NHHCIA NCC Income Analysis Form

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FYXX Native Hawaiian Health Care Improvement Act (NHHCIA) Non-Competing Continuation (NCC) Progress Report Native Hawaiian Health Care Systems (NHHCS) 
Income Analysis Form
You must report on projected income from all sources other than NHHCS funding for the third year of the 3-year period of performance (August 1, 20XX – July 31, 20XX). You must record this information using the Income Analysis Form. Instructions on how to complete the Income Analysis Form are located at the bottom of the sample table shown below.  										







Line #
Payer Category
Count of patients by Primary Medical Insurance 
Income per Patient 
Projected Income 
Projected Costs 
Difference between projected income & costs 


(a)
(b)
(c)
(d)
(e)
1
Medicaid





2
Medicare





3
Other Public





4
Private





5
Self-Pay





6
Total (Lines 1–5)












7
Other Federal Awards





8
State Government





9
Local Government





10
Private Grants/Contracts





11
Contributions





12
Pharmacy





13
Other





14
Applicant (Retained Earnings)





15
Total Other: (Lines 7–15)












16
Total Non-Federal (lines 6+15)























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/202X. 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 0.25 hours 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.