Checklist for Form 5B Scope Adjustments

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Checklist for Form 5B 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

    2. What kind of Scope Adjustment would you like to request? 


    • Update Location Type (change allowed only between Seasonal and Permanent) 

If approved, your health center will receive an email notification from HRSA.
	
    a. Explain the need for the change (for example, data related to a decrease or increase in demand for services at the site, loss or gain of providers, patient survey results, etc.) and describe how patients will be impacted. 
[textbox]

    • Update Service Area ZIP Codes
Notes: 
    • Only add a ZIP Code if at least 10 patients originate from that ZIP Code.
    • Mobile service sites may be used to provide services to the service area ZIP Codes identified on Form 5B for your health center’s permanent and seasonal service sites. Mobile service sites may also provide services to areas adjacent to those ZIP Codes. 
    • Your health center may not add additional ZIP Codes to its service area that are only served by a mobile service site and that are not identified on your health center’s Form 5B for a permanent or seasonal service site. 
    • Refer to the Health Center Program Scope of Project Policy Manual.

If approved, your health center will receive an email notification from HRSA.

    a. Explain why your health center is changing the service area ZIP codes that this site is serving. 
[textbox]

    b. How many patients originate from each service area ZIP Code that you are adding or removing for this site, and what is the impact on patient access? 
[textbox] 

    c. ZIP Codes Being Added to Your Health Center's Service Area: [textbox or electronic system auto-population] 
Note: These ZIP Codes are not on Form 5B for any of your health center’s current in-scope Service Sites.
c.1 For any new service area ZIP Codes that are not part of your health center’s current service area, explain why your health center is proposing to expand the service area. [textbox]
c.2. If any new service area ZIP Codes are not adjacent to your health center’s current service area, explain why. [textbox]
c.3 If any new service area ZIP Codes include political subdivisions, including school districts, not previously served by your health center, explain how your health center has addressed barriers resulting from the new service area's physical characteristics, residential patterns, and available transportation. [textbox]

WARNING -  The following service area ZIP Codes that you are removing will NO LONGER be part of your health center's service area because none of these service area ZIP Codes are on Form 5B for any of your health center's current in-scope Service Sites: [textbox or electronic system auto-population] 

Attach: 
    1. Current Service Area Map and Data Table: Select the “Service Area Competition” application map/table type in Health Center Program GeoCare Navigator. 
Your map must show your health center’s current:
    • In-scope sites 
    • Service area ZIP Codes 
    2. Proposed Service Area Map and Data Table: Select the “Service Area Competition” application map/table type in Health Center Program GeoCare Navigator. 
Your map must show your health center’s:
    • Current in-scope sites 
    • Proposed updated service area ZIP Codes
Note: The data table must include, at a minimum:
    • Low-Income Population (#)
    • Health Center Program: Penetration of Low-Income (%)
    • Health Center Program: Penetration of Total Population (%)
    • Dominant Health Center
    • Dominant Health Center Share of Patients (%)

[attachments – multiple, with at least two required] 

    • Update Total Hours of Operation
Note: Hours of operation are those hours when the health center site is open and providing in-person services, or a combination of in-person and telehealth services to patients. Hours when the health center site is providing only telehealth services are not included in the Hours of Operation.

If approved, your health center will receive an email notification from HRSA.

    a. Explain the need for the change in this site’s hours of operation and provide data supporting the need to decrease or increase hours of operation. This may include changes in demand for services during specific hours/times at the site, loss or gain of providers, or patient survey results. In addition, discuss how patients will be impacted. 
[textbox]

    • Update Months of Operation (Seasonal or Mobile Sites)

If approved, your health center will receive an email notification from HRSA.

    a. Explain the need for the change in the months of operation of this site and provide data supporting the need for the change. This may include changes in demand for services at the site during specific periods of the year, loss or gain of providers, or patient survey results. In addition, discuss how patients will be impacted. 
[textbox]

    • Add or Update Unique Identifier (Suite, Floor, Room, Building Information) for a Current In-Scope Site Address

If approved, your health center will receive a Notice of Award (NoA) or Notice of Look-Alike Designation (NLD).

Notes:
    • This request is to update a site that is located within a larger building or campus. For example, your health center provides services in Suite A and expands into Suite B of the same building with a single point of entry to the expanded suite.
    • You cannot change the physical street address of the site through this request.
    • You cannot use this request if adding a unique identifier would result in a separate physical address or a separate entry point. For example:
    • Your health center operates a site at 345 Main Street, Suite #4, and your health center plans to add a new site in Suite #12 at 345 Main Street. Your health center would add Suite #12 to scope as a separate request to add a site to Form 5B Site.
    • Your health center provides services in Building 5 and will now also provide services in Building 12 — a separate building on the same campus. Your health center would add Building 12 to scope as a separate request to add a site to Form 5B Site.
    • If you have any questions about Form 5B as it relates to your health center plans to expand into additional suites, rooms, or floors within a current Form 5B site, contact HRSA. HRSA will let you know if you need to request a Change in Scope for the separate address. 
    a. Provide a detailed explanation for why you are adding or updating the unique identifier for the street address of this site. 
[textbox]

Attach:
    1. A letter from a health center Authorizing Official (for example, CEO/Executive Director) that is on letterhead and that contains the following information: 
            ▪ Current 5B Physical Address; 
            ▪ Proposed 5B Corrected Address with the unique identifier; and
            ▪ An explanation and reason for the change
    2. Proof of the correct address showing the unique identifier (for example, utility bill, postal change documentation, current lease agreement, or other official documentation showing correct address)
    3. Floor Plan

[attachments – multiple, with at least one required]

    • Correct Physical Address for a Current In-Scope Site due to:
    • Typos in the current physical address; or
    • The physical address of the site is changed by another entity (for example, due to 911 reassignment, US Postal Service changes)

If approved, your health center will receive a Notice of Award (NoA) or Notice of Look-Alike Designation (NLD).

    a. Provide a detailed explanation of the reason for correcting the physical address of this site. As part of this explanation, include the following information: 
        ◦ Current 5B Physical Address; 
        ◦ Proposed 5B Corrected Address
[textbox]

Attach:
    1. Proof of the correct address (for example, utility bill, postal change documentation, current lease agreement, or other official documentation showing correct address)

[attachments – multiple, with at least one required]

    • Add an “Other” Site

If approved, your health center will receive a Notice of Award (NoA) or Notice of Look-Alike Designation (NLD).

Notes:  
    • Select this option if your health center operates a site that does not meet the Service Site definition but is where your health center provides one or more of the following in-scope health activities:
    • Administrative work for your health center project (for example, billing and accounting, information technology, human resources).
    • Services that do not generate a patient visit (for example, insurance enrollment, eligibility assistance, receiving services under the Women, Infants, and Children (WIC) Program). If the service generates a patient visit and all other site criteria are met, the location should instead be categorized as a Service Site.
    • Pharmaceutical services at a stand-alone pharmacy site that do not generate a patient visit.
    • Administrative, patient support, pharmaceutical, or other activities that are provided at a current in-scope Service Site (already documented on your health center’s Form 5B) do not need to be documented in a separate “Other Sites” entry on your health center’s Form 5B.
    a. Select which activities your health center proposes to provide at this site.
Select all that apply:
    • Administrative: Administrative work for your health center project (for example, billing and accounting, information technology, human resources).
    • Patient Support Services – No Visits Generated: Services that do not generate a patient visit (for example, insurance enrollment, eligibility assistance, receiving services under the Women, Infants, and Children (WIC) Program). 
    • Pharmacy – No Visits Generated: Pharmaceutical services at a stand-alone pharmacy site that do not generate a patient visit.
    b. Explain why your health center is proposing to add this site.
[textbox]

    • Delete an “Other” Site
If approved, your health center will receive an email notification from HRSA.

    a. Explain why your health center is proposing to delete this site.
[textbox]

    • Delete a Temporary Emergency Site

If approved, your health center will receive a Notice of Award (NoA) or Notice of Look-Alike Designation (NLD). 

Note: This action will remove the temporary site from your health center’s HRSA-approved scope of project. 
    a. Explain why your health center no longer needs this site to respond to the emergency. 
[textbox]

    • Delete a Transitional Care in Carceral Setting (TCCS) Site

If approved, your health center will receive a Notice of Award (NoA) or Notice of Look-Alike Designation (NLD). 
    a. Explain why your health center is proposing to delete this site.
[textbox]
    b. Discuss how your health center will support Justice-Involved Individuals Reentering the Community (JI-R individuals) served at the site in accessing your health center’s in-scope services upon release if they continue to reside in the community served by your health center.
[textbox]


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 XX/XX/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.