Form 20 Form 5A - clean

The Health Center Program Application Forms

Form 5A - clean

Form 5A: Services Provided

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 5A: SERVICES PROVIDED (REQUIRED SERVICES)

FOR HRSA USE ONLY

Grant Number

Application Tracking #




This form will pre-populate for competing continuation applicants. For more information, refer to the Service Descriptors for Form 5A: Services Provided and the Column Descriptors for Form 5A: Services Provided.



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)

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 Use Disorder Services




Case Management




Eligibility Assistance




Health Education




Outreach




Transportation




Translation





DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


FORM 5A: SERVICES PROVIDED (ADDITIONAL SERVICES)

FOR HRSA USE ONLY

Grant Number

Application Tracking 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 Dental Services




Behavioral Health Services

  • Mental Health Services




  • Substance Use Disorder Services




Optometry




Recuperative Care Program Services




Environmental Health Services




Occupational Therapy




Physical Therapy




Speech-Language Pathology/Therapy






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)

Nutrition




Complementary and Alternative Medicine




Additional Enabling/Supportive Services





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. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). 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 14N136B, Rockville, Maryland, 20857 or [email protected].


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 5A: Services Provided
SubjectForm 5A: Services Provided
AuthorHRSA
File Modified0000-00-00
File Created2021-01-14

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