Form 6 NHSC-Behavioral-Health-Services-Checklist-2020

Public Burden Statement: The purpose of this information collection is to obtain information
through the National Health Service Corps (NHSC) Loan Repayment Program (LRP), NHSC
Substance Use Disorder (SUD) Workforce LRP, and the NHSC Rural Community LRP applications,
which are used to assess an LRP applicant’s eligibility and qualifications for the LRP and to
obtain information for NHSC site applicants. Clinicians interested in participating in a NHSC LRP
must submit an application to the NHSC to participate in one of the NHSC programs, and health
care facilities must submit an NHSC Site Application and Site Recertification Application to
determine the eligibility of sites to participate in the NHSC as an approved service site. 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 information collection is 0915-0127 and it is valid until XX/XX/202X. This information
collection is required to obtain or retain a benefit (Section 333 [254f] (a)(1) of the Public Health
Service Act). Public reporting burden for this collection of information is estimated to average
0.5 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 14N136B, Rockville, Maryland, 20857 or [email protected].

Bureau of Health Workforce
U.S. Department of Health and Human Services Health
Resources and Services Administration

NHSC COMPREHENSIVE BEHAVIORAL HEALTH SERVICES CHECKLIST

Attach all signed affiliation agreements for any service elements not provided onsite.
**Only NHSC Site Administrators are permitted to submit certification documents**
Name of Site
Address
Section I. Core Comprehensive Behavioral Health Service Elements

The following three sets of services must be provided onsite; these services cannot be offered
through affiliation.

Provided Onsite
(Select One)
Yes
No

1. Screening and Assessment: Screening is the practice of determining the presence of risk
factors, early behaviors, and biomarkers which enables early identification of behavioral
health disorders (e.g., warning signs for suicide, substance abuse, depression) and early
access to care. Assessment is a structured clinical examination that analyzes patient biopsych-social information to evaluate a behavioral health complaint.
2. Treatment Plan: A formalized, written document that details a patient's current clinical
symptoms, diagnosis, and outlines the therapeutic strategies and goals that will assist the
patient in reducing clinical symptoms and overcoming his or her behavioral health issues. The
plan also identifies, where indicated, clinical care needs and treatment(s) to be provided by
affiliated health and behavioral health care providers and settings.
3. Care Coordination: Care Coordination is the practice of navigating and integrating the efforts
primary care, specialty health care and social service providers to support a patient’s health,
wellness and independence.

Section II. Additional Comprehensive Behavioral Health Service Elements

The following four sets of services may be provided onsite or through formal affiliation.
Signed affiliation agreements must be uploaded to the BHW Customer Service Portal for
any services not provided onsite.

1. Diagnosis: The practice of determining a patient’s emotional, socio-emotional, behavioral or
mental symptoms as a diagnosable disorder in accordance with the Diagnostic and Statistical
Manual of Mental Disorders (DSM; most current edition) and International Classification of
Disease (ICD; most current edition).
2. Therapeutic Services (including, but not limited to, psychiatric medication prescribing and
management, chronic disease management, and Substance Use Disorder Treatment): Broad
range of evidence-based or promising behavioral health practice(s) with the primary goal of
reducing or ameliorating behavioral health symptoms, improve functioning, and
restore/maintain a patient’s health (e.g., individual, family, and group psychotherapy/
counseling; psychopharmacology; and short/long-term hospitalization).

Provided Onsite
(Select One)
Yes

No

Section II. Additional Comprehensive Behavioral Health Service Elements

The following four sets of services may be provided onsite or through formal affiliation.
Signed affiliation agreements must be uploaded to the BHW Customer Service Portal for
any services not provided onsite.

3.

4.

5.

a.

Psychiatric Medication Prescribing and Management

b.

Substance Use Disorder Treatment

c.

Short/long-term hospitalization

d.

Other (Please list) _________________________________________________

e.

Other (Please list)___________________________________________________

Crisis/Emergency Services (including, but not limited to, 24-hour crisis call access): The
method(s) used to offer immediate, short-term help to individuals who experience an event
that produces emotional, mental, physical, and behavioral distress or problems. In some
instances, a crisis may constitute an imminent threat or danger to self, to others, or grave
disability. (Note: generic hotline, hospital emergency room referral, or 911 is not sufficient).
Consultative Services: The practice of collaborating with health care and other social service
providers (e.g., education, child welfare, and housing) to identify the biological,
psychological, medical and social causes of behavioral health distress, to determine
treatment approach(s), and to improve patient functioning.
Case Management: The practice of assisting and supporting patients in developing their
skills to gain access to needed health care, housing, employment, social, educational and
other services essential to meeting basic human needs and consistent with their health care
treatment, symptom management, recovery and independent functioning.

Provided Onsite
(Select One)
Yes

No

Section III. Affiliation Agreements for Off-Site Behavioral Health Services

For each of the services under Section II that are provided off-site, a formal affiliation agreement(s) must be uploaded to
the BHW Customer Service Portal. Under this section, the NHSC-approved site must provide basic information for each
entity with which a formal affiliation is in place.
Affiliated Entity:

Affiliated Entity:

Address:

Address:

Services Covered Under Affiliation:

Services Covered Under Affiliation:

Date Affiliation Agreement Executed:

Date Affiliation Agreement Executed:

Services available under this agreement are offered to all
without regard for the ability to pay? Yes □ No □

Services available under this agreement are offered to all
without regard for the ability to pay? Yes □ No □

Affiliated Entity:

Affiliated Entity:

Address:

Address:

Services Covered Under Affiliation:

Services Covered Under Affiliation:

Date Affiliation Agreement Executed:

Date Affiliation Agreement Executed:

Services available under this agreement are offered to all
without regard for the ability to pay? Yes □ No □

Services available under this agreement are offered to all
without regard for the ability to pay? Yes □ No □

Section IV. Certification of Compliance with Behavioral Health Clinical
Practice Requirements

Certify that the behavioral health site adheres to the clinical practice requirements for
behavioral health providers under the NHSC and supports NHSC participants in meeting their
obligation related to the clinical practice requirements.
Full-time: The site offers employment opportunities that adhere to the NHSC definition of
full-time clinical practice. Full-time clinical practice for behavioral health providers means a
minimum of 40 hours/week, for a minimum of 45 weeks/service year. At least 20 hours/week
must be spent providing patient care at the approved service site(s). Of the minimum 20
hours spent providing patient care, no more than 8 hours/week may be spent in a teaching
capacity, performing clinical-related administrative activities, or in an alternative setting (e.g.,
hospitals, nursing homes, and shelters) as directed by the approved sites. The remaining 20
hours/week must be spent providing patient care at the approved service site(s) or
performing service as a behavioral or mental health professional in schools or other
community-based settings when directed by the approved sites(s).

Site Meets
Criteria

(Select One)
Yes
No

Section IV. Certification of Compliance with Behavioral Health Clinical
Practice Requirements

Certify that the behavioral health site adheres to the clinical practice requirements for
behavioral health providers under the NHSC and supports NHSC participants in meeting their
obligation related to the clinical practice requirements.
Half-time: The site offers employment opportunities that adhere to the NHSC definition of
half-time clinical practice. Clinicians must work a minimum of 20 hours/week, for a minimum
of 45 weeks/service year. At least 10 hours/week are spent providing patient care at the
approved service site(s). Of the minimum 10 hours spent providing patient care, no more
than 4 hours per week may be spent in a teaching capacity, performing clinical-related
administrative activities, or in an alternative setting (e.g., hospital, nursing home, and
shelter), as directed by the approved site(s). The remaining 10 hours/week may be spent
providing patient care at the approved service site(s) or performing service as a behavioral or
mental health professional in schools or other community-based settings when directed by
the approved site(s).

Site Meets
Criteria

(Select One)
Yes
No

Section V. Site Certification:

By signing below, the NHSC Site Administrator is affirming the truthfulness and accuracy of the information in this
document.
I, _______________________________, hereby certify that the information provided above, and all supporting
information, is true and accurate. I understand that this information is subject to verification by the NHSC.
Signature

Date