24E Form 6B - edits

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6B: REQUEST FOR WAIVER OF BOARD MEMBER REQUIREMENTS	FOR HRSA USE ONLY
	Grant Number		Application Tracking Number
Note: This form is applicable if you are proposing to serve only special populations (i.e., HCH,MHC, and/or PHPC)
Request for Waiver
Name of Organization		Will pre-populate in EHB
1. New Waiver Request
Are you requesting a new waiver of the 51% patient majority governance requirement?		[_] Yes [_] No
2. For Applicants with Previous Waiver
2a. Do you currently have a waiver of the 51% patient majority governance requirement?		[_] Yes [_] No
2b. Are you requesting the patient majority waiver to be continued? (This question is required if you answered yes to question 2a.)		[_] Yes [_] No (Governing board is in full compliance)
3. Demonstration of Good Cause for Waiver (Demonstrate good cause for the waiver request by addressing the following areas)
3a. Provide a description of the population to be served and the characteristics of the population/service area that would necessitate a waiver. This question is required if you answered 'Yes' to question 1 and/or question 2b.) (maximum 1,000 characters)
3b. Provide a description of the health center’s attempts to meet the requirement to date and explain why these attempts have not been successful. This question is required if you answered 'Yes' to question 1 and/or question 2b.) (maximum 1,000 characters)
4. Alternative Mechanism Plan for Addressing Patient Representation
Present a plan for complying with the intent of the statute via an alternative mechanism that ensures patient input and participation in the organization, as well as direction and ongoing governance of the health center. (This question is required if you answered 'Yes' to question 1 and/or question 2b.) (maximum 1,000 characters)

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"