20E Form 5A - edits

The Health Center Program Application Forms

Form 5A - edits

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. . [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 5A: Services Provided
SubjectForm 5A: Services Provided
AuthorHRSA
File Modified0000-00-00
File Created2023-08-24

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