Checklist for Form 5A Scope Adjustments

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Checklist for Form 5A Scope Adjustments
Background
Changes to your health center’s scope of project are not effective until approved by HRSA.
For more information, refer to the Scope of Project Resources.
    1. Is this request a scope correction in preparation for or resulting from one or more site visits?
    • Yes 
    • No 

        1.1 If YES: Identify the related site visits.
[textbox] 

        1.2 If YES: Explain. [textbox] 

Description and Rationale
Required or Additional Service (Not in Column I to include Column I)
If approved, your health center will receive a Notice of Award (NoA) or Notice of Look-Alike Designation (NLD).

For any of the following Scope Adjustment changes:

    • From Column II to: Column I
    • From Column II to: Columns I and II
    • From Column II to: Columns I and III
    • From Column II to: Columns I, II, and III

    • From Columns II and III to: Column I
    • From Columns II and III to: Columns I and II
    • From Columns II and III to: Columns I and III
    • From Columns II and III to: Columns I, II, and III

    2. Explain why your health center is adding or changing a service delivery method for this service. Discuss the circumstances that enabled your health center to begin direct provision of the service.
[textbox]

Required or Additional Service (No longer Column I but still include Column II)

If approved, your health center will receive an email notification from HRSA. 
For any of the following Scope Adjustment changes:

    • From Columns I and II to: Column II 
    • From Columns I and II to: Columns II and III

    • From all Columns (Columns I, II, and III) to: Column II
    • From all Columns (Columns I, II, and III) to: Columns II and III

    2. Explain why your health center is no longer providing this service directly. Discuss the impact of your health center no longer providing the service directly on the patient population served.
[textbox]


Required or Additional Service (Adding Column II)

If approved, your health center will receive an email notification from HRSA. 
For any of the following Scope Adjustment changes:

    • From Column I to: Column II
    • From Column I to: Columns I and II
    • From Column I to: Columns II and III
    • From Column I to: All Columns (I, II, and III)

    • From Columns I and III to: Column II
    • From Columns I and III to: Columns I and II

    • From Columns I and III to: Columns II and III
    • From Columns I and III to: All Columns (I, II, and III)

    2. Explain why your health center is adding or changing a service delivery method for this service. Discuss the impact of providing the service via contract or subaward (Form 5A: Services Provided, Column II). If your health center will no longer provide the service directly (Column I is no longer selected on Form 5A), describe the impact on your health center’s patients.
[textbox]

    3. Attach a copy of your health center’s contract with the contractor or subaward agreement with the subrecipient for the service and, if needed, other documentation agreed to by both your health center and the contractor or subrecipient. 

The attachments must contain the complete contract or subaward agreement executed by all parties (for example, a signed paper copy, electronically signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda.

Within the attachments, clearly mark or highlight the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary. 

[attachments – multiple, with at least one required]

        3.1 The specific services to be performed by the contractor or subrecipient.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        3.2 The process for exchanging patient information between the health center and contractor or subrecipient to ensure patient access to services. 
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        3.3 How the health center will access patient medical records or documentation of services provided, consistent with applicable laws—specifically, the right of the health center to access the contractor’s or subrecipient’s patient health records related to the services provided on behalf of the health center. For example, laboratory, radiology, or other results.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        3.4 How contractor or subrecipient credentialing and privileging will be accomplished.
Note: The contract or subaward agreement language can be general and reference a more comprehensive process or policy. Credentialing and privileging for a contractor’s or subrecipient’s  providers may happen in many ways. For example, an individual contracted provider or a locum will participate in the health center’s credentialing and privileging program. In another example, the contractor has its own credentialing and privileging program and the health center has reviewed that program for compliance.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]
        3.5 How your health center will pay or provide funding to the contractor or subrecipient for services the contractor or subrecipient delivers on behalf of your health center.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]
        3.6 For subrecipients or if the contractor bills and collects for services: The ability of the health center to review the contractor’s or subrecipient’s billing and collections process and sliding fee discount schedule to ensure compliance with Health Center Program requirements.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]
        3.7 The applicability of federal and state laws including those related to patient privacy, HHS grant regulations, and civil rights, and any other requirements of your health center’s federal award.
Note: A contract or subaward agreement provision that requires the parties to comply with all laws generally (sometimes called a “catch-all” provision) may satisfy this criterion.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

Note: The contract or subaward agreement must address any additional applicable requirements, including those identified in Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual.
Required Service (Column III-Only to including Column I or Column II) 
If adding Column I:
If approved, your health center will receive a Notice of Award (NoA) or Notice of Look-Alike Designation (NLD).
Otherwise:
If approved, your health center will receive an email notification from HRSA.

For any of the following Scope Adjustment changes:

    • From Column III to: Column I
    • From Column III to: Column II
    • From Column III to: Columns I and II

    • From Column III to: Columns I and III
    • From Column III to: Columns II and III
    • From Column III to: All Columns (I, II, and III) 

    2. Does this request include adding Column I as a service delivery method?
    • Yes
    • No

2.1	If YES: Explain why your health center is adding or changing its service delivery method for this service. Discuss the circumstances that enabled your health center to begin direct provision of the service. 
[textbox]
    3. Does this request include adding Column II as a service delivery method?
    • Yes
    • No

        3.1  	If YES: Explain why your health center is adding or changing its service delivery method for this service. Discuss the impact of providing the service via contract or subaward.
[textbox]

    4. Attach a copy of your health center’s contract with the contractor or subaward agreement with the subrecipient for the service and, if needed, other documentation agreed to by both your health center and the contractor or subrecipient. 

The attachments must contain the complete contract or subaward agreement executed by all parties (for example, a signed paper copy, electronically-signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda. 
 
Within the attachments, clearly mark or highlight the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary.

[attachments – multiple, with at least one required]

        4.1 The specific services to be performed by the contractor or subrecipient.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        4.2 The process for exchanging patient information between the health center and contractor or subrecipient to ensure patient access to services. 
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        4.3 How the health center will access patient medical records or documentation of services provided consistent with applicable laws—specifically, the right of the health center to access the contractor’s or subrecipient’s patient health records related to the services provided on behalf of the health center.  For example, laboratory, radiology, or other results.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        4.4 How contractor or subrecipient credentialing and privileging will be accomplished.
Note: The contract or subaward agreement language can be general and reference a more comprehensive process or policy. Credentialing and privileging for a contractor’s or subrecipient’s providers may happen in many ways. For example, an individual contracted provider or a locum will participate in the health center’s credentialing and privileging program. In another example, the contractor has its own credentialing and privileging program and the health center has reviewed that program for compliance.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]
        4.5 How your health center will pay or provide funding to the contractor or subrecipient for services the contractor delivers on behalf of your health center.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]
        4.6 For subrecipients or if the contractor bills and collects for services: The ability of the health center to review the contractor’s or subrecipient’s billing and collections process and sliding fee discount schedule to ensure compliance with Health Center Program requirements.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]
        4.7 The applicability of federal and state laws including those related to patient privacy, HHS grant regulations, and civil rights, and any other requirements of your health center’s federal award.
Note: A contract or subaward agreement provision that requires the parties to comply with all laws generally (sometimes called a “catch-all” provision) may satisfy this criterion.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

Note: The contract or subaward agreement must address any additional applicable requirements, including those identified in Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual.



Reminder: If any information in this request is incomplete, HRSA may disapprove this request.



Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until 06/30/2029. 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.