Form 17E Form 3 - edits

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

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. In the Prior FY Income (e) column, enter the income data from the health center’s most recent fiscal year audit or interim financial statement.

Part 1: Patient Service Revenue – Program Income

Payer Category	Patients by Primary Medical Insurance (a)	Billable Visits (b)	Income per Visit (c)	Projected Income (d)	Prior FY Income
Medicaid
Medicare
Other Public
Private
Self Pay
Total (Lines 1-5)	will auto-calculate in EHB	will auto-calculate in EHB	N/A	will auto-calculate in EHB	will auto-calculate in EHB

Part 2: Other Income – Other Federal, State, Local, and Other Income

Other Federal	N/A	N/A	N/A
State Government	N/A	N/A	N/A
Local Government	N/A	N/A	N/A
Private Grants/ Contracts	N/A	N/A	N/A
Contributions	N/A	N/A	N/A
Other	N/A	N/A	N/A
Applicant (Retained Earnings)	N/A	N/A	N/A
Total Other: (Lines 7-13)	N/A	N/A	N/A	will auto-calculate in EHB	will auto-calculate in EHB

Total Non-Federal (Non-Health Center Program) Income (Program Income Plus Other)

Payer Category	Patients by Primary Medical Insurance (a)	Billable Visits (b)	Income per Visit (c)	Projected Income (d)	Prior FY Income (e)
Total Non-Federal (Lines 6+14)	N/A	N/A	N/A	will auto-calculate in EHB	will auto-calculate in EHB

Comments/Explanatory Notes (if applicable)

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"