

 

SERVICE TYPE

MODE OF SERVICE PROVISIONService Delivery Methods

DIRECT BY APPLICANT

(Health Center pays)

FORMAL WRITTEN CONTRACT/AGREEMENT
(Applicant Health Center pays for service)

FORMAL WRITTEN REFERRAL ARRANGEMENT/ AGREEMENT
(Applicant Health Center DOES NOT pay)

Required Services

Clinical Services

General Primary Medical Care

 

 

 

Diagnostic Laboratory

 

 

 

Diagnostic X-RayRadiology

 

 

 

Screenings

• Cancer

 

 

 

• Communicable Diseases

 

 

 

• Cholesterol

 

 

 

• Blood Lead Test for Elevated Blood Lead Level

 

 

 

• Pediatric Vision, Hearing, and Dental

 

 

 

Emergency Medical Services Coverage for Emergencies During and After Hours

 

 

 

Voluntary Family Planning

 

 

 

Immunizations

 

 

 

Well Child Services

 

 

 

Gynecological Care

 

 

 

Obstetrical Care

 

 

 

• Prenatal Care

• Intrapartum Care (Labor & Delivery)

• Postpartum Care

Prenatal and Perinatal Services

 

 

 

Preventive Dental

 

 

 

Referral to Behavioral Health¹

 

 

 

Referral to Substance Abuse¹

 

 

 

Referral to Specialty Services

 

 

 

Pharmacy Pharmaceutical Services

 

 

 

Substance Abuse Services (Required for HCH Programs):

HCH Required Substance Abuse Services

• Detoxification

 

 

 

• Outpatient Treatment

 

 

 

• Residential Treatment

 

 

 

• Rehabilitation (Non-Hospital Settings)

 

 

 

Non-Clinical Services

Case Management

Case Management

• Counseling/Assessment

 

 

 

• Referral

 

 

 

• Follow-Up/Discharge Planning

 

 

 

• Eligibility Assistance

 

 

 

Eligibility Assistance

Health Education

 

 

 

Outreach

 

 

 

Transportation

 

 

 

Translation

 

 

 

Substance Abuse Services (Required for HCH Programs):

• Harm/Risk Reduction (e.g., nicotine gum/patches, educational materials)

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 5A: SERVICES PROVIDED (ADDITIONAL SERVICES)	FOR HRSA USE ONLY
	Application Tracking Number		Grant Number
SERVICE TYPE	Service Delivery Methods
	DIRECT (Health Center pays)	FORMAL WRITTEN CONTRACT/AGREEMENT (Health Center pays)		FORMAL WRITTEN REFERRAL ARRANGEMENT (Health Center DOES NOT pay)

Additional Services (Optional)

Clinical Services

Urgent Medical Care

 

 

 

Additional Dental Services

• Restorative

 

 

 

• Emergency

 

 

 

Behavioral Health Services

• Treatment/Counseling

 

 

 

• Developmental Screening

 

 

 

• 24-Hour Crisis

 

 

 

• Mental Health Services

• Substance Abuse Services

 

 

 

Comprehensive Eye Exams and Vision Services Optometry

Recuperative Care Program Services

 

 

 

Environmental Health Services

 

 

 

Occupational-Related Health Services²

• Screening for Infectious Diseases

 

 

 

• Injury Prevention Programs

 

 

 

Occupational Therapy

 

 

 

Physical Therapy

 

 

 

HIV Testing

 

 

 

TB Therapy

 

 

 

Hepatitis C

• Screening

• Therapy/Treatment

Podiatry

 

 

 

Rehabilitation (Non-Hospital Settings)

 

 

 

Specialty (Please Specify: ____________)

Other (Please Specify: _______________)

 

 

 

Non-Clinical Services

WIC

 

 

 

Speech-Language Pathology/Therapy

Nutrition (not WIC)

 

 

 

Child Care

 

 

 

Housing Assistance

 

 

 

Employment and Education Counseling

 

 

 

Food Bank/Meals

 

 

 

Specialty (Please Specify: ____________)

Complementary and Alternative Medicine

Additional Enabling/Supporting Services

Other (Please Specify: _______________)

 

 

 

1. Applicants are required to provide behavioral health and substance abuse services by referral arrangements. However, applicants may provide these services by applicant or formal agreement in addition to by referral arrangements by indicating these services under additional services.

2. Additional Services for Health Centers serving Migrant and Seasonal Farm Workers (MSFWs).

3. 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 1.5 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 14N-3910-33, Rockville, Maryland, 20857.