LAL Cover page

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Look-Alike Cover Page
OMB No.: 0915-0285. Expiration Date: 6/30/2029
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration Cover Page
FOR HRSA USE ONLY

LAL Number
Application 
Tracking Number



Applicant Information
Legal Name
Will pre-populate in EHB
Employer Identification Number (e.g. 53-2079819)
Will pre-populate in EHB
Organizational DUNS
Will pre-populate in EHB
Mailing Address
Will pre-populate in EHB
Population Type

Select
Medically Underserved Populations (CHC) 
[_]
 Migratory and Seasonal Agricultural Workers (MSAW)
[_]
 Homeless Population (HP)
[_]
 Residents of Public Housing (RPH)
[_]
Point of Contact (POC) Information (Will pre-populate for LAL-RD)
Title of Position
Name
Phone
Email
Options





Authorizing Official (AO) Information
Title of Position
Name
Phone
Email
Options






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 0.5 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.