17E Form 3 - edits

The Health Center Program Application Forms

Form 3 - edits

OMB: 0915-0285

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

Form 3: Income Analysis

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

  1. Medicaid






  1. Medicare






  1. Other Public






  1. Private






  1. Self Pay






  1. 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

  1. Other Federal

N/A

N/A

N/A



  1. State Government

N/A

N/A

N/A



  1. Local Government

N/A

N/A

N/A



  1. Private Grants/ Contracts

N/A

N/A

N/A



  1. Contributions

N/A

N/A

N/A



  1. Other

N/A

N/A

N/A



  1. Applicant (Retained Earnings)

N/A

N/A

N/A



  1. 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)

  1. 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"



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 3 - 2017
AuthorBeth Hartmayer
File Modified0000-00-00
File Created2023-08-18

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