Form 21 Form 5B - clean

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 5B: SERVICE SITES	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Note: This form will pre-populate for competing continuation applicants. New and Competing Supplement Applicants: If you are requesting funding to target the general underserved community (CHC), residents of public housing (PHPC), or people experiencing homelessness (HCH), you must propose at least one new Service Delivery site or Administrative/Service Delivery site with the Location Type as 'Permanent' and operating for at least 40 hours. If you are proposing to serve ONLY migrant and seasonal agricultural workers (MHC), you must propose at least one new Service Delivery site or Administrative/Service Delivery site with the Location Type as 'Permanent' or 'Seasonal' and operating for at least 40 hours.

Site Qualification Criteria
Is the site an Admin-only site? If Yes, the site is an Admin-only site, select ‘Not Applicable’ for questions a through d below. If No, the site is a Service Delivery site, answer questions a through d Yes or No.	[_] Yes [_] No
Are/will health center visits be generated by documenting in the patients’ records face-to-face contacts between patients and providers?	[_] Yes [_] No [_] Not Applicable
Do/will providers exercise independent judgment in the provision of services to the patient?	[_] Yes [_] No [_] Not Applicable
Are/will services be provided directly by or on behalf of the grantee, whose governing board retains control and authority over the provision of the services at the location?	[_] Yes [_] No [_] Not Applicable
Are/will services be provided on a regularly scheduled basis (e.g., daily, weekly, first Thursday of every month)?	[_] Yes [_] No [_] Not Applicable

Is the site a Domestic Violence (Confidential) shelter? Select Yes for this question only if the site being added is a confidential site serving victims of domestic violence and the site address cannot be published due to the necessity to protect the location of the domestic violence shelter.	[_] Yes [_] No [_] Not Applicable

Site Information

Site Name

 

Site Physical Address

(Ensure your address contains the appropriate unique suite, building, or other notation, if appropriate. If the address displayed does not contain this information, select Change Physical Location and update as appropriate)

 

Site Type

[_] Administrative/Service Delivery Site

[_] Service Delivery Site [_] Administrative Site

Site Phone Number

 

Web URL

The following fields are required for “Service Delivery” and “Administrative/Service Delivery” site types:

Location Type

[_] Permanent

[_] Seasonal

[_] Mobile

[_] Migrant Voucher

[_] Intermittent

Site Setting

[_] All Other Clinic Types

[_] Hospital

[_] School

Date Site was Added to Scope

Read-only for sites already in scope and disabled when adding a new site

Site Operational Date

mm/dd/yyyy

FQHC Site Medicare Billing Number Status

[_] This site is neither permanent nor seasonal per CMS (i.e., does not require unique FQHC Medicare Billing Number)

[_] Health center does not/will not bill under the FQHC Medicare system at this site

[_] Number is pending; application for this site has been submitted to CMS

[_] Application for this site has not yet been submitted to CMS

[_] This site has a Medicare billing number

FQHC Site Medicare Billing Number

(Required if ‘This site has a Medicare billing number’ is selected in 'FQHC Site Medicare Billing Number Status' field)

FQHC Site National Provider Identification (NPI) Number

(Optional field)

Total Hours of Operation (when

patients will be served per week)

Months of Operation

Service Area Zip Codes

Number of Contract Service Delivery Locations
(Required only for ‘Migrant Voucher Screening’ Site Type)

 

Number of Intermittent Sites (Required only for ‘Intermittent Site’ Type)

 

Site Operated by

[_] Health Center/Applicant [_] Subrecipient [_] Contractor

Subrecipient or Contractor Information

(Required only if 'Subrecipient’ or ‘Contractor' is selected in 'Site Operated By' field)

Subrecipient/Contractor Organization Name
Subrecipient/Contractor Organization Physical Site Address
Subrecipient/Contractor EIN

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].