17 Form 3 - clean

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

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
Medicaid
Medicare
Other Public
Private
Self Pay
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

Other Federal	N/A	N/A	N/A
State Government	N/A	N/A	N/A
Local Government	N/A	N/A	N/A
Private Grants/ Contracts	N/A	N/A	N/A
Contributions	N/A	N/A	N/A
Other	N/A	N/A	N/A
Applicant (Retained Earnings)	N/A	N/A	N/A
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)
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. 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].