24E Form 6B - edits

The Health Center Program Application Forms

Form 6B - edits

Form 6B: Request for Waiver of Governance Requirements

OMB: 0915-0285

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


FORM 6B: REQUEST FOR WAIVER OF BOARD MEMBER REQUIREMENTS

FOR HRSA USE ONLY

Grant Number

Application Tracking Number



Note: This form is applicable if you are proposing to serve only special populations (i.e., HCH,MHC, and/or PHPC)

Request for Waiver

Name of Organization

Will pre-populate in EHB

1. New Waiver Request


Are you requesting a new waiver of the 51% patient majority governance requirement?

[_] Yes [_] No

2. For Applicants with Previous Waiver

2a. Do you currently have a waiver of the 51% patient majority governance requirement?

[_] Yes [_] No

2b. Are you requesting the patient majority waiver to be continued?

(This question is required if you answered yes to question 2a.)


[_] Yes [_] No (Governing board is in full compliance)

3. Demonstration of Good Cause for Waiver

(Demonstrate good cause for the waiver request by addressing the following areas)

3a. Provide a description of the population to be served and the characteristics of the population/service area that would necessitate a waiver.

This question is required if you answered 'Yes' to question 1 and/or question 2b.)

(maximum 1,000 characters)


3b. Provide a description of the health center’s attempts to meet the requirement to date and explain why these attempts have not been successful.

This question is required if you answered 'Yes' to question 1 and/or question 2b.)

(maximum 1,000 characters)


4. Alternative Mechanism Plan for Addressing Patient Representation

Present a plan for complying with the intent of the statute via an alternative mechanism that ensures patient input and participation in the organization, as well as direction and ongoing governance of the health center.

(This question is required if you answered 'Yes' to question 1 and/or question 2b.)

(maximum 1,000 characters)



Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. . [email protected] HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/[email protected]" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 6B: Request for Waiver of Board Member Requirements
SubjectForm 6B: Request for Waiver of Governance Requirements
AuthorHRSA
File Modified0000-00-00
File Created2021-01-14

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