Form 20 Form 5A - clean

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].