5A Services Provided Final

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY
Grant Number
Application Tracking #

FORM 5A: SERVICES PROVIDED
(REQUIRED SERVICES)

Service Type

Direct (Health
Center pays)

Service Delivery Methods
Formal Written
Contract/
Formal Written Referral
Agreement
Arrangement (Health
(Health Center
Center DOES NOT pay)
pays)

General Primary Medical Care
Diagnostic Laboratory
Diagnostic Radiology
Screenings
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
Preventive Dental
Pharmaceutical Services
HCH Required Substance Abuse Services
Case Management
Eligibility Assistance
Health Education
Outreach
Transportation
Translation

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY
Grant Number
Application Tracking Number

FORM 5A: SERVICES PROVIDED
(ADDITIONAL SERVICES)

Service Type
Additional Dental Services
Behavioral Health Services
• Mental Health Services
• Substance Abuse Services
Optometry
Recuperative Care Program Services
Environmental Health Services
Occupational Therapy
Physical Therapy
Speech-Language Pathology/Therapy

Direct (Health
Center pays)

Service Delivery Methods
Formal Written
Contract/
Formal Written Referral
Agreement
Arrangement (Health
(Health Center
Center DOES NOT pay)
pays)

Service Type

Direct (Health
Center pays)

Service Delivery Methods
Formal Written
Contract/
Formal Written Referral
Agreement
Arrangement (Health
(Health Center
Center DOES NOT pay)
pays)

Nutrition
Complementary and Alternative Medicine
Additional Enabling/Supportive Services
Other
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 14N-39, Rockville, Maryland, 20857.