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**DOCUMENT NUMBER: 2004-02**

**DATE:** September 30, 2003 **DOCUMENT TITLE:** Requirements of Fiscal
Year 2004 Funding Opportunity for Health Center New Access Point Grant
Applications

**TO:** Consolidated Health Center Grantees

Primary Care Associations

Primary Care Offices

Federally Qualified Health Center Look-Alikes

This application guidance details the eligibility requirements, review
criteria and awarding factors for organizations seeking a grant for
operational support of new access points in fiscal year (FY) 2004. An
important element of the Bureau of Primary Health Care's (BPHC)
commitment to improving and expanding access to needed primary health
care services is the support of new access points for the delivery of
primary health care services for the underserved. Even though action on
the FY 2004 appropriation has not been completed, the BPHC anticipates
being able to accept applications from organizations seeking a grant for
operational support for new health center access points under the
Consolidated Health Center Program (Community Health Center (CHC),
Migrant Health Center (MHC), Health Care for the Homeless (HCH), Public
Housing Primary Care (PHPC) and School Based Health Center (SBHC))
authorized under section 330 of the Public Health Service Act as
amended.

This application guidance supercedes Program Information Notice (PIN)
2003-01 used to detail the requirements, review criteria and awarding
factors for organizations seeking a grant for operational support of a
new access point in FY 2003. For FY 2004 the following differences
should be noted:

-   New application due dates have been established

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-   Some review criteria have changed

-   Administrative Priority award factors have been eliminated

-   A form has been added for governance waiver requests for applicants
    requesting support for a HCH, PHPC and/or MHC new access point as
    applicable

-   Directions for electronic submission of the application have been
    included

-   Information on obtaining a required Data Universal Numbering System
    (DUNS) is included

This application guidance is the first in a series of funding
opportunities available in FY 2004 to strengthen and expand primary
health care services. The BPHC will issue two additional application
guidances to announce opportunities for funding to 1) expand medical
capacity at existing practice locations, and 2) service expansion
activities such as oral health and mental health/substance abuse
enhancements.

Two application cycles have been announced for new access point
applications for FY 2004. Competitive new access point applications will
demonstrate a high level of need in their community, present a sound
proposal to meet this need, show that the organization is ready to
rapidly initiate the proposal, display responsiveness to the health care
environment of the serviced area and demonstrate collaborative and
coordinated delivery systems for the provision of health care to the
underserved in their communities.

It is the responsibility of the applicant to ensure that the complete
application is **submitted electronically or postmarked** by the
published due date. For FY 2004, applications postmarked by December 1,
2003, will be reviewed with funding decisions announced on or about
March 15, 2004. Applications postmarked by June 18, 2004, will be
reviewed with funding decisions announced on or about August 15, 2004.
Applications submitted electronically or postmarked after June 18, 2004,
will not be accepted for processing and will be returned. Applications
will be considered received on time if received or mailed by 11:59 p.m.
Eastern time on the due date, as shown only by the electronic submission
record or a legible U.S. Postal Service dated postmark or a legible date
receipt from a commercial carrier. Please indicate that you are
responding to HRSA 04-034: NDSCS.

If you have questions regarding the FY 2004 health center new access
point application and/or the review process described in this
application guidance please call Tonya Bowers in the Division of Health
Center Development on (301) 594-4300 or <TBOWERS@>HRSA.GOV .

> ![](media/image2.png){width="1.8541666666666667in"
> height="0.3645833333333333in"}
>
> Sam S. Shekar, M.D., M.P.H.
>
> Assistant Surgeon General and
>
> Associate Administrator for Primary Health Care

Attachments

**Department of Health and Human Services**

**Health Resources and Services Administration**

**Bureau of Primary Health Care**

**FISCAL YEAR 2004**

**NEW ACCESS POINT CONSOLIDATED**

**GRANT APPLICATION**

**CFDA \# 93.224**

**HRSA-04-034**

For use with

PHS-5161-1

**FY 2004 NEW ACCESS POINT CONSOLIDATED GRANT APPLICATION GUIDANCE**

# TABLE OF CONTENTS

TABLE OF CONTENTS [i](#table-of-contents)

INTRODUCTION [iii](#introduction)

I. INTRODUCTION [iv](#__RefHeading___Toc50808006)

II\. GENERAL INFORMATION
[vi](#iii.-general-new-access-point-application-information)

> WHO CAN APPLY? [vi](#who-can-apply)
>
> WHAT ARE THE ELIGIBILITY REQUIREMENTS?
> [vii](#what-are-the-eligibility-requirements)
>
> WHAT IS A NEW ACCESS POINT? [vii](#what-is-a-new-access-point)
>
> WHAT IS A NEW START APPLICANT? [vii](#what-is-a-new-start-applicant)
>
> WHAT IS A SATELLITE APPLICANT? [vii](#what-is-a-satellite-applicant)
>
> HOW MANY APPLICATIONS CAN BE SUBMITTED?
> [viii](#how-many-applications-can-be-submitted)
>
> WHAT TYPES OF REQUESTS WILL BE CONSIDERED?
> [viii](#what-types-of-requests-will-be-considered)
>
> WHAT TYPES OF REQUESTS WILL NOT BE CONSIDERED?
> [viii](#what-types-of-requests-will-not-be-considered)
>
> WHAT IS THE MAXIMUM LEVEL OF SUPPORT?
> [ix](#what-is-the-maximum-level-of-support)
>
> WHEN ARE APPLICATIONS DUE? [v](#applications-due-dates)
>
> WHERE APPLICATIONS SHOULD BE SENT?
> [v](#application-submission-information)

SECTION I: GENERAL INFORMATION [1](#general-information)

I. GOAL OF THE NEW ACCESS POINT STRATEGY
[2](#i.-goal-of-the-new-access-point-strategy)

II\. OVERVIEW AND ROLE OF HEALTH CENTERS IN THE DELIVERY OF HEALTH CARE
TO MEDICALLY UNDERSERVED POPULATIONS
[2](#ii.-overview-and-role-of-health-centers-in-the-delivery-of-health-care-to-medically-underserved-populations)

III\. EXPECTED RESULTS [2](#iii.-expected-results)

IV\. PROGRAM SPECIFIC REQUIREMENTS/EXPECTATIONS
[4](#iv.-specific-requirementsexpectations)

V. LETTER OF INTEREST [6](#v.-letter-of-interest)

VI\. REVIEW PROCESS [7](#vi.-review-process)

VII\. TECHNICAL ASSISTANCE SET-ASIDE
[8](#vii.-technical-assistance-set-aside)

VIII\. COMPLETION OF THE NEED FOR ASSISTANCE WORKSHEET
[9](#viii.-completion-of-the-need-for-assistance-worksheet)

IX\. FEDERAL TORT CLAIMS ACT COVERAGE /MEDICAL MALPRACTICE INSURANCE
[9](#ix.-federal-tort-claims-act-coveragemedical-malpractice-insurance)

X. 340B DRUG PRICING PROGRAM [10](#x.-340b-drug-pricing-program)

SECTION II: APPLICATION PREPARATION [12](#application-preparation)

I. APPLICATION PREPARATION [13](#i.-application-preparation)

II\. STRUCTURE AND CONTENT OF THE APPLICATION
[13](#ii.-structure-and-content-of-the-application)

A. SEQUENCE OF THE APPLICATION [13](#sequence-of-the-application)

B. CONTENT OF THE APPLICATION
[14](#b.-content-of-the-application-instructions-for-preparing-each-required-section-of-the-application)

III\. INSTRUCTIONS REGARDING FORMATTING OF THE APPLICATION
[17](#iii.-instructions-regarding-formatting-of-the-application)

SECTION III: PROJECT DESCRIPTION and REVIEW CRITERIA
[18](#review-criteria)

I. PROJECT SUMMARY
[19](#i.-project-summary-recommend-approximately-2-3-pages-no-points-awarded)

II\. PROJECT DESCRIPTION
[20](#ii.-project-description-recommend-approximately-25-30-pages)

A. Description of the service area/community and target population
[20](#a.-description-of-the-service-areacommunity-and-target-population-maximum-10-points-recommend-approximately-3-4-pages)

B. Strategic Planning
[22](#b.-strategic-planning-maximum-10-points-recommend-approximately-2-3-pages)

C. Service Delivery Strategy and Model
[23](#c.-service-delivery-strategy-and-model-maximum-20-points-recommend-approximately-4-5-pages)

D. Health Care Services
[24](#d.-health-care-services-maximum-15-points-recommend-approximately-5-6-pages)

E. Organizational Capabilities and Expertise
[26](#e.-organizational-capabilities-and-expertise-maximum-15-points-recommend-approximately-3-4-pages)

F. Budget
[27](#f.-budget-maximum-10-points-recommend-approximately-2-3-pages)

G. Governance
[28](#g.-governance-maximum-10-points-recommend-approximately-2-3-pages-see-pin-98-12-for-additional-information-on-section-330-governance-requirements.)

h\. Readiness
[29](#h.-readiness-maximum-10-points-recommend-approximately-1-2-pages)

SECTION IV: INSTRUCTIONS FOR DEVELOPING the HEALTH CARE PLAN AND THE
BUSINESS PLAN
[30](#instructions-for-developing-the-health-care-plan-and-the-business-plan)

I. GUIDELINES FOR DEVELOPING THE HEALTH CARE PLAN AND THE BUSINESS PLAN
[31](#i.-guidelines-for-developing-the-health-care-plan-and-the-business-plan)

Sample Format for the Health Care Plan & Business Plan Presentations
[32](#health-care-plan-business-plan-presentations)

SECTION V: GUIDELINES FOR DEVELOPING THE NEW ACCESS POINT APPLICATION
BUDGET PRESENTATION
[33](#guidelines-for-developing-the-new-access-point-application-budget-presentation)

I. GUIDELINES FOR THE BUDGET PRESENTATION
[34](#i.-guidelines-for-the-budget-presentation)

A. MAXIMUM REQUEST FOR FEDERAL FUNDING
[34](#maximum-request-for-federal-funding)

B. ONE-TIME MINOR CAPITAL COSTS [34](#b.-one-time-minor-capital-costs)

C. REASONABLENESS AND APPROPRIATENESS OF THE BUDGET
[35](#c.-reasonableness-and-appropriateness-of-the-budget)

II\. COMPLETION OF THE BUDGET FORMS
[35](#ii.-completion-of-the-budget-forms)

A. Form SF 424A, Sections A-F [35](#a.-form-sf-424a-sections-a-f)

B. BUDGET NARRATIVE [36](#b.-budget-narrative)

C. INSTRUCTIONS FOR THE COMPLETION OF FORM 3: INCOME ANALYSIS FORMAT
[37](#c.-instructions-for-the-completion-of-form-3-income-analysis-format)

Sample Budget Narrative [40](#sample-budget-narrative)

SECTION VI: FORMS [43](#forms)

I. DESCRIPTIONS of THE FORMS [44](#i.-descriptions-of-the-forms)

FORM 1 -- PART A, GENERAL INFORMATION WORKSHEET
[46](#general-information-worksheet---fiscal-year-2004)

FORM 1 -- PART B, BPHC FUNDING REQUEST SUMMARY
[47](#bphc-funding-request-summary)

FORM 1 -- PART C, NEW ACCESS POINT APPLICATION CHECKLIST
[48](#new-access-point-application-checklist)

FORM 2, PROPOSED STAFF PROFILE [49](#form-2---proposed-staff-profile)

FORM 3, INCOME ANALYSIS FORMAT
[50](#form-3---income-analysis-format-year-1-year-2-year-3)

FORM 4, COMMUNITY CHARACTERISTICS
[51](#form-4---community-characteristics)

FORM 5 -- PART A, SERVICES PROVIDED [52](#services-provided)

FORM 5 -- PART B, SERVICE SITES [53](#service-sites)

FORM 6 -- PART A, CURRENT BOARD MEMBER CHARACTERISTICS
[54](#form-6-part-a-current-board-member-characteristics)

FORM 6 -- PART B, REQUEST FOR WAIVER OF GOVERNANCE REQUIREMENTS
[55](#request-for-waiver-of-governance-requirements)

FORM 7, COMPLIANCE CHECKLIST [56](#compliance-checklist)

FORM 8, HEALTH CENTER AFFILIATION CHECKLIST
[58](#health-center-affiliation-checklist)

SECTION VI: EXHIBITS [61](#exhibits)

EXHIBIT 1, PRIMARY CARE ASSOCIATION AND PRIMARY CARE OFFICE CONTACTS
[62](#primary-care-office-contacts)

EXHIBIT 2, DEFINITIONS FOR NEW ACCESS POINTS
[68](#definitions-for-new-access-points)

ATTACHMENTS [72](#attachments)

ATTACHMENT A, ELIGIBILITY CRITERIA FOR NEW ACCESS POINTS
[73](#new-access-points---fiscal-year-2004)

ATTACHMENT B, AWARDING FACTORS FOR NEW ACCESS POINTS
[74](#new-access-points-fiscal-year-2004)

ATTACHMENT C, NEED FOR ASSISTANCE CRITERIA FOR NEW ACCESS POINTS
[75](#new-access-points-fiscal-year-2004-1)

ATTACHMENT D, NEED FOR ASSISTANCE WORKSHEET FOR NEW ACCESS POINTS
[78](#new-access-points-fiscal-year-2004-2)

## 

# 

# INTRODUCTION 

[]{#__RefHeading___Toc50808006 .anchor}

## I. INTRODUCTION

President Bush's fiscal year (FY) 2004 budget proposes an increase of
\$122 million in the appropriation for the Consolidated Health Center
Program authorized under section 330 of the Public Health Service (PHS)
Act. The increase represents the third installment in the President's
multi-year plan to serve an additional 6 million people in 1,200 of the
Nation's neediest communities through new or significantly expanded
health center access points.

The Bureau of Primary Health Care's (BPHC) new access point consolidated
grant application has been designed for new applicants and existing
grantees applying for operational support of a new access point(s) under
the Consolidated Health Center Program including:

Community Health Centers (CHC) - section 330(e)

Migrant Health Centers (MHC) - section 330(g)

Health Care for the Homeless (HCH) - section 330(h)

> Public Housing Primary Care (PHPC) - section 330(i)
>
> Schools Based Health Centers (SBHC) -- section 330

In FY 2004, two application cycles have been announced for new access
points. The final funds available to support new access points under the
Consolidated Health Center Program will be based on the level of funds
appropriated for section 330 of the PHS Act. For FY 2004, the BPHC
anticipates that \$56 million will be available to support health center
new access points.

This application guidance provides a brief overview of the BPHC's new
access point strategy along with more detailed information on the FY
2004 eligibility requirements, review criteria and awarding factors for
new health center access points. For the purposes of this document, the
term "health center" refers to the diverse types of health centers
(i.e., CHC, MHC, HCH, PHPC and SBHC) that are supported under Section
330 of the PHS Act.

## II. GENERAL APPLICATION INSTRUCTIONS

#### OTHER DOCUMENTS TO REVIEW:

> **All applicants requesting funds to support a new access point under
> section 330 of the PHS act must use this guidance.** The entire
> application guidance should be reviewed thoroughly prior to making a
> decision to apply. In addition, it is recommended that applicants also
> thoroughly review the following reference documents.

-   Section 330 of the PHS Act as amended (Health Care Safety Net
    Amendments of 2002, Public Law 107-251)

-   PIN 98-12, **"**Implementation of the Section 330 Governance
    Requirements" (signed April 28, 1998)

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-   PIN 98-23, "Health Center Program Expectations" (signed August 17,
    1998)

-   PIN 98-24, "Amendment to PIN 97-27 Regarding Affiliation Agreements
    of Community and Migrant Health Centers" (signed August 17, 1998)

-   PIN 97-27, "Affiliation Agreements of Community and Migrant Health
    Centers" (signed July 22, 1997)

-   PIN 2001-13, "Clarification of Program Requirements and Benefits for
    Bureau of Primary Health Care Supported School-Based Health Centers"
    (signed June 6, 2001)

-   PAL 2002-09, "President's Initiative to Expand Health Centers"
    (signed May 16, 2002)

> These documents and any others referenced in this grant application
> kit are available on the Bureau of Primary Health Care (BPHC) web
> page: http://www.bphc.hrsa.gov/pinspals/. A complete application
> package is also available on the BPHC web page, or you may request the
> materials from the HRSA Grants Application Center (GAC). To request a
> hard copy of an application kit for this program, please call toll
> free at (877) HRSA-123 or email at <hrsagac@hrsa.gov>. When contacting
> the Grants Application Center regarding application materials, please
> refer to the Program Announcement Number, P.A. 04-034: New Delivery
> Sites and New Starts in Programs Funded under the Health Centers
> Consolidation Act (NDSCS).

#### DUNS NUMBER: 

**Beginning October 1, 2003, all applicants will be required to have a
Data Universal Numbering System (DUNS) number to apply for a grant from
the Federal Government.** The DUNS number is a unique nine-character
identification number provided by the commercial company Dun &
Bradstreet. There is no charge to obtain a DUNS number.

Organizations are encouraged to obtain a DUNS number now if it is
believed an application(s) will be submitted to any Federal agency on or
after October 1, 2003. Proactively obtaining a DUNS number will
facilitate the receipt and acceptance of applications after September
2003.

A DUNS number is also required before an organization can register in
the Federal Government's Central Contractor Registry (CCR), which is
required to do business with the government, including electronically
applying for HRSA grants. Additional information on registering with the
CCR or obtaining a DUNS number can be found at
<http://www.hrsa.gov/grants>.

#### APPLICATIONS DUE DATES:

> It is the responsibility of the applicant to ensure that the complete
> application is **submitted electronically or postmarked** by the
> published due date. For FY 2004, applications postmarked by December
> 1, 2003, will be reviewed with funding decisions announced on or about
> March 15, 2004. Applications postmarked by June 18, 2004, will be
> reviewed with funding decisions announced on or about August 15, 2004.
> Applications received electronically or postmarked after June 18,
> 2004, will be discarded without further processing. Applications will
> be considered received on time if they are received or mailed by 11:59
> p.m. Eastern time on the due date, as shown, only by the electronic
> submission record or a legible U.S. Postal Service dated postmark or a
> legible date receipt from a commercial carrier. Please indicate that
> you are responding to HRSA 04-034: NDSCS.

#### APPLICATION SUBMISSION INFORMATION:

> Applications may be SUBMITTED ELECTRONICALLY OR POSTMARKED by 11:59
> p.m. Eastern time on the due date. Information for preparing either
> paper or electronic applications can be found at
> <http://www.hrsa.gov/grants>.
>
> If mailing the application, the **original and two copies of the
> application, including all attachments MUST be sent to:**

HRSA Grants Application Center

> Attn: Grants Management Officer
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, Maryland 20879
>
> Phone: 1-877-477-2123
>
> Fax: 1-877-477-2345

Email: [hrsagac@hrsa.gov]{.underline}

Information on preparing a paper application can be found at
[www.hrsa.gov/grants.htm](http://www.hrsa.gov/grants.htm). Applicants
will receive written confirmation of receipt of the application by mail
within 10 days of submission. The confirmation will include the unique
identifying number assigned to the application. If written confirmation
of receipt is not received within 10 days, applicants are encouraged to
call 1-877-477-2123.

> HRSA is encouraging applicants take advantage of the new on-line
> application option. To register and apply on-line, applicants should
> refer to <https://grants.hrsa.gov/webexternal/registration.asp> or
> <http://www.hrsa.gov/grants>. HRSA's on-line application system is
> designed to maximize data accuracy and speed processing. For help
> using the on-line application system, call 1-877-GO4-HRSA
> (1-877-464-4772) between 8:30 a.m. to 5:30 p.m. eastern time or email
> the <callcenter@hrsa.gov>.
>
> Applicants filing electronically must register with the HRSA grants
> application system before work can begin on-line. All electronic
> applications will be date stamped as received at 5:00 p.m. Eastern
> time on the date of submission regardless of the actual time of
> submission. Applicants submitting electronically will receive email
> confirmation of on-time receipt within two hours. The confirmation
> will also include the unique identifying number assigned to the
> application. If confirmation is not received within 2 hours,
> applicants are encouraged to call 1-877-464-4772.

In filing the application electronically, application narratives and
spreadsheets will need to be created separately and submitted as
attachments to the application. You will be prompted to "upload" your
attachments at strategic points within the application interface. The
following document types will be accepted as attachments: WordPerfect
(.wpd), Microsoft Word (.doc), Microsoft Excel (.xls), Rich Text Format
(.rtf), Portable Document Format (.pdf).

> **Applications submitted electronically or postmarked later than 11:59
> p.m. Eastern time on June 18, 2004 or sent to any other address will
> be discarded without further consideration.**

## III. GENERAL NEW ACCESS POINT APPLICATION INFORMATION

#### WHO CAN APPLY?

Public or private nonprofit entities, including tribal, faith-based and
community-based organizations, may apply for a grant for operational
support of new access points under the Consolidated Health Center
Programs authorized under section 330 of the PHS Act. Applicants are
expected to demonstrate compliance with the requirements for the
specific type of health center (i.e., CHC, MHC, HCH, PHPC, SBHC) for
which funding is requested.

#### WHAT ARE THE ELIGIBILITY REQUIREMENTS?

An application will be considered eligible if it meets all of the
specific eligibility requirements listed in Attachment A (page
[88](#attachment-a) of this document). Applications that do not meet the
eligibility requirements will be discarded without further processing.

#### WHAT IS A NEW ACCESS POINT?

A new access point is a new delivery site for the provision of
comprehensive primary and preventive health care services. The two types
of new access points referenced in this application guidance are (1) new
starts and (2) satellites. (These are described below.) Every new access
point is expected to demonstrate compliance with the applicable
requirements of section 330 of the PHS Act, the implementing regulations
and BPHC Program Expectations.

To be competitive, new access point applications will:

(a) demonstrate that all persons will have ready access to the full
    range of required primary, preventive, enabling (see Exhibit 2, page
    [83](#exhibit-2), for a definition) and supplemental health
    services, including oral health care, mental health care and
    substance abuse services, either directly on-site or through
    established arrangements without regard to ability to pay;

(b) demonstrate compliance at the time of application (or a plan for
    compliance within 120 days of a grant award) with the requirements
    of section 330, its guidelines and regulations;

(c) demonstrate how section 330 funds will expand services and increase
    the number of people served through the establishment of a new
    service delivery site(s) and/or at an existing site(s) not currently
    within a BPHC funded scope of project;

(d) demonstrate that the site(s) will be operational and services will
    be initiated within 120 days of a grant award; and

(e) Demonstrate how section 330 funds will augment already available
    funds and in-kind resources to expand existing primary health care
    service capacity to currently underserved populations.

#### WHAT IS A NEW START APPLICANT?

A new start applicant is an organization that **currently DOES NOT
RECEIVE Federal grant support the Consolidated Health Center Program
authorized under section 330 of the PHS Act**. A new start application
should address the entire scope of the project being proposed for
Federal support. Approved and funded new start applicants may receive
funding for up to three years.

#### WHAT IS A SATELLITE APPLICANT? 

> A satellite applicant is an organization **that CURRENTLY RECEIVES
> grant support under under Section 330 of the PHS Act.** All satellite
> applicants MUST propose to establish a new access point(s) to serve a
> new patient population that is outside the applicant's approved scope
> of project (i.e., a site(s) not listed on the applicant's most
> recently submitted Exhibit B "Service Sites" from the continuation
> application or approved Change in Scope request). A satellite
> application should address **ONLY** the service area and target
> population of the proposed new access point(s) (i.e., only the new
> site(s) and service area proposed in the satellite application, not
> all of the sites or the entire service area of the applicant) in terms
> of need, population to be served and the new delivery system being
> proposed. Applicants may request support for a satellite site that is
> within the current service area if the site will be serving a
> population/area that currently does not have access to care either at
> the applicant's current site(s) or through other providers of care in
> the area. Approved and funded applications from satellite applicants
> will be aligned with the current section 330 grant project period.

**HOW MANY SITES AND FUNDING PROGRAMS CAN BE REQUESTED?**

> New start and satellite applicants may submit an application for
> Federal support to establish a single new access point or multiple
> access points and may request funding to support one or multiple types
> of health centers (i.e., CHC, MHC, HCH, PHPC, SBHC) based on the
> population(s) to be served. Applicants should indicate on Form 1-A
> (see page [48](#form-1-part-a)) and Form 1-B (see page
> [49](#form-1--part-b)) their request for funding under the specific
> section 330 programs.

#### HOW MANY APPLICATIONS CAN BE SUBMITTED?

> In FY 2004, applicants may submit more than one application; however,
> the BPHC will accept only one application per organization per
> application review cycle (i.e., only one application may be submitted
> by an organization for consideration in the two announced review
> cycles in FY 2004). In considering a second/subsequent application for
> a new access point, please be advised that the BPHC will issue only
> one award to an organization for this purpose in FY 2004.

#### WHAT TYPES OF REQUESTS WILL BE CONSIDERED?

> For FY 2004, all new access point applications that are considered to
> be eligible (see Attachment A, page [88](#attachment-a)) complete (see
> Form 1-C, page [50](#form-1-part-c)), and responsive to Federal
> Register Notice, dated September 9, 2003, will be considered for
> funding. Applicants must demonstrate how section 330 funds will expand
> services and increase the number of people served through the
> establishment of a new service delivery site(s) and/or at an existing
> site(s). \[All satellite applications must propose to establish a new
> access point(s) outside of their approved scope of project under any
> section 330 program.\]

#### WHAT TYPES OF REQUESTS WILL NOT BE CONSIDERED?

**For FY 2004, the following types of applications WILL NOT be
considered:**

(1) new start or satellite applications proposing a new access point(s)
    to provide a single service, such as dental, mental health or
    prenatal services;

(2) new start or satellite applications proposing a new access point(s)
    to exclusively serve a single age group (e.g., children) or
    lifecycle (e.g., geriatric only). However, applicants may target a
    subset of the population, for example services for homeless children
    and adolescents; or organizations applying for operational support
    for a school based health center targeting children and adolescents.
    Even when a population subset is targeted, services must also be
    made available to other community members.

(3) satellite applications from currently funded section 330 grantees to
    support the expansion of capacity (additional providers, new
    services, etc.) at a site(s) already in their approved scope of
    project including applications requesting funding to establish a new
    type of health center (i.e., CHC, MHC, HCH, PHPC, SBHC) at sites
    already listed under the organization's Federal scope of project;

(4) satellite applications from currently funded section 330 grantees to
    support the relocation of a site(s) already in their approved scope
    of project to a new location/facility;

(5) applications from organizations that do not propose to establish a
    new access point for the provision of comprehensive primary and
    preventive health care services;

(6) applications from organizations that request Federal funding in
    excess of the established cap for FY 2004 in Year 1, Year 2, or Year
    3; and

(7) applications from organizations designated as exceptional/high risk
    grantees.

#### WHAT IS THE MAXIMUM LEVEL OF SUPPORT?

> For FY 2004, the BPHC has established a **cap of \$650,000 for section
> 330 support** of new access points. The cap is the **maximum amount of
> section 330 funding** that can be requested in a new access point
> grant application in FY 2004 regardless of the number and/or type of
> new access points to be supported through the application and not all
> applicants approved and funded will receive that amount. **Applicants
> may request support up to \$150,000 in Year 1 only for one-time minor
> capital costs for equipment and/or alteration/renovation (see Exhibit
> 2, page [83](#exhibit-2), for a definition); however, the total
> request for section 330 support MUST NOT exceed the established cap of
> \$650,000 in Year 1, Year 2 or Year 3. Applications that present a
> request for support in excess of the established cap in Year 1, Year 2
> or Year 3 will be discarded without further consideration**
>
> It is expected that the request for Federal support and the budgets
> presented in the application will be reasonable and appropriate based
> on the scope of the services to be provided and the number and type
> (i.e, homeless, migrant, public housing residents, low income children
> and adolescents, etc.) of individuals to be served (see Form 1-A, page
> [48](#form-1-part-a)). The budget should be consistent with the health
> care and business plans presented in the application. The following is
> provided as a guideline in developing the Federal budget request:
> \$150 Federal grant dollars per general community user, \$200 Federal
> grant dollars per migrant/seasonal farmworker user, \$200 Federal
> grant dollars per homeless user; \$200 Federal grant dollars per
> public housing user; and \$200 Federal grant dollars per school-based
> health center user.
>
> Federal funding levels will be reviewed prior to a final funding
> decision and may be adjusted based on the past performance (if an
> existing section 330 grantee) and an analysis of experience related to
> operating costs, utilization, provider staffing and revenue
> generation. Federal funding levels for new start applicants may also
> be adjusted based on analysis of the budget and cost factors. See
> Section V of this application guidance for further information and
> instruction on the development of the application budget.

#### IV. OTHER INFORMATION: 

1.  **The Consolidated Health Center program is subject to the
    provisions of Executive Order 12372, as implemented by 45 CFR Part
    100**. Executive Order 12372 allows States the option of setting up
    a system for reviewing applications from within their States for
    assistance under certain Federal programs. The application packages
    pursuant to this notice will contain a listing of States with review
    systems and will provide a single point of contact (SPOC) in the
    State for review. A list of SPOC contacts may be found at
    <http://www.whitehouse.gov/omb/grants/spoc.html>. Applicants (other
    than federally-recognized Indian tribal governments) should contact
    their SPOC's as early as possible to alert them to the prospective
    applications and receive any necessary instructions on the State
    process. For proposed projects serving more than one State, the
    applicant is advised to contact the SPOC of each affected State. The
    due date for State process recommendations is 60 days after the
    applicable Federal application receipt due date. The BPHC does not
    guarantee that it will accommodate or explain its responses to State
    process recommendations received after the due date. (See
    "Intergovernmental Review of Federal Programs," Executive Order
    12372, and 45 CFR Part 100, for description of the review process
    and requirements.)

> 2\. **Public Health System Reporting Requirements**: Under these
> requirements (approved by the Office of Management and Budget
> 0937-0195), the community-based non-governmental applicant must
> prepare and submit a Public Health System Impact Statement (PHSIS) to
> the head of the appropriate State and local health agencies in the
> area(s) to be impacted no later than the Federal application due date:
>
> a\) A copy of the face page of the application (SF 424).

b\) A summary of the project, not to exceed one page, which provides:

-   A description of the population to be served whose needs would be
    met under the proposal.

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-   A summary of the services to be provided, and

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-   A description of the coordination planned with the appropriate State
    or local health agencies.

# 

# SECTION I:

# 

# GENERAL INFORMATION

## I. GOAL OF THE NEW ACCESS POINT STRATEGY

President Bush's Initiative to Expand Health Centers, which began in FY
2002, will increase health care access to **1,200** of the Nation's
neediest communities through new and/or significantly expanded health
center access points over five years. One way to achieve this goal is
through the creation of new access points for the provision of
comprehensive primary and preventive health care services in areas of
high need that will improve the health status and decrease health
disparities of the medically underserved populations to be served. These
access points may be targeted toward an entire community or toward a
specific population group in a community that has been identified as
having unique and significant barriers to affordable and accessible
health care services.

The mission of the BPHC is "to increase access to comprehensive primary
and preventive health care and to improve the health status of
underserved and vulnerable populations." All of the programs
administered by the BPHC are focused toward ensuring the availability
and accessibility of essential primary and preventive health services to
the people who have the most limited access to services and face the
greatest barriers to care. The BPHC is committed to the goal of
improving and expanding access to health care for all Americans
nationwide, and most importantly for the estimated 41 million uninsured
people in the United States who do not have adequate access to
affordable, appropriate primary and preventive health care.

Overall for FY 2004, the BPHC will support new health center access
point applications that demonstrate a high level of need in their
community, present a sound proposal to meet this need, and show that
they are ready to rapidly initiate this proposal. In addition, the
competitive nature of the health care environment demands that primary
care providers be part of community-based delivery systems; therefore,
the BPHC will support those health centers that can demonstrate
responsiveness to their health care environment and that have
established collaborative and coordinated delivery systems for the
provision of health care to the underserved in their communities.

#  {#section-4 .Style1}

## II. OVERVIEW AND ROLE OF HEALTH CENTERS IN THE DELIVERY OF HEALTH CARE TO MEDICALLY UNDERSERVED POPULATIONS

New access point grants made under section 330 are a prominent part of
President Bush's goal to increase access to primary health care services
to those Americans who need them most. Individually, each health center
plays an important role in this plan and combined they have had a
critical impact on the health care status of underserved and vulnerable
populations throughout the United States. At the end of FY 2003, there
were over 825 federally-funded health centers with more than 3,400
primary care delivery sites located in urban and rural underserved areas
throughout the U.S. and its territories. Approximately 12 million
medically underserved and uninsured patients receive high quality,
cost-effective, culturally appropriate, accessible and affordable
preventive and primary health care services through the federally-funded
health centers.

## III. EXPECTED RESULTS

The BPHC recognizes that health centers face rapid changes in their
local, State and national health care environment and, in order to be
more responsive, the BPHC will conduct two application cycles in FY
2004. To assist organizations in their consideration of a new access
point application, the BPHC has identified several critical areas that
should be examined prior to developing an application.

The BPHC has placed an emphasis on the **readiness** of an applicant to
initiate the proposed project plan. To that end, the BPHC will commit
adequate funds to each of the two application cycles so there is no
"advantage" to applying early in the fiscal year. The BPHC expects an
organization to apply for section 330 new access point funding only when
it can demonstrate that the **new access point(s) will be operational
within 120-days of a grant award**. Competitive applicants will
demonstrate at a minimum, that within 120-days of a grant award, (1) a
facility will be available, ready for occupancy and adequate to serve
the proposed population/community and (2) providers will be available to
serve at the new access point. However, BPHC will consider on a case by
case basis, a request to extend the time limit up to 180 days for a new
access point to become fully operational for good cause.

In addition to readiness, all competitive organizations must demonstrate
that the proposed new access point(s) will serve populations in areas
with the **greatest need for services**. All applicants must submit a
completed Need for Assistance Worksheet (see Attachment D, page
[94](#attachment-d)) as part of the application to demonstrate the
relative need for additional primary health care services in their
proposed service area. Applicants are encouraged to self-score the need
for assistance worksheet (see Attachment C, page [89](#attachment-c),
for the basis for scoring the worksheet). Only those applications that
score 70 or higher on the need for assistance component of the
application will have the merits of the application evaluated by an
Independent Review Committee. In addition to incorporating the need for
assistance worksheet into the application, applicants are also
encouraged to submit the completed worksheet as part of a Letter of
Interest (see page [6](#v.-letter-of-interest)) prior to submitting an
application.

Competitive new access point applicants will demonstrate that the
proposed project will **increase access** to primary health care
services and reduce health disparities in the community/population to be
served. A competitive applicants will also demonstrate the extent to
which the receipt of the section 330 grant will increase access to care
in terms of the number of people to be served and the number of primary
care providers to be made available to the population. Competitive
applicants will further detail the current level of services available
to the community and how, with the additional Federal support being
requested, the organization proposes to develop a system of care which
increases access to care, services and available primary care providers
to the target population. New access point applicants must demonstrate
their efforts to achieve the goals of **Healthy People 2010** as part of
their efforts to increase access and reduce health disparities.
(Information on [Healthy People 2010]{.underline} is available at:
www.health.gov/healthypeople/.)

Competitive applicants will **demonstrate compliance**, with all
requirements of section 330 of the PHS Act, the programs' implementing
regulations (42 CFR 51c.301-404), and BPHC guidelines, including the
Health Center Program Expectations, at the time of application. In order
to confirm compliance, applicants are required to submit a completed
Compliance Checklist (see Form 7, page [61](#form-7-page-1-of-2)) that
has been certified as accurate by the Chairperson of the Board of
Directors.

Competitive applicants will **present a sound and complete plan** for
the successful establishment of a new access point(s). This plan should
demonstrate responsiveness to the identified health care needs of the
target population, appropriate short- and long-term strategic planning,
and coordination with other providers of care. Competitive applicants
will respond thoroughly and completely to the review criteria presented
in Section III of this guidance in the presentation of their proposed
new access point project.

Competitive applicants will present **a reasonable and accurate 3-year
budget** based on the activities proposed in the project plan.
Competitive applicants will present a budget for the new access point(s)
and request Federal funds that are reasonable and appropriate based on
the scope of the services to be provided and the number of new
individuals to be served. The budget should be consistent with the
health care and business plans presented in the application. Approved
Federal funding levels will be reviewed and may be adjusted based on
performance and an analysis of actual experience related to operating
costs, utilization, provider staffing and revenue generation. Applicants
are encouraged to carefully review Section V of this document for
further clarification and instructions on the presentation of the budget
for new access point grant applications.

Applicants are encouraged to collaborate with the appropriate Primary
Care Associations and/or Primary Care Offices (PCAs/PCOs. -- see Exhibit
1, page [67](#exhibit-1)) in determining their readiness to develop an
application for a new access point.

## IV. SPECIFIC REQUIREMENTS/EXPECTATIONS

As stated above, all applicants are expected to demonstrate compliance
with the applicable requirements of section 330 of the PHS Act and BPHC
guidelines, including the Health Center Program Expectations (PIN
98-23). Applicants seeking support for CHC and MHC are also expected to
demonstrate compliance with the implementing regulations (42 CFR Part
51c. 301-404). In addition to these general requirements, there are
specific requirements and expectations for applicants requesting funding
under each type of health center authorized under section 330.
Applicants requesting funding to support one or more health center types
are expected to demonstrate compliance in the application with
guidelines, expectations and requirements, as applicable. Failure to
document and demonstrate compliance in the application will
significantly reduce the likelihood of approval and funding.

COMMUNITY HEALTH CENTER (CHC) APPLICANTS (section 330(e)):

Competitive CHC applicants will demonstrate 1) that the new access
point(s) will increase access to comprehensive primary and preventive
health care and improve the health status of underserved and vulnerable
populations in the area to be served, 2) that the proposed new access
point(s) will address the major health care needs of the target
population and will assure the availability and accessibility of
essential primary and preventive health services, including oral health
and mental health and substance abuse services, to all individuals in
the service area, and 3) compliance with section 330(e) and all
applicable BPHC guidelines.

MIGRANT HEALTH CENTER (MHC) APPLICANTS (section 330(g)):

> Competitive MHC applicants will 1) address how the special needs of
> migratory and seasonal farmworkers and their families are being or
> will be met, 2) describe how they will ensure that farmworkers will
> have access to comprehensive and preventive health care services,
> including oral health, mental health and substance abuse services
> through mechanisms such as: outreach that is integrated into the
> primary health care delivery system; use of mobile vans or health
> teams that travel to migrant camps; transportation; extended clinic
> hours; etc, 3) describe how they will address the special
> environmental health concerns that are associated with migratory and
> seasonal farmworkers, and 4) demonstrate compliance with sections
> 330(e) and 330(g), and all applicable BPHC regulations and guidelines.
>
> Competitive MHC applicants will include information about how the
> health center governance requirements will be/are being addressed. For
> organizations that are *only* requesting support for a MHC, HCH and/or
> a PHPC and are requesting a waiver for all or some portion of the
> governance requirements, must submit a description of the reasons for
> the waiver and the alternative mechanism being proposed to ensure
> consumer input should in compliance with guidelines as described in
> PIN 98-12. The waiver request should be submitted as a letter with the
> application and applicants should submit Form 6, Part B (see page
> [60](#form-6---part-b)). Applicants that are also approved and funded
> to support a CHC or SBHC are not eligible for a waiver.
>
> Migrant voucher programs may propose to arrange for the delivery of
> required services with existing providers through contractual
> arrangements. Assurance must be provided that the target population
> has access to the full-range of required services. Voucher programs
> must also describe how adjustments will be made for service delivery
> during peak and off-season cycles. New start migrant voucher programs
> that do not meet the governance requirements of section 330 must
> request a waiver from this requirement.

HEALTH CARE FOR THE HOMELESS (HCH) APPLICANTS (section 330(h)):

> Competitive HCH applicants will 1) demonstrate that the new access
> point(s) will increase access to comprehensive primary and preventive
> health care and improve the health status of underserved homeless
> people in the area to be served, 2) address the major health care
> needs of the target population and assure the availability and
> accessibility of essential primary and preventive health services,
> including oral health and mental health and substance abuse services,
> and 3) demonstrate compliance with sections 330(e) and 330(h), and all
> applicable BPHC regulations and guidelines.
>
> Competitive HCH applicants will 1) indicate the mechanism for
> delivering substance abuse services to homeless patients, 2) describe
> the manner in which comprehensive outreach is to be conducted, and how
> transportation and other enabling services will be provided, and 3)
> describe the manner in which case management, eligibility assistance,
> and access to housing services will be made available to homeless
> patients.
>
> Competitive HCH applicants will include information about how the
> health center governance requirements will be/are being addressed. For
> organizations that are *only* requesting support for a HCH, PHPC
> and/or MHC and are requesting a waiver for all or some portion of the
> governance requirements, must submit a description of the reasons for
> the waiver and the alternative mechanism being proposed to ensure
> consumer input should in compliance with guidelines as described in
> PIN 98-12. The waiver request should be submitted as a letter with the
> application and applicants should submit Form 6, Part B (see page
> [60](#form-6---part-b)). Applicants that are also approved and funded
> to support a CHC or SBHC are not eligible for a waiver.

PUBLIC HOUSING PRIMARY CARE (PHPC) APPLICANTS (section 330(i)):

Competitive PHPC applicants will 1) demonstrate that the new access
point(s) will increase access to comprehensive primary and preventive
health care and improve the health status of underserved public housing
residents in the area to be served, 2) address the major health care
needs of the target population and assure the availability and
accessibility of essential primary and preventive health services,
including oral health and mental health and substance abuse services,
and 3) demonstrate compliance with sections 330(e) and 330(i), and all
applicable BPHC regulations and guidelines.

> Competitive PHPC applicants will include information about how the
> health center governance requirements will be/are being addressed. For
> organizations that are *only* requesting support for a PHPC, HCH
> and/or MHC and are requesting a waiver for all or some portion of the
> governance requirements, must submit a description of the reasons for
> the waiver and the alternative mechanism being proposed to ensure
> consumer input should in compliance with guidelines as described in
> PIN 98-12. The waiver request should be submitted as a letter with the
> application and applicants should submit Form 6, Part B (see page
> [60](#form-6---part-b)). Applicants that are also approved and funded
> to support a CHC or SBHC are not eligible for a waiver.

SCHOOL BASED HEALTH CENTER (SBHC) APPLICANTS (section 330):

SBHC applicants must 1) demonstrate in their proposal how the new access
point(s) will increase access to comprehensive primary and preventive
health care, which includes referrals, tracking and follow-up, 2)
address the major health care needs of the target population and ensure
the availability and accessibility of essential primary and preventive
health services, including oral health, mental health, and substance
abuse services, and 3) demonstrate compliance with section 330 and all
applicable BPHC regulations and guidelines.

Competitive SBHC applicants will propose a school-based health center
that serves other community members in addition to the students
attending the school(s) where the SBHC is located. Community members may
be served in other locations operated by the applicant organization. If
the applicant organization has sites within the "scope of project" that
will serve non-students at the SBHC (e.g. teachers), that arrangement
must be described. The proposed site must operate at least 30 hours per
week at each school-based health center, except in sparsely populated
and rural areas utilizing mobile vans. The van must be operational at
least 30 hours per week at school sites. Some SBHC services may be
provided off site through established arrangements within the applicant
organization. SBHC applicants must provide a signed agreement with the
school that is hosting the SBHC.

## V. LETTER OF INTEREST

The submission of a Letter of Interest (LOI) is recommended but not
required in order to submit an application for new access point funds in
FY 2004. Past history has shown that applicants have benefited from the
feedback provided through the LOI process.

Applicants are encouraged to submit a LOI to the BPHC as soon as it
begins considering an application for Federal support of a new access
point. The BPHC uses the LOI process to provide feedback to the
organization to improve the quality of its application and its
opportunity for funding consideration in FY 2004. Through this process
the BPHC will examine whether the proposal is consistent with the
objectives of the Consolidated Health Center Program, demonstrates
readiness to initiate the project, and assures the completeness of the
need for assistance data. **The BPHC will provide feedback within
30-days of receipt of the LOI; therefore, it is recommended that
organizations submit the LOI at least 45 days prior to the submission of
the final application in order for the applicant to integrate the BPHC
response.**

The LOIs should be less than 7 pages and address the level of need in
the community for additional primary care services and a brief
description of the proposed project and the stage of readiness for
initiating operations.

**In addition to a completed NEED FOR ASSISTANCE WORKSHEET found in
Attachment D (page [94](#attachment-d)) of this application guidance, it
is recommended that each LOI include a brief description of each of the
following:**

(a) the new access point project being proposed: the location and
    sponsoring organization;

(b) the proposed target population (identify any special populations to
    be served) and service area including whether (1) it is defined as
    urban or rural and (2) identification of any federally-designated
    Medically Underserved Area (MUA)/Medically Underserved Population
    (MUP) designations;

(c) issues creating a high need for primary health services for the
    target population including any significant or unique barriers to
    care;

(d) other providers of care in the service area including any other
    section 330 grantees;

(e) a brief description of all health care services to be provided
    including primary care, mental health, substance abuse, and oral
    health care services as well as the mechanism of the provision of
    each service (e.g., direct service, referral, etc.)

(f) the proposed applicant organization, stage of development and
    ability to meet requirements for program compliance;

(g) other available health care resources in the area and any proposed
    partnerships; and

(h) the readiness to receive funding including that the facility
    identified for the new access point will be operational and
    providers will be available within 90 days of a grant award.

LOIs may be sent via e-mail to [LOIs@HRSA.GOV](mailto:LOIs@BPHC.GOV) or
mailed to:

> **Bureau of Primary Health Care**
>
> **Division of Health Center Development**
>
> **4350 East-West Highway, 3rd Floor**
>
> **Bethesda, Maryland 20814**
>
> **ATTN: New Access Point LOI**

It is also recommended that a copy of the LOI be sent to the appropriate
PCA and PCO. After a LOI is submitted and feedback is provided,
applicants are encouraged to work with the PCAs, and PCOs to develop the
strongest possible application for funding. (See Exhibit 1, page
[67](#exhibit-1), for a complete list of PCAs and PCOs).

## VI. REVIEW PROCESS 

For FY 2004, applications postmarked by December 1, 2003, will be
reviewed with funding decisions announced on or about March 15, 2004.
Applications postmarked by June 18, 2004, will be reviewed with funding
decisions announced on or about August 15, 2004. Applications submitted
electronically or postmarked after 11:59 p.m. on June 18, 2004, will be
discarded without further consideration. Applications will be considered
received on time if they are received electronically or postmarked by
11:59 p.m. Eastern time on the due date, as shown only by the electronic
submission record or a legible U.S. Postal Service dated postmark or a
legible date receipt from a commercial carrier.

All new access point applications will be reviewed initially for
eligibility (see Attachment A, page [88](#attachment-a)), completeness
(see Form 1-C, page [50](#form-1-part-c)) and responsiveness to the
application guidelines. **Those applications that are determined to be
ineligible, incomplete or non-responsive to the grant application
guidance and/or section 330 program requirements will be discarded
without further consideration.**

Those applications that are determined to be eligible will have the need
for assistance and merits of the application evaluated by an Independent
Review Committee (IRC) comprised of Federal and non-Federal experts.
Reviewers are experts in the field of endeavor for which support is
requested and often are engaged or were previously engaged in comparable
activities performed by the applicant.

The need for assistance component of the application will be evaluated
first by the IRC using the need for assistance criteria with points
assigned up to a maximum of 100 points (see Attachment C, page
[89](#attachment-c)). Applicants that score 70 or higher on the need for
assistance component of the application will have the merits of the
proposal evaluated by reviewers using published review criteria with
points assigned up to a maximum of 100 points total (see Section III,
page [18](#section-iii)). Funding preference(s) will be determined by
the reviewers based on supporting documentation contained in the
application. (See Attachment B, page [89](#attachment-b), for a list of
Awarding Factors.)

HRSA reserves the right to review fundable applicants for compliance
with BPHC program expectations through a review of site visits, audit
data, Uniform Data System (UDS) or similar reports, Medicare/Medicaid
cost reports, external accreditation or performance review reports, etc.
as applicable.

## VII. TECHNICAL ASSISTANCE SET-ASIDE

The changing health care environment demands that key health center
management staff including Chief Executive Directors, Chief Financial
Directors, Clinical Directors and Chief Information Officers, work
together as a team to develop a strong organizational structure and
processes designed to ensure the provision of high quality health care
services and the overall success of their project. Experience has proven
that organizations that start with these attributes have the highest
probability of being successful.

**Each new start applicant is expected to budget for and set-aside a
minimum of 2 percent of the expected award for technical assistance and
performance improvement activities.** Each new start that is selected
for funding will receive a site visit within 90 days of a grant award to
assist them in identifying areas of needed technical assistance. Once
funded, successful new start applicants are encouraged to work with
their project officer and PCA and/or PCO contact (see Exhibit 1 -- page
[67](#exhibit-1)) to develop a workplan and budget that prioritizes and
addresses identified areas of needed technical assistance and training.
Examples of the areas of technical assistance and training activities
include: administration; governance; managed care; financial management;
Management Information Systems (MIS); clinical management;
reengineering; and cluster clinical collaboratives.

## VIII. COMPLETION OF THE NEED FOR ASSISTANCE WORKSHEET

New access point applications that do not include a completed Need for
Assistance Worksheet (see Attachment D, page [94](#attachment-d)) will
be considered non-responsive and will be discarded without further
consideration.

The basis for the scoring of the Need for Assistance Worksheet is
presented in Attachment C (see page [89](#attachment-c)). The evaluation
of Need for Assistance will be based on data about both the proposed
service area and target population. The **new start applicants** are
expected to provide data for the proposed scope of project. The
**satellite applicants** are expected to provide data for the proposed
new service delivery site ONLY.

The following guidelines are provided for completing the Need for
Assistance Worksheet. If the responses to the Need for Assistance
Worksheet are not presented appropriately, as described below, the
applicant will receive the minimum points allowed for the applicable
question.

1.  All responses must be given in the format requested (i.e., if a
    percentage is requested, the response must be a percentage; if a
    rate is requested, the response must be a rate).

2.  Documentation of the source of the data is required.

3.  Data cited must be the most recent data available.

4.  Data must be from a reliable and independent source including:
    Census data; Service area data; Local or State-level data; and/or
    National data, where no other data is available.

> NOTE: Applicants should use the most geographically focused data
> available. Applicants may not use data generated by their own internal
> data systems to complete the Need for Assistance Worksheet.

5.  Each response must clearly address the target population(s) to be
    served. If an applicant proposes to serve multiple sites or service
    areas, the Need for Assistance Worksheet should include responses
    that represent the total targeted populations/areas. No more than
    one response should be submitted for each question.

6.  All responses must be finite numbers (i.e., 212) and cannot be
    presented as ranges (i.e., 31-35).

7.  In completing the Health Disparities section, a response must be
    presented for the target population as well as for the benchmark
    area. A benchmark response, such as County, State, National or other
    established reporting area, must be used as a point of comparison
    for the target population. As with item #4, applicants should use
    the most geographically focused data available for both the target
    population and the benchmark area.

8.  Only one response may be provided under the Health Disparity Factor
    "2bb. Other".

## IX. FEDERAL TORT CLAIMS ACT coverage/MEDICAL MALPRACTICE INSURANCE

Organizations that receive grant funds under section 330 are eligible
for protection from suits alleging medical malpractice through the
Federally Supported Health Centers Assistance Act of 1992 (Act). The Act
provides that health center employees may be deemed Federal employees
and be afforded the protections of the Federal Tort Claims Act (FTCA). A
health center must apply to be deemed annually.

In order for its employees to be deemed, a health center must have
implemented policies and procedures that reduce the risk of malpractice;
and have reviewed and verified the credentials of all licensed and
certified health care practitioners. More specifically, a health center
must have a governing board-approved quality assurance plan with a copy
of the most recent minutes submitted with the deeming application and a
credentialing and privileging policy that meets the requirements of BPHC
PIN 2002-22. All licensed or certified health care practitioners must be
credentialed and privileged before a health center deeming application
can be approved. Finally, the health center must agree to fully
cooperate with the Attorney General in defending any claims and must not
have a history of claims having been files against the U.S. Government.

Health centers must be aware that participation in the FTCA program is
[not guaranteed]{.underline}. New start applicants should include the
costs associated with the purchase of appropriate malpractice insurance
in the proposed budget, and may later request deeming if funded. The
search for malpractice insurance, if necessary, should begin as soon as
possible.

If currently deemed, applicants seeking a new access point grant need
not submit a new FTCA deeming application. If their new access point
application is approved and funded the new access point will be part of
their approved scope of project and covered by their existing deemed
status. If not currently deemed new and existing grantees may submit a
separate deeming application found in PIN 99-08 to:

> HRSA
>
> FTCA Program: Deeming Application
>
> 150 S. Independence Mall West
>
> Suite 1172
>
> Philadelphia, PA 19106-3499

For assistance in completing a deeming application please contact Susan
Lewis, HRSA/BPHC/Division of Clinical Quality at 215-861-4373 or
slewis@hrsa.gov.

For general information on this malpractice program please review PIN
99-08, and contact our toll free hotline 866-FTCA-HELP (866-382-2435).

## X. 340B DRUG PRICING PROGRAM

Organizations that receive grant funds under section 330 of the PHS Act
are eligible to purchase prescription and non-prescription medications
for their clients (outpatients only) at reduced cost through the 340B
Drug Pricing Program. Grantees are not required to operate/own a
pharmacy in order to participate in this program. Given the pharmacist
shortage nationwide, grantees may want to consider contracting with a
local pharmacy. In order to participate in this program, a health center
must submit a Program Registration Form to the Bureau of Primary Health
Care, Division of Health Center Development, Pharmacy Affairs Branch,
along with its Medicaid information.

For general information on the 340B program, please contact the Division
of Health Center Development, Pharmacy Affairs Branch at 800-628-6297 or
visit the website at <http://bphc.hrsa.gov/opa>.

## 

## 

## 

# 

# 

# SECTION II:

# 

# APPLICATION PREPARATION

## I. APPLICATION PREPARATION

The purpose of this application guidance is to provide comprehensive,
supplemental grant application instructions and formats for ALL
applicants seeking support for a new access point(s) under the
Consolidated Health Center Programs in FY 2004. **This application
should be used in conjunction with Application Form PHS‑5161‑1. The
PHS‑5161‑1 includes standard instructions prescribed by the Office of
Management and Budget (OMB), therefore, that information is not repeated
in this document.**

Applicants are encouraged to thoroughly review documents referenced on
page iv of this application guidance prior to finalizing a decision to
apply and/or preparing an application for submission. In developing
applications, applicants are encouraged to work with the appropriate PCA
and/or /PCO (Exhibit 1, page [67](#exhibit-1)) and to use feedback
provided through the LOI process to prepare high quality, competitive
applications. Applicants should provide all required information in the
**sequence** and **format** described in the instructions. Information
and data should be accurate and consistent and directions and written
instructions should be followed carefully and completely. Applications
not meeting application requirements 1) may be considered non-responsive
and discarded without further consideration or 2) may result in lower
score by the IRC.

**Only those materials/documents included with the application submitted
by the announced deadline will be considered**. Supplemental
materials/documents submitted after the application deadline will not be
included for consideration. Applicants that choose to attach letters of
support are reminded to include these documents with their application
package. Letters of support sent directly to DHHS, HRSA, or BPHC
administratrs will not be added to application packets.

## II. STRUCTURE AND CONTENT OF THE APPLICATION

### SEQUENCE OF THE APPLICATION

> Application components should be assembled as follows:

-   PHS 5161-1: Face Sheet (SF 424)

-   Abstract

-   Table of Contents

-   General Information Worksheet (FORM 1-A, page [48](#form-1-part-a))

-   New Access Point Application Checklist (FORM 1-C, page
    [50](#form-1-part-c))

-   Need for Assistance Worksheet (Attachment D, page
    [94](#attachment-d))

-   PHS 5161-1 Requirements:

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-   Non-Construction Assurances (SF 424B)

-   Certifications (Pages 17 - 19)

-   PHS Checklist (Pages 25 - 26)

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-   Budget Presentation:

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-   BPHC Funding Request Summary (FORM 1-B, page [49](#form-1--part-b))

-   PHS 5161-1: Form SF 424A, Sections A‑F

-   Budget Narratives - each for Year 1, Year 2 and Year 3

-   Proposed Staff Profile - each for Year 1, Year 2 and Year 3 (FORM 2,
    page [52](#form-2---proposed-staff-profile))

-   Income Analysis Format -- each for Year 1, Year 2 and Year 3 (FORM
    3, page [53](#form-3---income-analysis-format-year-1-year-2-year-3))

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-   Project Summary (see Section III of this document)

-   Project Description (see Section III of this document)

-   Health Care Plan (see Section IV of this document)

-   Business Plan (see Section IV of this document)

-   Appendices:

> \- Forms 4-8 (Pages
> [55](#form-4---community-characteristics)-[63](#form-8---page-1-of-3))
> All applicants must submit Forms 4-7. Only applicants requesting a
> waiver for governance requirements must submit Form 6-B. Only those
> applicants requesting funding for a CHC, MHC and/or SBHC must submit
> Form 8.
>
> \- All Other Required Attachments (See FORM 1-C, page
> [50](#form-1-part-c))
>
> \- Other Attachments as applicable
>
> Failure to include all of these pieces of the application may result
> in an application being considered as incomplete or non-responsive.
> Applications are limited to no more than 200 pages in total including
> all required and optional documents.

### 

### B. CONTENT OF THE APPLICATION: instructions for preparing each required section of the application 

> **1. PHS 5161-1 Face Sheet (SF 424)**
>
> **2. ABSTRACT:** This document may be transmitted to Congress and
> other agencies within the Department of Health and Human Services
> (HHS), or used in press releases to provide a short description of the
> services provided by this grant application. Applicants should use the
> following format: at the top of the abstract please provide the
> congressional districts within the proposed service area and the types
> of HRSA/BPHC funding requested (e.g., CHC, MHC, HCH, PHPC, and/or
> SBHC). The abstract should not exceed one page in length and include
> the following information:

-   A brief history of the organization, the community to be served and
    the target population.

-   Numbers of providers, FTEs, delivery locations, services, users, and
    total encounters using data included in you application expected at
    full operational capacity (see Exhibit 1, page [67](#exhibit-1)) for
    the proposed new access point project.

-   State initiatives/managed care, CHIP, 1115 Waivers, etc. that impact
    the proposed new access point project.

-   Other relevant information.

> **3. TABLE OF CONTENTS**: To facilitate review, include a table of
> contents or index reflecting the major headings, including
> sub-headings and applicable page numbers.
>
> **4. GENERAL INFORMATION WORKSHEET** - FORM 1-A, page
> [48](#form-1-part-a)
>
> **5. NEW ACCESS POINT APPLICATION CHECKLIST** - FORM 1-c, page
> [50](#form-1-part-c)
>
> **6. NEED FOR ASSISTANCE WORKSHEET** -- ATTACHMENT D, page
> [94](#attachment-d)
>
> **7. PHS 5161-1 REQUIREMENTS**:

-   Non-Construction Assurances (SF 424B)

-   Certifications (Pages 17-19)

-   Checklist (Pages 25-26)

> **8. BUDGET PRESENTATION** - Budget presentations should be included
> for Year 1, Year 2 and Year 3. Project periods for satellite
> applicants will be aligned with the existing project and new starts
> will be awarded up to a 3-year project period. See instructions in
> Section V of this document for further guidance on completing the
> budget presentation.

-   BPHC Funding Request Summary (FORM 1-B, page [49](#form-1--part-b))

-   PHS 5161-1: Form SF 424A, Sections A‑F

-   Budget Narratives for Year 1, Year 2, and Year 3

-   Proposed Staff Profile - one each for Year 1, Year 2, and Year 3
    (FORM 2, page [52](#form-2---proposed-staff-profile))

-   Income Analysis Format -- one each for Year 1, Year 2, and Year 3
    (FORM 3, page
    [53](#form-3---income-analysis-format-year-1-year-2-year-3))

> **9. PROJECT SUMMARY** - see Section III of this document for specific
> guidance.
>
> **10. PROJECT DESCRIPTION** -- see Section III of this document for
> specific guidance.

11. **HEALTH CARE PLAN** - a sample format is provided in Section IV of
    this document. In general, this section should be used to outline
    plans related to identified community health needs/issues as well as
    quality improvement activities within the practice that are
    *specific to the new access point(s) for which Federal funding is
    being requested*. Fiscal, administrative, MIS and leadership
    activities are, in general, described in the Business Plan. However,
    clinically related MIS, administrative or management issues may also
    be described in the Health Care Plan. Health centers that have
    successfully completed a Health Disparities Collaborative or
    implemented any type of quality improvement, should indicate how the
    new access point will be included in accreditation activities and
    the continuation and spread of the disease management and quality
    improvement activities. In addition to major community health
    related issues related to the new access point, applicants are
    expected to address the following in their Health Care Plan, as
    applicable:

-   Major health related goals and objectives for each of the life
    cycles (see Exhibit 3 for definition) to be served by the new access
    point(s).

-   Improving performance, quality, and outcomes, e.g., quality
    improvement plan activities, Clinical Outcome Measures, Healthy
    People 2010 Objectives, Health Disparities Collaboratives, HEDIS
    measures, accreditation standards, Relative Value Units, GAPS and
    Bright Futures.

-   Eliminating Health Disparities as appropriate for the target
    community, e.g., infant mortality, adult and pediatric
    immunizations, diabetes mellitus, cardiovascular disease, HIV
    infection, cancer prevention, asthma, hypertension, obesity.

-   Retention and recruitment of qualified staff.

-   Risk management plan.

-   Unresolved clinical issues identified in a previous Notice of Grant
    Award (NGA), Primary Care Effectiveness Review (PCER), and/or
    pre-application guidance letter, as applicable.

> If special populations (e.g., migrant/seasonal agricultural workers,
> residents of public housing, homeless persons, low-income school
> children, etc.), are included in the target population for the new
> access point(s), the health care plan must describe how the special
> access problems and the unique health care needs of these populations
> are being met.
>
> Satellite applicants must demonstrate the extent to which the
> satellite site will be integrated into the applicant's existing
> clinical, administrative and financial systems already in use in the
> existing program.
>
> **12. BUSINESS PLAN** - a sample format is provided in Section IV of
> this document. All new access point applicants should use this section
> to outline goals and objectives *specific to the new access point for
> which Federal funding is being requested* and consistent with
> applicable program specific guidances and BPHC program expectations.
> The Business Plan should also indicate how the goals and objectives of
> the new access point are tied into the overall operational business
> goals of the organization.
>
> The Business Plan should be formatted in the categories of
> Administrative, Governance, Fiscal, and MIS. Applicants are expected
> to address the following issues, as applicable, in the Business Plan.

-   Financial implications to the organization related to the new access
    point(s)

-   Cost-savings activities such as joint purchasing or network
    development

-   Continuous quality improvement relative to administrative/fiscal
    activities.

-   Plans for attaining and maintaining long-term viability (i.e.,
    future requirements for space, personnel, capital, etc.)

> The Business Plan must also address in narrative form those issues
> that cannot be captured in the table format, such as the following
> items:

-   Audit conditions or exceptions as identified in the most recent
    report.

-   Managed care arrangements and their impact on the organization.

-   Factors that may have affected, or are expected to affect, progress
    for the new access point in either a positive or negative way.

-   Current grantees should also address outstanding business/management
    issues identified in a previous NGA, pre-application guidance
    letter, and/or Primary Care Effectiveness Report (PCER).

> **13. APPENDICES** - required FORMS 4 -- 8 and ATTACHMENTS (see FORM
> 1-C, page [50](#form-1-part-c), for a list of required forms and
> attachments). *Only applicants requesting funding for a CHC, MHC
> and/or SBHC are required to submit Form 8 (page
> [63](#form-8---page-1-of-3)). Only applicants requesting a waiver for
> governance requirements must submit Form 6-B.* All forms and
> attachments are expected to reflect the scope of the application
> submitted as appropriate. Therefore, new start applications should
> include information on the entire scope of the project for which
> funding is being sought and satellite applications should address only
> the service area of the new site(s) (i.e., only the new area proposed
> under the satellite, not the entire service area of the applicant).
> Satellite applicants are expected to demonstrate the extent to which
> the new site(s) will be integrated into the existing clinical,
> administrative and financial systems.

14. **OTHER ATTACHMENTS** -- Applicants may include other attachments
    and documents to the application as applicable to support the
    proposed project plan.

> *Applicants are reminded that applications are limited to no more than
> 200 pages IN TOTAL for all required and optional attachments*.

## III. INSTRUCTIONS REGARDING FORMATTING OF THE APPLICATION

> Applications and the attachments:

-   **MUST NOT** exceed 200 pages including all required and optional
    attachments.

-   **MUST** be typed single-spaced in standard size black type (not to
    exceed 15 characters per inch) on 8½ x 11 paper that can be
    photocopied;

-   **MUST** be serially numbered starting with the SF 424 Face sheet
    (all pages, including any sectional inserts, are to be included in
    the numbering of pages);

-   **MUST** have the applicant's name included on every page;

-   **MUST** use conventional border margins;

-   **MUST** use only one side of each page;

-   **MUST** be secured with rubber bands or binder clips;

-   **MUST NOT** use spiral bound or glued binders;

-   **MUST NOT** have Photocopy Reductions;

-   **MUST NOT** have over-sized documents, posters, videotapes,
    cassette tapes, or other materials which cannot be photocopied;

> Figures, charts, tables, figure legends, and footnotes may be smaller
> in size but must be clear and readily legible. Applicants are
> cautioned against using color prints or graphics. The BPHC must make
> additional copies of an application for review purposes, any color
> print or graphics may not duplicate successfully. Computer-generated
> facsimiles may be substituted for any of the forms provided in this
> packet. Such substitute forms should be printed in black ink, but must
> maintain the exact wording and format of the government-printed forms
> contained in the PHS 5161-1, including all captions and spacing.
> Deviations may be grounds for BPHC to reject the entire application.
>
> **Applicants are reminded that applications MUST NOT exceed 200 pages
> IN TOTAL including all required and optional attachments. Any pages in
> excess of 200 will not be considered as part of the review of the
> application.**

# SECTION III:

# 

# PROJECT DESCRIPTION

# and

# REVIEW CRITERIA

## I. PROJECT SUMMARY (recommend approximately 2-3 pages) (no points awarded)

> The project summary is intended to be a **brief synopsis of the
> community/target population, the applicant organization and the scope
> of the proposed new access point project**. The applicant should
> summarize the need for health services in the community and the
> organization's proposed response to that need. More specifically, the
> following issues should be addressed:
>
> ***ALL APPLICANTS MUST RESPOND TO THE FOLLOWING CRITERIA:***

### Overview of the community/population 

1)  Provide a brief description of the service area (e.g., urban, rural,
    sparsely populated (less than 7 people per square mile)) and
    identify any Medically Underserved Areas (MUAs), Medically
    Underserved Populations (MUPs), High Impact Areas, and Health
    Professional Shortage Areas (HPSAs), if applicable.

2)  Identify the type of community/target population(s) (e.g., low
    income, elderly, farmworker, homeless population, low income school
    children/adolescents and their families, public housing residents,
    etc.).

3)  Indicate how many people will be served once the program is at full
    operational capacity after two years.

4)  Describe the major and unique health care needs of the target
    population.

5)  Describe unique characteristics of the community/target population
    and health indicators (e.g., employment status, ethnicity/culture,
    languages, etc.).

6)  Describe any major issues or barriers to care faced by the target
    population(s).

### B. Overview of the organization 

1)  Provide a brief history of the organization including its mission
    statement, the date the organization was founded, how long the
    organization has been providing primary health care services to the
    target population, its status and history as a designated Federally
    Qualified Health Center or provider of primary care; and the nature
    of the entity or partner that established the organization (e.g.,
    established by a faith-based entity), as applicable.

2)  Describe the organizational structure and the philosophy behind the
    design of the organizational structure (including sponsorship or
    corporate affiliation, if appropriate).

3)  Describe the major linkages with community (public and private)
    organizations (e.g., other health care programs, human service
    agencies, health professional education programs, integrated service
    networks, school systems, housing programs, etc.)

4)  Identify unique characteristics and significant accomplishments of
    the organization including past or current services related to the
    section 330 health center(s) and provision of primary care.

### C. Project Plan

1)  Describe the organization's general approach to meeting
    community/target population health care needs

2)  Describe the proposed service delivery model and the services to be
    provided

3)  Describe the proposed staffing and facility layout and readiness of
    the new access point(s)

## II. PROJECT DESCRIPTION (recommend approximately 25-30 pages)

> The project description should be **a detailed picture of the
> community/target population to be served, the applicant organization
> and its plan for addressing the identified health care needs/issues of
> the community/target population**. \[See Exhibit 3, for a definition
> of target population and service area.\] In general, this section
> includes a description of the health care needs of the
> community/target population, the factors responsible for these needs,
> community resources available to meet community health needs, the
> planning process and community needs assessment that precipitated the
> grant application, how the organization has/will integrate services
> with other efforts in the community, the extent to which the
> applicant's project plan addresses the specific program requirements
> (i.e., compliance), the organization's capacity to address the health
> needs and experience in providing services, and the readiness of the
> applicant organization to initiate the proposed project. The plan
> should include in the Health Care and Business Plan sections, the
> specific, measurable and timeframed outcome objectives to be achieved,
> and describe who will do what, when, where, how, to what extent, and
> to what effect to achieve the outcome objectives.
>
> **The project plan is expected to describe the new access point(s) at
> full operational capacity. For a definition of full operational
> capacity and the appropriate ratios for calculating operational
> capacity, refer to Exhibit 2 of this guidance.**
>
> Throughout this section, reference may be made to exhibits and charts,
> as needed, in order to reflect information about multiple sites and/or
> geographic or demographic data. These exhibits and charts should be a
> part of the required/optional attachments. **The attachments should
> not contain any narrative.**
>
> The following review criteria will be used by the IRC to evaluate (out
> of 100 points) each new access point application. **The project
> description should be organized according to the following headings
> and instructions.**
>
> ***ALL APPLICANTS MUST ADDRESS THE FOLLOWING REVIEW CRITERIA. In
> addition, applicants must address the appropriate health center
> specific review criteria which follows at the end of each section.*
> Failure to address these criteria may result in the application being
> disapproved by the IRC.**

### A. Description of the service area/community and target population (maximum 10 points) (recommend approximately 3-4 pages)

1.  Applicant describes the service area(s)/community(ies) to be served
    by the new access point(s):

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(a) Identify the counties, census tracts, minor civil divisions,
    schools/school districts, etc., (as appropriate) in the service
    area.

(b) Discuss any geographic factors and/or culturally specific
    characteristics that impact access to and the delivery of health
    care services.

(c) Describe any relevant geographic barriers to care and other factors
    impacting access to care.

(d) Describe any significant changes over the past year in the service
    area or population being served (i.e., influx of refugee population,
    or closing of local hospital, etc.)

> 2\. Applicant describes the target population(s) (e.g., general
> community members, migrant/seasonal agricultural workers, residents of
> public housing, homeless persons, low-income school children, etc.)
> within the service area/community:

(a) Identify the unserved and underserved populations in the community.

(b) Describe the unique demographic characteristics of the target
    population (e.g., age, gender, insurance status, unemployment,
    poverty level, ethnicity/culture, education, etc.).

(c) Define any special health care needs of the target population(s).

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(e) Identify any other populations that are in need of access to primary
    health care (e.g., migrant/seasonal farmworkers, homeless
    populations, residents of public housing, low-income school
    children/adolescents and their families).

(f) Describe relevant access to care and health status indicators of the
    target population/community. These should be indicated in the Need
    for Assistance Worksheet and addressed in the Health Care Plan.

(g) Describe the unique characteristics and other factors of the target
    population.

> 3\. Applicant identifies how many people will be served and the number
> of projected encounters that will be generated after the first year of
> operation and at full operational capacity (within two years at the
> proposed funding level) at the proposed new access point(s). This
> information should be consistent with the information presented on
> Form 1-A (page [48](#form-1-part-a)).
>
> 4\. Applicant identifies and describes the most significant barriers
> to care, gaps in services, significant health disparities and the
> major health care problems in the community that will be addressed by
> the new access point. (The Health Care Plan should present goals and
> measurable, time-framed objectives to address these identified needs.)
>
> 5\. Applicant identifies any health care providers of care, resources
> and/or services of other public and private organizations within the
> proposed service area that are providing care to the target
> population(s) including all other federally qualified health centers
> and section 330 grantees.
>
> 6\. Applicant identifies any section 330 funding received, including
> any special initiatives (e.g., integrated service network, dental
> pilot, etc.) and urgent supplemental funds and/or funds received from
> other related Federal programs such as Healthy Start, Housing and
> Urban Development Homeless resources, etc.
>
> ***In addition to the above criteria, applicants requesting funding
> for a new access point(s) for the following types(s) of health center
> must also respond to the following criteria:***

*FOR HCH APPLICANTS:*

> \(a\) In areas where there is one or more existing section 330(h)
> grantee, new start applicants demonstrate collaboration and
> coordination of services with other providers including the existing
> section 330 grantees (e.g., contracts, MOUs, letters of support from
> the current grantee(s), etc.).

### B. Strategic Planning (maximum 10 points) (recommend approximately 2-3 pages)

> 1\. Applicant demonstrates a thorough understanding of the health care
> environment including:

(a) the impact in the State of the implementation of SCHIP, 1115 and
    1915(b) waivers, State Medicaid prospective payment system; Medicaid
    managed care, State laws, current and proposed welfare reform
    initiatives, etc.;

(b) the impact that these changes have had on the access to services or
    demand for services among the target population(s); and

(c) the organization's strategic response to these issues.

> 2\. Applicant demonstrates whether/how the proposed new access point
> is a priority in the State for increasing access to care for the
> underserved. \[Contact the State PCA and/or State PCO for more
> information on the marketplace and unmet needs priorities. (Exhibit 1,
> page [67](#exhibit-1))\]
>
> 3\. Applicant describes the organization's role and relationships
> within the community including:

(a) how the organization fits into the community and its service
    delivery network;

(b) the role of clients, community, staff and Board of Directors in
    establishing and developing the proposed new access point; and

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4.  Applicant demonstrates and provides evidence of the community's
    support for the organization and the proposed new access point
    (e.g., letters of commitment, Memoranda of Understanding, etc.).
    Applicants may include letters of support and MOUs as appropriate,
    and/or may include a list of additional letters of commitment, MOUs,
    etc on file at the health center.

> 5\. Applicant describes the strategic planning process for the
> development of the new access point including any community input and
> Board involvement in the development of the proposed project and any
> collaboration and support from other federally qualified health
> centers in the area.
>
> ***In addition to the above criteria, applicants requesting funding
> for a new access point(s) for the following types(s) of health center
> must also respond to the following criteria:***

*FOR MHC APPLICANTS:*

(a) Applicant demonstrates that there has been an increase in the MSFWs
    in the service area(s) over the past 3 years.

(b) Applicant discusses the agricultural area, the impact of
    agriculture, and relationship between the crops, growing seasons and
    their impact on the influx of MSFWs (e.g., the need for hand labor
    or the number of temporary workers).

(c) Applicant discusses any network of care for migrant health. Discuss
    linkages (e.g., MOAs, MOUs, contracts, etc.) with other migrant
    health organizations such as Migrant Education, Migrant Head Start,
    and Migrant WIC programs. Submit copies of all signed agreements,
    contracts, etc.

*FOR PHPC APPLICANTS:*

(a) Applicant documents a formal relationship with the local Public
    Housing Authority and Public Housing resident groups within the
    community.

### C. Service Delivery Strategy and Model (maximum 20 points) (recommend approximately 4-5 pages)

> 1\. Applicant describes the proposed service delivery model (e.g.,
> freestanding, single or multi-site, migrant voucher, or combination)
> including a discussion of comprehensiveness and continuity of care,
> services provided via contract, the referral system process and access
> problems the model would address and resolve.
>
> 2\. Applicant describes how the proposed model is most appropriate and
> responsive to the identified community health care needs (i.e., the
> applicant provides a service delivery plan of services and staffing
> that addresses the priority health and social problems of the target
> population for all the major life cycles). In particular, the service
> delivery plan should address the special health care needs documented
> in the application, the Health Care Plan and the Need for Assistance
> Worksheet.
>
> 3\. Applicant discusses the extent to which project activities are
> coordinated and integrated with the activities of other federally
> qualified health centers and section 330 grantees, State and local
> health services delivery projects and programs serving the same
> population(s) including any actual or proposed partnerships and
> collaborative activities. Provide copies of all relevant contracts,
> memorandum of understanding, letters of commitment or investment
> (e.g., from the school board, local hospital, public health
> department), etc., as part of the application attachments.
>
> 4\. Applicant discusses the extent to which the proposed service
> delivery model will increase access to primary health care services
> for the medically underserved in the community/target population.
>
> 5\. Applicant discusses the extent to which the proposed service
> delivery model will, and demonstrates a clear plan to, reduce or
> eliminate disparities identified in the population or community to be
> served.
>
> 6\. Applicant describes how the proposed new access point(s) is a
> cost-effective approach to meeting the primary care needs of the
> target population given the health care needs of the target population
> and the level of health care resources currently available in the
> community.
>
> 7\. Applicant demonstrates, in cases where the site(s) are already
> operational, how section 330 funds will augment/supplement existing
> services, resources and providers to expand accessibility and
> availability of primary health care services to underserved
> populations
>
> ***In addition to the above criteria, applicants requesting funding
> for a new access point(s) for the following types(s) of health center
> must also respond to the following criteria:***
>
> *FOR MHC APPLICANTS:*
>
> \(a\) Applicant describes an outreach program that will increase
> access to primary and preventive health care services and how the
> outreach program is integrated into the primary care delivery system.
>
> *FOR SBHC APPLICANTS:*
>
> \(a\) Applicant provides documentation of access to health care during
> the summer.

*FOR PHPC APPLICANTS:*

(a) Applicant documents a formal agreement with the local Public Housing
    Authority that demonstrates the sufficient provision of
    comprehensive services.

*FOR HCH APPLICANTS:*

> \(a\) Applicant describes, for each service offered, the service
> setting (e.g. permanent clinic site, mobile van, shelter site, etc.)

### D. Health Care Services (maximum 15 points) (recommend approximately 5-6 pages)

1.  Applicant demonstrates how the required primary, preventive and
    supplemental health services (e.g., enabling services, eligibility
    assistance, outreach, and transportation) will be available and
    accessible to all lifecycles of the target population either
    directly on-site or through established arrangements.

2.  Applicant demonstrates a clear and defined plan for providing oral
    health care that assures availability and accessibility to the
    target population either directly on-site or through established
    arrangements (contract, referral, etc.).

> 3\. Applicant demonstrates a clear and defined plan for providing
> mental health care and substance abuse services that assures
> availability and accessibility to the target population either
> directly on-site or through established arrangements (contract,
> referral, etc.).
>
> 4\. Applicant demonstrates that the proposed clinical staffing pattern
> (e.g., number and mix of primary care physicians and other providers
> and clinical support staff, language and cultural appropriateness,
> etc.) at the new access point is appropriate for the level and mix of
> services to be provided.
>
> 5\. Applicant demonstrates that the services will be culturally and
> linguistically appropriate.
>
> 6\. Applicant demonstrates through the Health Care Plan that priority
> health care needs of the target population will be addressed and
> health disparities will be reduced.
>
> 7\. Applicant demonstrates a detailed plan for recruiting and
> retaining appropriate health care providers as appropriate for
> achieving the proposed staffing pattern.
>
> 8\. Applicant demonstrates an understanding of the most common causes
> of mortality, and the incidence and prevalence of chronic and
> infectious diseases in the target population, and discusses activities
> to address these issues including participation in or plans for
> participating in a formal disease/care management and system
> improvement program, such as the BPHC-supported or sponsored Health
> Disparities Collaborative.
>
> 9\. Applicant demonstrates their efforts or plans to achieve the goals
> of **Healthy People 2010** as part of their efforts to increase access
> and reduce health disparities. (Information on [Healthy People
> 2010]{.underline} is available at: www.health.gov/healthypeople/.)
>
> 10\. Applicant discusses comprehensiveness, coordination and
> continuity of care, including:

(a) Hours of operation to assure services are available and accessible
    at times required for meeting the needs of the population including
    evenings and weekends as appropriate;

(b) Mechanism to assure professional coverage during the hours when the
    health center is closed;

(c) Case management system that demonstrates care coordination at all
    levels of health care, including arrangements for referrals,
    hospital admissions discharge planning and patient tracking; and

(d) Means to obtain patient feedback including conducting patient
    satisfaction surveys.

> ***In addition to the above criteria, applicants requesting funding
> for a new access point(s) for the following types(s) of health center
> must also respond to the following criteria:***
>
> *FOR MHC APPLICANTS:*
>
> \(a\) Applicant describes how the health care needs associated with
> the environmental hazards to which farmworkers and their families are
> exposed will be met.
>
> \(b\) Applicant describes the setting(s) in which health and enabling
> services will be provided, i.e., are there special arrangements to
> provide services at camps and/or farms; use of mobile teams and or
> vans; extended hours/weekend services, etc.
>
> *FOR SBHC APPLICANTS:*

(a) Applicant provides evidence of on site care through established
    arrangements with the school staff and providers (e.g. school nurse,
    school psychologist, etc.) when applicable.

*FOR HCH APPLICANTS:*

> \(a\) Applicant describes the mechanism for informing homeless people
> of the availability of services and the features of its outreach
> program.

(b) Applicant discusses coordination of services with providers of
    housing, job training, and other essential support for persons who
    are homeless. The applicant must also describe its relationship with
    homeless coalitions, advocacy groups, and "Continuum of Care" in
    their community.

### E. Organizational Capabilities and Expertise (maximum 15 points) (recommend approximately 3-4 pages)

1.  Applicant demonstrates why it is the appropriate entity to establish
    the new access point(s) and why these funds are needed (e.g., staff
    skills, capacity, clinical outcomes, cultural and linguistic
    competence, evaluation capabilities, etc.).

2.  Applicant describes its experience and expertise in working with the
    target population(s), in addressing the identified health care needs
    and in developing and implementing appropriate administrative,
    clinical, and financial management systems.

3.  Applicant demonstrates that its structure, management system and
    lines of authority are appropriate and adequate for the size and
    scope of the proposed project.

4.  Applicant demonstrates that the key management staff of the health
    center is appropriate and that the process for hiring key management
    staff is in accordance with Health Center Program Expectations and
    BPHC guidelines.

5.  Applicant demonstrates financial viability and accounting and
    internal controls in accord with sound financial management
    procedures that are appropriate to the size of the organization,
    funding requirements, and staff skills available.

6.  Applicant demonstrates the ability to monitor the quality and
    outcomes of the services provided (e.g., adequate management
    information systems, established quality assurance program, patient
    feedback, etc.).

7.  Applicant demonstrates the ability to evaluate the quality and
    outcomes of the services provided including an evaluation plan that
    includes specific time framed, measurable outcomes and clear
    methods/action steps.

8.  Applicant demonstrates through the Business Plan that operational
    issues and administrative, financial and clinical systems for the
    establishment of the new access point will be addressed.

9.  Applicant demonstrates the ability or a plan \`to enhance the
    quality of care, increase the efficiency and effectiveness of
    operations, and reduce costs through the use of technological
    improvements such as the use of telehealth, distance learning,
    remote patient monitoring, personal data assistants (PDAs),
    interactive video, satellite broadcasting and store-and-forward
    technology.

> 10\. Applicant demonstrates a performance improvement system that
> includes eliminating disparities in health outcomes, reducing patient
> risk, improving patient satisfaction, credentialing and privileging,
> incident reporting, etc., that integrates planning, management,
> leadership and governance into the evaluation processes of program
> effectiveness.

### F. Budget (maximum 10 points) (recommend approximately 2-3 pages)

1.  Applicant provides an annualized 12-month budget and narrative each
    of support requested (i.e., for year 1, year 2 and year 3). The
    budget should be appropriate and reasonable in terms of:

```{=html}
<!-- -->
```
(a) The level of requested Federal grant funds for year 1, year 2 and
    year 3 versus total budget;

(b) The total resources required to achieve the goals and objectives
    (i.e., to achieve the applicant's proposed service delivery plan) of
    the new access point(s);

(c) The maximization of non-grant revenue relative to the proposed plan
    and leveraging of other resources.

(d) The projected patient income for each year of support requested
    (i.e., year 1, year 2 and year 3) is reasonable based on the patient
    mix and number of projected users and encounters.

(e) The number of proposed users and encounters at full operational
    capacity.

(f) The total cost per user and encounter.

(g) The total grant dollars per user.

(h) One-time minor capital needs.

```{=html}
<!-- -->
```
2.  Applicant describes the extent to which Federal section 330 funds
    will be used to expand services and capacity to provide services. If
    the applicant is purchasing/taking over/assuming a clinic(s)
    operation as part of the proposal, the applicant must demonstrate
    the level of continued commitment and collaboration of the other
    organization to assure the viability of the clinic operation.

3.  Applicant demonstrates that the Federal grant funds requested are
    being used to leverage other sources of funding and that alternative
    sources of revenue (i.e., Medicaid, SCHIP, and other third party
    resources) are being maximized to support the operation of the new
    access point(s).

4.  Applicant demonstrates that the Business Plan goals and objectives
    are targeted to activities related to the new access point and
    demonstrate appropriate financial planning in the development of the
    proposal and for the long-term success of the project.

> ***In addition to the above criteria, applicants requesting funding
> for a new access point(s) for the following types(s) of health center
> must also respond to the following criteria:***
>
> *FOR SBHC APPLICANTS*:

(a) Applicant itemizes the estimated value of in-kind resources
    (including equipment, rent, personnel, renovations and alterations).

*FOR PHPC APPLICANTS:*

> \(a\) Applicant demonstrates no more than 20 percent of the grant
> funds will be used for outreach activities.

### G. Governance (maximum 10 points) (recommend approximately 2-3 pages) (See PIN 98-12 for additional information on Section 330 Governance Requirements.)

> *See PIN 98-12 for additional information on section 330 governance
> requirements. Applicants MUST provide a copy of the signed bylaws
> demonstrating compliance with and reflecting all functions and
> responsibilities cited in section 330.*

1.  Applicant describes the structure of the Board in terms of size,
    expertise, and representativeness of the populations served.

2.  Applicant demonstrates its plan for assuring that the Board
    appropriately represents the community/target population to be
    served by the new access point(s).

3.  Applicant demonstrates that the Governing Board is representative of
    (for new start applicants) or will include (for satellite
    applicants) representation from the proposed service area.

4.  Applicant discusses the mechanism to train the governing board and
    new governing board members in appropriate responsibilities and
    requirements of the Federal grant program.

> ***In addition to the above criteria, applicants requesting funding
> for a new access point(s) for the following types(s) of health center
> must also respond to the following criteria:***
>
> ***FOR CHC, MHC and SBHC APPLICANTS ONLY***:
>
> \(a\) Applicant demonstrates through completion of Form 8, Affiliation
> Checklist (page [63](#form-8---page-1-of-3)), that any potential
> affiliations related to the operation and management of the new access
> point comply with the requirements and guidelines set forth in the
> BPHC Program Expectations and PINs 97-27 and 98-24.
>
> ***FOR HCH, PHPC AND MHC APPLICANTS ONLY**:*

(a) Where applicable, applicant clearly requests a waiver of governance
    requirements. Only PHPC, HCH and MHC applicants that receive or are
    only requesting funding under for one of these types of health
    centers may request a waiver. Applicants that receive/are requesting
    funding for a CHC and/or SBHC are not eligible to request a waiver.
    If a waiver is requested, the applicant has identified which
    requirements are to be waived and has presented alternative
    arrangements proposed in lieu of required elements and must complete
    Form 6-Part B (see page [60](#form-6---part-b)). \[See PIN 98-12,
    "Implementation of Section 330 Governance Requirements" (signed
    April 28, 1998)\].

> ***FOR MIGRANT VOUCHER PROGRAMS**:*
>
> \(a\) Where applicable, migrant voucher programs that are not
> CHC-based, clearly requests a waiver from the governing board
> requirements. Applicant identifies plans to utilize migrant and
> seasonal farmworker representation on advisory councils to meet the
> requirements for consumer input. New start voucher programs that do
> not meet the governance requirements of section 330, must request a
> waiver.

### h. Readiness (maximum 10 points) (recommend approximately 1-2 pages)

1.  Applicant demonstrates that the proposed facility(ies) is the most
    appropriate for serving the target population based on issues of
    transportation, population density, and available providers.

2.  Applicant demonstrates that the new access point facility(ies) is
    appropriate and reasonable in terms of the proposed number of new
    users, the size and number of exam rooms based on the proposed level
    of staffing and scope of services to be provided. Provide floor
    plans.

3.  Applicant demonstrates that the proposed timeline for initiating
    services is reasonable.

4.  Applicant provides evidence that the facility will be available and
    operational within 120-days of a grant award as expected. Provide
    appropriate documentation (e.g., lease agreement, intent to lease,
    renovation plans, etc., as appropriate).

5.  Applicant provides evidence that the appropriate staff and providers
    will be available and operational within 120-days of a grant award
    as expected. Provide appropriate documentation (e.g., provider
    contracts, commitment letters, etc.).

> ***In addition to the above criteria, applicants requesting funding
> for a new access point(s) for the following types(s) of health center
> must also respond to the following criteria:***
>
> *FOR HCH, SBHC, PHPC APPLICANTS*:
>
> \(a\) Applicant includes, where appropriate, an agreement from site
> sponsor to allow applicant organization to provide services at
> specified location.
>
> *FOR SBHC APPLICANTS:*

(a) Applicant provides the plan for compliance to the certification
    and/or licensure processes, if the applicant is in a state with
    certification and/or where licensure is required for SBHCs.

#  

# SECTION IV:

# 

# INSTRUCTIONS FOR DEVELOPING the HEALTH CARE PLAN AND THE BUSINESS PLAN

## I. GUIDELINES FOR DEVELOPING THE HEALTH CARE PLAN AND THE BUSINESS PLAN

The following components are intended for use in both the Health Care
and Business Plans. Presenting the plans in \"landscape\" print format
may facilitate easier reading and usage.

**Problem/Need Statements** are clearly and specifically defined
descriptions of major needs or problems, quantified where possible. The
problem/need statements should tie into and flow from the overall
project description. For example, such statements in the Health Care
Plan may address:

1.  Needs of the overall health system, covering multiple programs and
    populations,

2.  Identification of disparities in health outcomes among populations
    served,

3.  Need for practice performance improvement in a targeted health
    disparity area,

4.  Problems of a specific program, service, or population, and

5.  Specific public health problems (e.g., high infant mortality; **high
    prevalence of HIV disease;** complications from diabetes; high
    prevalence of cocaine addiction).

    Please refer to Section II for information that should be addressed
    in the Business Plan.

**Column 1: Goals and Objectives.** Goals are relatively broad and
express a sense of a desired future state or direction. Goals should
address identified needs or problems and are usually long-term.
Objectives are descriptions of desired, measurable, time‑limited results
or outcomes. These objectives (intended results or outcomes) are
measures of progress towards a goal. They can be used to identify an
acceptable level of performance or establish criteria for evaluation.
Objectives can be either short‑term (less than 1 year) or long‑term (1
year or longer). Use an upper case letter (A\...) for each goal and list
corresponding objectives by number (1\...).

**Column 2: Key Action Steps** - the major activities that must occur to
accomplish an objective - critical actions that must be taken to attain
the measurable outcome or end result. Reference each action step by
corresponding upper case letter for goal, number for objective, and
lower case letter for action step (i.e., A.1.a.).

**Column 3: Expected Outcome** - action steps to be taken towards an
objective; quantifiable documented outcomes to be achieved. This column
must be completed for each objective. Reference each action step in the
same manner as above for Key Action Steps.

**Column 4: Data, Evaluation, & Measurement** - the source of data,
evaluation method and measurement used to evaluate progress towards an
objective or to identify the actual outcome distinguished in the
objective. Reference each action step in the same manner as above for
Key Action Steps.

**Column 5: Person/Area Responsible** -- indicate the person or area of
the operation responsible for the tracking, evaluation and completion of
the objectives and key action steps.

**Column 6: Comments** - supplementary information for related entries
in the plan. Reference each action step in the same manner as above for
Key Action Steps.

######## [Sample Format for the]{.mark} 

######## [Health Care Plan & Business Plan Presentations]{.mark}

This sample format is provided as a broad outline for the Health Care
Plan and Business Plan presentations. Additional information may be
provided to fully describe your proposal:

+-------+--------------+----------+---------------+--------+---------+
| Pr    |              |          |               |        |         |
| oblem |              |          |               |        |         |
| /Need |              |          |               |        |         |
| State |              |          |               |        |         |
| ment: |              |          |               |        |         |
+-------+--------------+----------+---------------+--------+---------+
| G     | Key Action   | Expected | Data,         | Perso  | C       |
| oals/ | Steps        | Outcome  | Evaluation &  | n/Area | omments |
| Objec |              |          | Measurement   | Respo  |         |
| tives |              |          |               | nsible |         |
+-------+--------------+----------+---------------+--------+---------+
| A.    | A.1.(a)      | A.1.(a)  | A.1(a) Data,  | A      | A.1.(a) |
| Goal  | Action step  | Expected | Evaluation &  | .1.(a) | C       |
| (1)   | 1 for        | Outcome  | Measurement   | Perso  | omments |
|       | Objective 1  |          |               | n/Area |         |
| A.1.  |              | A.1.(b)  | A.1(b) Data,  |        | A.1.(b) |
| Obje  | A.1 (b)      | Expected | Evaluation &  | A      | C       |
| ctive | Action step  | Outcome  | Measurement   | .1.(b) | omments |
| (1)   | 2 for        |          |               | Perso  |         |
|       | Objective 1  | A.2.(a)  | A.2.(a) Data, | n/Area | A.2.(a) |
| A.2.  |              | Expected | Evaluation &  |        | C       |
| Obje  | A.2.(a)      | Outcome  | Measurement   | A      | omments |
| ctive | Action step  |          |               | .2.(a) |         |
| (2)   | 1 for        | A.2.(b)  | A.2.(b) Data, | Perso  | A.2.(b) |
|       | Objective 2  | Expected | Evaluation &  | n/Area | C       |
|       |              | Outcome  | Measurement   |        | omments |
|       | A.2 (b)      |          |               | A      |         |
|       | Action step  |          |               | .2.(b) |         |
|       | 2 for        |          |               | Perso  |         |
|       | Objective 2  |          |               | n/Area |         |
+-------+--------------+----------+---------------+--------+---------+
| B.    | B.1.(a)      | B.1.(a)  | B.1.(a) Data, | B      | B.1.(a) |
| Goal  | Action step  | Expected | Evaluation &  | .1.(a) | C       |
| (2)   | 1 for        | Outcome  | Measurement   | Perso  | omments |
|       | Objective 1  |          |               | n/Area |         |
| B.1.  |              | B.1.(b)  | B.1.(b) Data, |        | B.1.(b) |
| Obje  | B.1 (b)      | Expected | Evaluation &  | B      | C       |
| ctive | Action step  | Outcome  | Measurement   | .1.(b) | omments |
| (1)   | 2 for        |          |               | Perso  |         |
|       | Objective 1  | B.2.(a)  | B.2.(a) Data, | n/Area | B.2.(a) |
| B.2.  |              | Expected | Evaluation &  |        | C       |
| Obje  | B.2.(a)      | Outcome  | Measurement   | B      | omments |
| ctive | Action step  |          |               | .2.(a) |         |
| (2)   | 1 for        | B.2.(b)  | B.2.(b) Data, | Perso  | B.2.(b) |
|       | Objective 2  | Expected | Evaluation &  | n/Area | C       |
|       |              | Outcome  | Measurement   |        | omments |
|       | B.2 (b)      |          |               | B      |         |
|       | Action step  |          |               | .2.(b) |         |
|       | 2 for        |          |               | Perso  |         |
|       | Objective 2  |          |               | n/Area |         |
+-------+--------------+----------+---------------+--------+---------+
| C.    | C.1.(a)      | C.1.(a)  | C.1.(a) Data, | C      | C.1.(a) |
| Goal  | Action step  | Expected | Evaluation &  | .1.(a) | C       |
| (3)   | 1 for        | Outcome  | Measurement   | Perso  | omments |
|       | Objective 1  |          |               | n/Area |         |
| C.1.  |              | C.1.(b)  | C.1.(b) Data, |        | C.1.(b) |
| Obje  | C.1 (b)      | Expected | Evaluation &  | C      | C       |
| ctive | Action step  | Outcome  | Measurement   | .1.(b) | omments |
| (1)   | 2 for        |          |               | Perso  |         |
|       | Objective 1  | C.2.(a)  | C.2.(a) Data, | n/Area | C.2.(a) |
| C.2.  |              | Expected | Evaluation &  |        | C       |
| Obje  | C.2.(a)      | Outcome  | Measurement   | C      | omments |
| ctive | Action step  |          |               | .2.(a) |         |
| (2)   | 1 for        | C.2.(b)  | C.2.(b) Data, | Perso  | C.2.(b) |
|       | Objective 2  | Expected | Evaluation &  | n/Area | C       |
|       |              | Outcome  | Measurement   |        | omments |
|       | C.2 (b)      |          |               | C      |         |
|       | Action step  |          |               | .2.(b) |         |
|       | 2 for        |          |               | Perso  |         |
|       | Objective 2  |          |               | n/Area |         |
+-------+--------------+----------+---------------+--------+---------+

# 

# SECTION V:

# 

# GUIDELINES FOR DEVELOPING THE NEW ACCESS POINT APPLICATION BUDGET PRESENTATION

## I. GUIDELINES FOR THE BUDGET PRESENTATION 

This section explains the development and requirements for the
preparation and presentation of a 3-year budget submitted as part of the
application for Federal support of a new access point(s) under the
Consolidated Health Center Program. In order for reviewers to
effectively evaluate the new access point application, an applicant
**must** present three complete 12-month budgets (i.e., one 12-month
budget and narrative each for year 1 and one 12-month budget and
narrative for years 2 and 3).

The BPHC recognizes that budgeted operational costs and income may be
lower in year 1 due to gradual ascent to full capacity; and it is also
anticipated that year 1 may appropriately include some unique one-time
costs such as equipment and alterations/renovations (see Exhibit 2 on
page [83](#exhibit-2), for a definition). It is expected that the year 2
and year 3 budgets, will represent the organization at full operational
capacity (see Exhibit 2, page [83](#exhibit-2), for a complete
definition) and implementation of the project scope.

All budgets should be developed based on the estimated funding required
to accomplish the proposed project. The Form 424A budget forms the basis
for the budget presentation that will enable reviewers to make judgments
as to the appropriateness and reasonableness of the proposed costs as
they relate to the Project Description, Health Care Plan and Business
Plan (see below for specific instructions on completing the SF424A).
**Each budget should be accompanied by a complete and comprehensive
Budget Narrative that provides an explanation for each budget line
item**.

Federal funding levels will be reviewed for consistency and may be
adjusted based on an analysis of performance and actual experience
related to operating costs, utilization, provider staffing and revenue
generation, for the specific service area.

### MAXIMUM REQUEST FOR FEDERAL FUNDING

> For FY 2004, the BPHC has established a **cap of \$650,000 for section
> 330 support** of new access points. The cap is the **maximum amount of
> section 330 funding** that can be requested in a new access point
> grant application in FY 2004 regardless of the number and/or type of
> new access points to be supported through the application and not all
> applicants approved and funded will receive that amount. **The total
> request for section 330 support (inclusive of any request for one-time
> minor capital costs in Year 1) MUST NOT exceed the established cap of
> \$650,000 in Year 1, Year 2 or Year 3. Applications that present a
> request for support in excess of the established cap in Year 1, Year 2
> or Year 3 will be discarded without further consideration**

### B. ONE-TIME MINOR CAPITAL COSTS 

> As part of the year 1 budget, applicants may include one-time minor
> capital costs up to \$150,000, associated with equipment and/or
> capital alteration/renovation. **Federal funding requested for year 1
> (*inclusive* of any request for one-time funds) must be at or below
> the established cap for federal funding of new access points** (i.e.,
> operational request + one-time ≤ Federal cap). No major one-time
> capital costs should be included in the Federal request for the year 2
> or year 3 budget.

### C. REASONABLENESS AND APPROPRIATENESS OF THE BUDGET

> It is expected that the request for Federal support and the budgets
> presented in the application will be reasonable and appropriate based
> on the scope of the services to be provided and the number and type
> (i.e, homeless, migrant, public housing residents, low income children
> and adolescents, etc.) of individuals to be served (see Form 1-A, page
> [48](#form-1-part-a)). The budget should be consistent with the health
> care and business plans presented in the application. The following is
> provided as a guideline in developing the Federal budget request:
> \$150 Federal grant dollars per general community user, \$200 Federal
> grant dollars per migrant/seasonal farmworker user, \$200 Federal
> grant dollars per homeless user; \$200 Federal grant dollars per
> public housing user; and \$200 Federal grant dollars per school-based
> health center user.

## II. COMPLETION OF THE BUDGET FORMS

Application of Federal cost principles relates only to Federal grant
funds as outlined in the Health Centers Consolidation Act of 1996.
Amounts in the budgets may be rounded (i.e., hundreds, thousands).

### A. Form SF 424A, Sections A-F 

> 1\. Budget Summary, SF 424A, Section A
>
> Section A line 1 should reflect the proposed budget for Year 1 of the
> new access point project; Section A line 2 should reflect the proposed
> budget for Year 2; and Section A line 3 should reflect the proposed
> budget for Year 3 of the new access point project.
>
> 2\. Budget Categories, SF 424A, Section B
>
> This section is a summary of all budget calculations and information
> for the new access point project budget. Each line represents a
> distinct category that should be addressed in the budget narrative.
> The columns are designated "grant program, function or activity."
> Column (1) should reflect all of the costs of Year 1 of the new access
> point project. Column (2) should reflect the costs of Year 2 of the
> new access point project. Column (3) should reflect the costs of Year
> 3 of the new access point project. Each column should distribute all
> the costs of the project budget for the defined period, including all
> non-Federal funds (State, local and other operational funding and
> patient service revenue).
>
> The SF 424A, Section B, row 7 should reflect only the projected
> patient service revenue for the service delivery program shown in the
> column above.
>
> **Adequate justification must be presented in narrative form for
> information relative to the total new access point budget, identifying
> individual program costs. Narrative justification items should be
> identifiable in the Business or Health Care Plan, as appropriate. See
> below for further detail.**
>
> 3\. Non-Federal Resources, SF 424A, Section C and Forecasted Cash
> Needs, Section D are non-applicable
>
> 4\. Budget Estimates of Federal Funds Required for the Balance of the
> Project, SF 424A, Section E
>
> This Section has four columns for the future Federal funding estimates
> for future support. **The request for future year support** **must not
> exceed the established Federal cap of \$650,000 in any subsequent year
> of funding**.

### B. BUDGET NARRATIVE

> Expense information must include further detail by object class. The
> budget justifications for the new access point must be provided in
> sufficient detail to support one-step below the object class category
> level, as described below. In addition, if there are budget items for
> which costs are shared with other programs (e.g., HRSA programs or an
> independent home health program administered by the applicant
> organization), the basis for the allocation of costs between
> federally-supported programs and other independent programs must be
> explained.
>
> **Any significant changes in the costs of each object class from year
> 1 to year 2 and year 2 to year 3 should be fully explained and
> justified in the budget narratives for year 1, 2 and 3. The impact on
> the Federal request should be discussed.**

a)  **Personnel:** Reference Form 2 as justification for dollar figures.

b)  **Fringe Benefits:** Itemize the components that comprise the fringe
    benefit rate (e.g., health insurance, FICA, SUTA, life insurance,
    retirement plan). For any increase greater than 5 percent over the
    prior year rate, provide an explanation.

c)  **Equipment:** Only major (with a cost over \$5,000 per unit)
    equipment items need to be itemized. Items costing less than \$5,000
    should be aggregated with a brief explanation. Grant funds are
    limited to no more that \$150,000 for one-time capital costs (e.g.,
    equipment and A&R) in year 1 only.

d)  **Supplies:** Categorize supplies according to type -- medical, lab,
    pharmacy, office, etc. Explain how the amounts were developed (e.g.,
    medical supplies were based on 20,000 encounters at \$2 per
    encounter to arrive at the \$40,000 appearing in the budget).

e)  **Travel:** Itemize travel costs according to traveler type
    (Executive Director, Project Director, Board, provider for
    continuing medical education (CME), etc.) and explain how the
    amounts were developed. It is not necessary to itemize each trip or
    the costs associated with each trip. (Example: CME 12 trips @
    \$1,200 each)

f)  **Contractual:** Categorize substantive programmatic or
    administrative contracts costs according to type (e.g., medical
    referral, lab referral, management consultant) under 2 headings --
    patient care and non-patient care by costs.

g)  **Alteration and Renovation (A&R):** Describe all proposed A&R
    necessary for the new access point project. Grant funds are limited
    to no more that \$150,000 for one-time capital costs (e.g.,
    equipment and A&R) in year 1 only.

h)  **Other:** Itemize all costs in this category and explain in
    sufficient detail. In most cases, consultant costs for technical
    assistance, legal fees, rent, utilities, insurance, dues,
    subscriptions, and audit related costs would fall under this
    category.

i)  **Indirect Costs** (refer to PHS 5161-1, page 31)

### C. Instructions for the Completion of Form 3: Income Analysis Format

> Revenue information should be presented in a format that shows how
> projections for patient service revenue for each year were made by
> breaking out revenue by payment source. **Note that self-payors need
> only be broken out by 100 percent payors, sliding scale, and
> nominal-fee payors.**
>
> If a capitated managed care program is included, the applicant should:
> describe each current capitated managed care arrangement, identifying
> the services for which the applicant is at risk; provide the current
> number of enrollees and support for the projected number of enrollees
> included in the total user count, and separately identify income and
> expenses based on the actual number of enrollees.
>
> **Projecting revenue should involve the following steps and can be
> presented using the sample Income Analysis format.**

########## 1. Special Instructions for Fee for Service

(a) Enter in column a) the number of visits that will be covered by each
    type of payment source -- Medicaid, Medicare, other third-party
    payors and patient self-pay (categorized by 100 percent pay, sliding
    fee pay and zero percent self pay).

(b) Enter in column b) the average charge per visit by payor category.

(c) Enter in column c) the total charges for each payment source. This
    may be obtained by multiplying column a) by column b).

(d) Enter in column d) the average adjustment of the average charge per
    visit. NOTE: Adjustments in this column relate to projected
    disallowance and sliding fee discounts to the average charge per
    visit.

(e) Enter in column e) the total amount billed by payment source. This
    is computed by subtracting from column c), **total charges**, the
    total estimated adjustments \[column a) x column d)\].

(f) Enter in column f) the estimated collection rate (%) by payor
    category.

(g) Enter in column g) the total projected income for the projected
    Budget Period. Multiply column e) by column f).

(h) Column h) represents the Actual Accrued Income for the latest 12-
    month period for which data are available by payor category. The
    applicant should compare figures in columns g) and h) and explain in
    the Budget Presentation any significant increase or decrease in
    income.

########## 2. Special Instructions for Capitation Arrangements

(a) Enter in column a) the projected number of visits for enrollees
    under capitation arrangements for each major contract. Although by
    definition, capitation is not based on visits, an estimated number
    of total visits figure should be reported in this column.

(b) Enter in column e) the total gross capitation amount to be received
    under the capitation arrangement.

(c) Enter in column f) the collection rate excluding anticipated
    contractual withholds, if any.

(d) Enter in column g) the total projected income. This should be equal
    to net receipts \[column e) x col f)\].

(e) Enter in column h) the actual accrued income for the latest 12-
    month period for which data are available by payor category. The
    applicant should compare figures in columns g) and h) and explain in
    the Budget Presentation any significant increases or decreases in
    income.

> **Note: Charge-Based Income includes such revenues as insurance filing
> fees and surplus managed care distributions, and Non-Charge-Based
> Income includes interest receipts, contracts to serve as Medical
> Director of a nursing home, etc.**

##### 3. State, Local and Other Operational Funding 

(a) List by amount, source, and purpose.

(b) Include the source and value of in-kind donations in this
    description, including donated pharmaceuticals, such as samples.

SAMPLE SF424a

OMB Approval No. 0348-0044

+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| D |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| F |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| R |               |      |       |      |       |        |          |
| M |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| n |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| n |               |      |       |      |       |        |          |
| s |               |      |       |      |       |        |          |
| t |               |      |       |      |       |        |          |
| r |               |      |       |      |       |        |          |
| u |               |      |       |      |       |        |          |
| c |               |      |       |      |       |        |          |
| t |               |      |       |      |       |        |          |
| i |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| n |               |      |       |      |       |        |          |
| P |               |      |       |      |       |        |          |
| r |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| g |               |      |       |      |       |        |          |
| r |               |      |       |      |       |        |          |
| a |               |      |       |      |       |        |          |
| m |               |      |       |      |       |        |          |
| s |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| D |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| M |               |      |       |      |       |        |          |
| M |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| R |               |      |       |      |       |        |          |
| Y |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | Grant Program | Cat  | Esti  |      | New   |        |          |
|   |               | alog | mated |      | or    |        |          |
|   | Function or   | of   | U     |      | Re    |        |          |
|   |               |      | nobli |      | vised |        |          |
|   | Activity      | Fed  | gated |      | B     |        |          |
|   |               | Dome | Funds |      | udget |        |          |
|   | \(a\)         | stic |       |      |       |        |          |
|   |               |      |       |      |       |        |          |
|   |               | As   |       |      |       |        |          |
|   |               | sist |       |      |       |        |          |
|   |               | No.  |       |      |       |        |          |
|   |               |      |       |      |       |        |          |
|   |               | \    |       |      |       |        |          |
|   |               | (b\) |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   |               |      | Fe    | Non  | Fe    | Non‑F  | Total    |
|   |               |      | deral | ‑Fed | deral | ederal |          |
|   |               |      |       | eral | *     |        | \(g\)    |
|   |               |      | \(c\) |      | *\*** | \(f\)  |          |
|   |               |      |       | \    |       |        |          |
|   |               |      |       | (d\) | \(e\) |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 1 | **New Access  |      | \$0   | \$0  | >     | >      | > \$8    |
| \ | Point Year    |      |       |      |  \$55 |  \$7,4 | ,023,934 |
| . | 1**           |      |       |      | 0,000 | 73,934 |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 2 | **New Access  |      | \$0   | \$0  | >     | >      | > \$9    |
| \ | Point Year    |      |       |      |  \$43 |  \$9,0 | ,510,741 |
| . | 2**           |      |       |      | 9,699 | 71,042 |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 3 | **New Access  |      | \$0   | \$0  | >     | >      | > \$10   |
| \ | Point Year    |      |       |      |  \$47 |  \$9,5 | ,263,196 |
| . | 3**           |      |       |      | 5,690 | 82,506 |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 4 |               |      | \$0   | \$0  | > \$0 | > \$0  | > \$0    |
| \ |               |      |       |      |       |        |          |
| . |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 5 | TOTALS        |      |       |      |       |        |          |
| \ |               |      |       |      |       |        |          |
| . |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
|   |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| D |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| R |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 6 | Object Class  | **G  |       |      |       |        | Total    |
| \ | Category      | rant |       |      |       |        |          |
| . |               | Pro  |       |      |       |        | \(5\)    |
|   |               | gram |       |      |       |        |          |
|   |               | Func |       |      |       |        |          |
|   |               | tion |       |      |       |        |          |
|   |               | or   |       |      |       |        |          |
|   |               | Ac   |       |      |       |        |          |
|   |               | tivi |       |      |       |        |          |
|   |               | ty** |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   |               | \    | \(2\) | \    | \(4\) |        |          |
|   |               | (1\) | *     | (3\) |       |        |          |
|   |               | **   | *Year | **   |       |        |          |
|   |               | Year | 2**   | Year |       |        |          |
|   |               | 1**  |       | 3**  |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | a\. Personnel | >    | > \   | >    |       |        |          |
|   |               |  \$4 | $5,42 |  \$5 |       |        |          |
|   |               | ,587 | 2,816 | ,500 |       |        |          |
|   |               | ,223 |       | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | b\. Fringe    | > \  | > \   | >    |       |        |          |
|   | Benefits      | $951 | $1,12 |  \$1 |       |        |          |
|   |               | ,849 | 5,234 | ,130 |       |        |          |
|   |               |      |       | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | c\. Travel    | >    | > \$3 | >    |       |        |          |
|   |               | \$25 | 5,010 | \$40 |       |        |          |
|   |               | ,432 |       | ,690 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | d\. Equipment | > \  | > \$0 | >    |       |        |          |
|   |               | $118 |       |  \$0 |       |        |          |
|   |               | ,000 |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | e\. Supplies  | >    | > \   | >    |       |        |          |
|   |               |  \$1 | $1,95 |  \$2 |       |        |          |
|   |               | ,452 | 2,300 | ,330 |       |        |          |
|   |               | ,940 |       | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | f\.           | > \  | >     | > \  |       |        |          |
|   | Contractual   | $326 |  \$39 | $425 |       |        |          |
|   |               | ,020 | 5,100 | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | g\.           | >    | > \$0 | >    |       |        |          |
|   | Construction  | \$32 |       |  \$0 |       |        |          |
|   | --            | ,000 |       |      |       |        |          |
|   | Alterati      |      |       |      |       |        |          |
|   | on/Renovation |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | h\. Other     | > \  | >     | > \  |       |        |          |
|   |               | $530 |  \$58 | $632 |       |        |          |
|   |               | ,470 | 0,281 | ,506 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | i\. Total     | >    | > \   | >    |       |        |          |
|   | Direct        |  \$8 | $9,51 | \$10 |       |        |          |
|   | Charges (sum  | ,023 | 0,741 | ,058 |       |        |          |
|   | of 6a‑6h)     | ,934 |       | ,196 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | j\. Indirect  | >    | > \$0 | >    |       |        |          |
|   | Charges       |  \$0 |       |  \$0 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | k\. TOTALS    | >    | > \   | >    |       |        |          |
|   | (sum of 6i    |  \$8 | $9,51 | \$10 |       |        |          |
|   | and 6j)       | ,023 | 0,741 | ,058 |       |        |          |
|   |               | ,934 |       | ,196 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 7 | Program       | >    | > \   | >    |       |        |          |
| \ | Income        |  \$5 | $6,95 |  \$7 |       |        |          |
| . |               | ,770 | 6,304 | ,537 |       |        |          |
|   |               | ,180 |       | ,506 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+

Standard Form 424A (7-97)

\* Applicants are limited to the level of Federal funds identified in
Program Guidance. Prescribed by OMB Circular A-102

######## Sample Budget Narrative

This sample budget narrative is provided as a broad outline. Providing
additional information and detail is recommended to fully describe your
proposal. **Any significant changes in the costs of each object class
from year 1 to year 2 and year 2 to year 3 should be fully explained and
justified in the budget narratives for years 1, 2, and 3. The impact on
the Federal request should be discussed.**

**REVENUE:** (From FORM 3 -- Income Analysis) [Year 1]{.underline} [Year
2]{.underline} [Year 3]{.underline}

**PATIENT SERVICE INCOME** \$5,770,180 \$6,956,042 \$7,537,506

(including Pharmacy)

**LOCAL & STATE GRANTS** \$1,253,500 \$1,565,000 \$1,700,000

(Break out by fund source)

**LOCAL FUNDING** \$450,254 \$550,000 \$550,000

**FEDERAL BPHC 330 GRANT** \$550,000 \$439,699 \$475,690

**OTHER FEDERAL FUNDING** \$0

(Break out by fund source)

**TOTAL: REVENUE \$8,023,934 \$9,510,741 \$10,263,196**

**EXPENSES:** [Year 1]{.underline} [Year 2]{.underline} [Year
3]{.underline}

**PERSONNEL**: See Personnel by Position

and BPHC Program \$4,587,223 \$5,422,816 \$5,500,000

**FRINGE BENEFITS**: Break out each

portion of Fringe Benefits: \$951,849 \$1,125,234 \$1,130,000

FICA

Retirement, etc.

**TOTAL: PERSONNEL & FRINGE \$5,539,072 \$6,548,050 \$6,730,000**

**TRAVEL:**

Providers CME (\$ per full-time equivalent (FTE)) \$ \$ \$

Nursing CME (\$ per FTE) \$ \$ \$

Other Professional CME (\$ per FTE) \$ \$ \$

Travel to meetings (\$ per attendees x \# of trips) \$ \$ \$

Executive Director (2 meetings)

Board Chair (2 meetings)

Management & Board \$ \$ \$

State and National Meetings \$ \$ \$

Other Board/Management Travel \$ \$ \$

Local Travel (# of trips @ organization's mileage rate) \$ \$ \$

> **TOTAL: TRAVEL \$ 25,432 \$ 35,010 \$ 45,690**

**EQUIPMENT:**

See attached Equipment Listing

**TOTAL: EQUIPMENT \$118,000 \$ 0 \$ 0**

**SUPPLIES:**

Office & Printing Supplies \$X.XX per encounter \$ \$ \$

Medical & Dental Records \$X.XX per encounter \$ \$ \$

Medical Supplies \$X.XX per encounter \$ \$ \$

Pharmacy Supplies including Drugs

Average per \# of Prescriptions \$ \$ \$

X-ray supplies Average per \# of X-rays \$ \$ \$

Laboratory supplies per average \# of procedures \$ \$ \$

Building and Maintenance Supplies per \# of sites \$ \$ \$

**TOTAL: SUPPLIES \$1,452,940 \$1,952,300 \$2,430,000**

**Expenses Continued:** [Year 1]{.underline} [Year 2]{.underline} [Year
3]{.underline}

**CONTRACTUAL** (Please describe with enough detail to justify the
costs)

"Patient Care Contracts"

Outside Reference Lab \$ \$ \$

XYZ Company for any tests that cannot be

Performed in house (Avg \# of procedures

X Avg Cost) \$ \$ \$

Outside Contract Pharmacies (describe)

(Avg \# of prescriptions X Avg Cost) \$ \$ \$ GYN/OB Contract with ABC
Company

(Avg \# of Patients served X Avg Cost) \$ \$ \$

Ophthalmologist with RST Company

(Avg \# of patients @ Avg Cost) \$ \$ \$

Temporary Nursing Coverage

(Avg \# of days @ Avg Costs) \$ \$ \$

**Subtotal: Patient Care Contracts \$ \$ \$**

"Non-Patient Contracts"

Housekeeping Services with LMN Company

for \# of sites \$ \$ \$

Security Services with DEF Company for

\# of hours per site \$ \$ \$

Computer Maintenance Contract \$ \$ \$

**Subtotal: Non-Patient Contracts \$ \$ \$**

**TOTAL: CONTRACTUAL \$386,020 \$395,100 \$425,000**

**ALTERATION & RENOVATIONS**: (describe if applicable)

Alteration and renovation of unused building space for use as dental
operatories

**TOTAL: A&R** \$ **32,000** **\$0 \$0**

**OTHER**:

Payroll Processing Services \$ \$ \$

Audit Services with JKL Company \$ \$ \$

Legal Fees with WXY Company fee per hour \$ \$ \$

Association Dues \$ \$ \$

Building Contents Insurance \$ \$ \$

Telephone Service \$ \$ \$

Answering Services \$ \$ \$

Postage \$ \$ \$

Utilities \$ \$ \$

Rent (describe per site) \$ \$ \$

Marketing/Outreach \$ \$ \$

Any special taxes (describe) \$ \$ \$

Technical Assistance \$ \$ \$

**TOTAL: OTHER \$530,470 \$580,281 \$632,506**

**TOTAL: ALL BUDGET \$8,023,934 \$ 9,510,741 \$10,263,196**

**EQUIPMENT:** [Year 1]{.underline} [Year 2]{.underline} [Year
3]{.underline}

#### 

4 exam tables (4 @ \$3,000) \$ 12,000 \$0 \$0

1 Medical X-Ray (1 @ \$17,800) \$ 17,800 \$0 \$0

4 Dental Units (4 @ \$ 4,500) \$ 18,000 \$0 \$0

4 Dental Chairs (4 @ \$4,000) \$ 16,000 \$0 \$0

1 Dental X-Ray (1 @ \$10,200) \$ 10,200 \$0 \$0

8 Stools (8 @ \$250) \$ 2,000 \$0 \$0

20 Handpieces (20 @ \$600) \$ 12,000 \$0 \$0

1 Developing Unit (1 @ \$2,000) \$ 2,000 \$0 \$0

8 PCs and related software (8 @ 3,500) \$ 28,000 \$0 \$0

### 

**TOTAL ALL EQUIPMENT \$ 118,000 \$0 \$0**

# 

# SECTION VI:

# 

# FORMS 

## I. DESCRIPTIONS of THE FORMS

> The forms are sample formats for supplying application requirements in
> a concise and consistent fashion. Shaded areas of Forms (rows and/or
> columns) should not be completed. Computer-generated facsimiles may be
> substituted for any of the forms provided in this packet. Such
> substitute forms should be printed in black ink, but they must
> maintain the exact wording and format of the government-printed forms,
> including all captions and spacing.
>
> **ALL NEW START AND SATELLITE NEW ACCESS POINT APPLICANTS SHOULD
> SUBMIT COMPLETE INFORMATION IN THE FORMAT PROVIDED FOR EACH FORM.**
>
> **New Start applicants should complete the forms based on the entire
> scope of the project (i.e., total for all sites). Satellite applicants
> should complete the form based on ONLY the new access point being
> proposed.**
>
> **FORM 1, Part A -- General Information Worksheet:** Provides summary
> information. This form should present information that is consistent
> with the budget, user and encounter projections presented in the
> project description, Health Care and Business Plans and any other
> FORMS.
>
> **FORM 1, Part B -- BPHC-Funding Request Summary:** To facilitate
> identification of the amount of Federal funding being requested, each
> applicant must complete the BPHC Funding Request Summary.
>
> **FORM 1, Part C -- Application Checklist:** All applicants must
> submit as part of a complete application, the documents noted on the
> checklist. Other documents identified on the checklist must be
> available onsite if necessary.
>
> **FORM 2 -- Proposed Staff Profile:** Identifies the total personnel
> and number of FTEs to staff the new access point and number to be
> supported by the new access point funds. New Start applicants should
> include staff for the entire scope of the project (i.e., total for all
> sites). Satellite applicants should include a staffing profile for
> ONLY the new access point being proposed.
>
> **FORM 3 -- Income Analysis Format:** Presents revenue information
> showing how projections for patient service revenue for each year were
> made by breaking out revenue by payment source.
>
> **FORM 4 -- Community and User Characteristics:** Reports
> community-wide and target population data for the most recent period
> for which data are available. Estimates are acceptable.
>
> **FORM 5, Part A -- Services Provided**: Applicants should identify
> what services will be available at the new access site(s) and how
> these services will be provided.
>
> **FORM 5, Part B -- Service Sites:** New start applicants should
> include all sites to be included under the Scope of the Project.
> Satellite applicants should include all current sites listed on the
> most recent Exhibit B "Service Sites" (from the most recently
> submitted continuation application or approved Change in Scope
> Request) and clearly identify the new proposed site.
>
> **FORM 6, Board Member Characteristics**: Applicants should list all
> current board members and provide relevant characteristics. Satellite
> applicants should note any new board members being added as a result
> of the new access point.
>
> FORM 6, Part B -- Request for Waiver of Governance Requirements (if
> applicable):
>
> Health centers are eligible for a governance waiver ONLY IF they
> receive/are requesting only HCH, PHPC, or MHC funding. Requests for
> waivers will not be granted to applicants that are also approved and
> funded for CHC or SBHC funding. If a waiver is requested, applicant
> should clearly identify which requirements are to be waived, and
> present alternative arrangements in lieu of the required elements.
> (See PIN 98-12 for additional information.)
>
> FORM 7, Compliance Checklist: This form provides a checklist for
> assuring compliance with all section 330 requirements.
>
> FORM 8, Affiliation Checklist (CHC, MHC and SBHC applicants ONLY): In
> accordance with PIN 98-24, submission of Form 8 is required with all
> CHC, MHC and SBHC applications. The completed exhibit will provide the
> BPHC information regarding any proposed affiliation arrangements. This
> information will be used to assure that organizations receiving BPHC
> funds comply with the requirements and guidelines set forth in the
> BPHC Program Expectations for Health Centers and PINs 97-27 and 98-24.
> Grantees that have received a letter from the BPHC approving an
> affiliation agreement, since the issuance of PIN 98-24, should submit
> the approval letter with the completed Exhibit G (from the most
> recently submitted continuation application or approved Change in
> Scope Request). If a new affiliation is being proposed as a result of
> the new access point proposal, the applicant must submit all pertinent
> documents as part of the application.

######## FORM 1 -- PART A

######## GENERAL INFORMATION WORKSHEET - FISCAL YEAR 2004

Applicant Name: Name of Contact Person:

Mailing/Street Address: Title:

City, State, Zip:

Phone: Fax: Email:

Proposed Service Area (City, County, State -- Relevant Zip Codes) :

**Please Check ONE on each line:**

1.) PRIVATE NONPROFIT PUBLIC ENTITY

2.) NEW START SATELLITE (UDS #: [)]{.underline}

3.) MEDICALLY UNDERSERVED AREA MEDICALLY UNDERSERVED POPULATION N/A

4.) URBAN RURAL SPARSELY POPULATED/FRONTIER (persons/ mile^2^:
[)]{.underline}

**Please check all that apply:**

**Tribal Entity Public Health Department Hospital Faith-based
Organization University Local Government**

  ---------- ------------------- --------------------- --------------------
             **TOTAL Federal     **TOTAL ONE-TIME**    **TOTAL PROJECT
             Funding Requested**                       BUDGET**

  **Year 1**                                           

  **Year 2**                     []{.mark}             []{.mark}

  **Year 3**                     []{.mark}             []{.mark}
  ---------- ------------------- --------------------- --------------------

**[GENERAL INFORMATION]{.underline}: New start applicants** proposing
one or more delivery sites should report combined data for all of the
sites to be included under the scope of project. **Satellite
applicants** should provide data for the proposed NEW DELIVERY SITE(S)
ONLY. If a site(s) is already operational, please report the current
number of users/encounters with the projected number of users and
encounters after 2 years of operation. If the site(s) is not
operational, report current number as "0". **Data reported should be
unduplicated for users and encounters.**

Total New Access Point Service Area Population: Total New Access Point
Target Population:

Total Number at Full Operational Capacity after 2 years: ENCOUNTERS:
USERS:

  ------------------------------------ ---------------- ------------------
  UNDUPLICATED COUNTS                  CURRENT NUMBER   Projected at FULL
                                                        CAPACITY

  Medical Users                                         

  Medical Encounters                                    

  Dental Users                                          

  Dental Encounters                                     

  Mental Health Users                                   

  Mental Health Encounters                              

  Substance Abuse Service Users                         

  Substance Abuse Service Encounters                    
  ------------------------------------ ---------------- ------------------

  ---------------------------------------- ------------ -----------------
                                           CURRENT      Projected at FULL
                                           NUMBER       CAPACITY

  TOTAL FTE Medical Providers (Physicians,              
  Nurse Practitioners, Physicians                       
  Assistants, etc.)                                     

  TOTAL FTE Dental Providers (Dentists and              
  hygienists)                                           

  TOTAL FTE Mental Health Providers                     
  (Psychiatrists, psychologists, MSWs,                  
  etc.)                                                 

  TOTAL FTE Substance Abuse Service                     
  Providers                                             
  ---------------------------------------- ------------ -----------------

######## 

######## FORM 1- Part B

######## BPHC FUNDING REQUEST SUMMARY

######## 

<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 11%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"></td>
<td colspan="10"><p><strong>FEDERAL FUNDS REQUESTED</strong></p>
<p><strong>BASED ON A 12-MONTH BUDGET FOR YEAR 1, YEAR 2 OR YEAR
3</strong></p></td>
</tr>
<tr class="even">
<td rowspan="3"><strong>REQUESTED BPHC FUNDING:</strong></td>
<td rowspan="3"><strong>TYPE OF HEALTH CENTER</strong></td>
<td colspan="6"><strong>NEW START</strong></td>
<td colspan="4"><strong>SATELLITE</strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Year 1</strong></td>
<td colspan="2"><strong>Year 2</strong></td>
<td><strong>Year 3</strong></td>
<td colspan="2"><strong>Year 1</strong></td>
<td><strong>Year 2</strong></td>
<td><strong>Year 3</strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Operational</strong></td>
<td><strong>One-time (up to $150,000)</strong></td>
<td colspan="2"><strong>Operational</strong></td>
<td><strong>Operational</strong></td>
<td><strong>Operational</strong></td>
<td><strong>One-time (up to $150,000)</strong></td>
<td><strong>Operational</strong></td>
<td><strong>Operational</strong></td>
</tr>
<tr class="odd">
<td><strong>Community Health Center</strong></td>
<td><strong>CHC – 330(e)</strong></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Migrant Health Center</strong></td>
<td><strong>MHC – 330(g)</strong></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Health Care for the Homeless</strong></td>
<td><strong>HCH – 330(h)</strong></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>School Based Health Centers</strong></td>
<td><strong>SBHC – 330(e)</strong></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Public Housing Primary Care</strong></td>
<td><strong>PHPC – 330(i)</strong></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><strong>TOTAL FEDERAL FUNDING REQUEST</strong></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>ESTIMATED FUNDING for New Start or Satellite
Activity</strong></td>
<td colspan="4" rowspan="9"><blockquote>
<p><strong>NOTE: New access point applicants may request funding for one
or more types of health centers authorized under section 330. Funding
listed above will constitute a request for funding for the specified
types of health centers.</strong></p>
<p><strong>NOTE: The Federal support requested in Year 1, 2, 3 MAY NOT
exceed the published cap of $650,000 established for new access
point.</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td><strong>FUNDING PROGRAM:</strong></td>
<td colspan="2"><p><strong>YEAR 1</strong></p>
<p><strong>TOTAL BUDGET</strong></p></td>
<td colspan="3"><p><strong>YEAR 2</strong></p>
<p><strong>TOTAL BUDGET</strong></p></td>
<td colspan="2"><p><strong>YEAR 3</strong></p>
<p><strong>TOTAL BUDGET</strong></p></td>
</tr>
<tr class="odd">
<td><strong>A. Federal</strong></td>
<td colspan="2"><strong>$</strong></td>
<td colspan="3"><strong>$</strong></td>
<td colspan="2"><strong>$</strong></td>
</tr>
<tr class="even">
<td><strong>B. Applicant</strong></td>
<td colspan="2"><strong>$</strong></td>
<td colspan="3"><strong>$</strong></td>
<td colspan="2"><strong>$</strong></td>
</tr>
<tr class="odd">
<td><strong>C. State</strong></td>
<td colspan="2"><strong>$</strong></td>
<td colspan="3"><strong>$</strong></td>
<td colspan="2"><strong>$</strong></td>
</tr>
<tr class="even">
<td><strong>D. Local</strong></td>
<td colspan="2"><strong>$</strong></td>
<td colspan="3"><strong>$</strong></td>
<td colspan="2"><strong>$</strong></td>
</tr>
<tr class="odd">
<td><strong>E. Other</strong></td>
<td colspan="2"><strong>$</strong></td>
<td colspan="3"><strong>$</strong></td>
<td colspan="2"><strong>$</strong></td>
</tr>
<tr class="even">
<td><strong>F. Program Income</strong></td>
<td colspan="2"><strong>$</strong></td>
<td colspan="3"><strong>$</strong></td>
<td colspan="2"><strong>$</strong></td>
</tr>
<tr class="odd">
<td><strong>G. Total</strong></td>
<td colspan="2"><strong>$</strong></td>
<td colspan="3"><strong>$</strong></td>
<td colspan="2"><strong>$</strong></td>
</tr>
</tbody>
</table>

######## FORM 1 -- Part C

######## NEW ACCESS POINT APPLICATION CHECKLIST

######## 

######## 

+-----------------------------------------------------+-----------------+
| **DOCUMENTS TO BE INCLUDED**                        |                 |
|                                                     |                 |
| **WITH APPLICATION \*\***                           |                 |
+-----------------------------------------------------+-----------------+
| **ALL DOCUMENTS LISTED BELOW MUST BE INCLUDED WITH  | **APPLICATION   |
| APPLICATION UNLESS SPECIFICALLY NOTED**             | PAGE \# (s)**   |
+-----------------------------------------------------+-----------------+
| **GENERAL INFORMATION**                             |                 |
+-----------------------------------------------------+-----------------+
| PHS 5161-1 - Face Sheet (SF 424 -- Application for  |                 |
| Federal Assistance)                                 |                 |
+-----------------------------------------------------+-----------------+
| Abstract                                            |                 |
+-----------------------------------------------------+-----------------+
| Table of Contents                                   |                 |
+-----------------------------------------------------+-----------------+
| Form 1, Part A: General Information Worksheet       |                 |
+-----------------------------------------------------+-----------------+
| Form 1, Part C: New Access Point Application        |                 |
| Checklist                                           |                 |
+-----------------------------------------------------+-----------------+
| Need For Assistance Worksheet (Attachment D, page   |                 |
| [94](#attachment-d))                                |                 |
+-----------------------------------------------------+-----------------+
| PHS 5161-1 - Standard Assurances (SF 424B --        |                 |
| Non-Construction Programs)                          |                 |
+-----------------------------------------------------+-----------------+
| PHS 5161-1 - Certifications (Pages 17-19)           |                 |
+-----------------------------------------------------+-----------------+
| PHS 5161-1 - Checklist (Pages 25 - 26)              |                 |
+-----------------------------------------------------+-----------------+
| **BUDGET INFORMATION**                              |                 |
+-----------------------------------------------------+-----------------+
| Form 1, Part B: BPHC Funding Request Summary        |                 |
+-----------------------------------------------------+-----------------+
| PHS 5161-1 - Form SF 424A, Sections A‑F (2 pages)   |                 |
+-----------------------------------------------------+-----------------+
| 12-month Budget for Year 1, Year 2 and Year 3       |                 |
+-----------------------------------------------------+-----------------+
| Budget Narrative for Year 1, Year 2 and Year 3      |                 |
+-----------------------------------------------------+-----------------+
| Form 2: Proposed Staff Profile (one each for Year   |                 |
| 1, Year 2 and Year 3)                               |                 |
+-----------------------------------------------------+-----------------+
| Form 3: Income Analysis Format (one each for Year   |                 |
| 1, Year 2 and Year 3)                               |                 |
+-----------------------------------------------------+-----------------+
| **BODY OF APPLICATION**                             |                 |
+-----------------------------------------------------+-----------------+
| Project Summary                                     |                 |
+-----------------------------------------------------+-----------------+
| Project Description                                 |                 |
+-----------------------------------------------------+-----------------+
| Health Care Plan                                    |                 |
+-----------------------------------------------------+-----------------+
| Business Plan                                       |                 |
+-----------------------------------------------------+-----------------+
| **REQUIRED ATTACHMENTS**                            |                 |
+-----------------------------------------------------+-----------------+
| Form 4: Community Characteristics                   |                 |
+-----------------------------------------------------+-----------------+
| Form 5, Part A: Services Provided                   |                 |
+-----------------------------------------------------+-----------------+
| Form 5, Part B: Service Sites                       |                 |
+-----------------------------------------------------+-----------------+
| Form 6, Part A: Current Board Member                |                 |
| Characteristics                                     |                 |
+-----------------------------------------------------+-----------------+
| Form 6, Part B: Request For Waiver Of Governance    |                 |
| Requirements *(only those applicants requesting a   |                 |
| governance waiver)*                                 |                 |
+-----------------------------------------------------+-----------------+
| Form 7: Compliance Checklist                        |                 |
+-----------------------------------------------------+-----------------+
| Form 8: Affiliation Checklist *(CHC, MHC and SBHC   |                 |
| applicants only)*                                   |                 |
+-----------------------------------------------------+-----------------+
| Map of service area identifying new access          |                 |
| point(s), MUAs/MUPs, and other primary care         |                 |
| providers                                           |                 |
+-----------------------------------------------------+-----------------+
| Organization Chart                                  |                 |
+-----------------------------------------------------+-----------------+
| Corporate Bylaws                                    |                 |
+-----------------------------------------------------+-----------------+
| Articles of Incorporation                           |                 |
+-----------------------------------------------------+-----------------+
| Job or Position Description for Key Personnel       |                 |
+-----------------------------------------------------+-----------------+
| Resumes for Key Personnel                           |                 |
+-----------------------------------------------------+-----------------+
| Co-Applicant Agreement (if applicable)              |                 |
+-----------------------------------------------------+-----------------+
| Other contracts, agreements, etc. as applicable or  |                 |
| required                                            |                 |
+-----------------------------------------------------+-----------------+
| Signed Lease/Intent to Lease/Rent Agreement/etc.    |                 |
| (if applicable)                                     |                 |
+-----------------------------------------------------+-----------------+
| Most recent independent financial audit including   |                 |
| all management letters                              |                 |
+-----------------------------------------------------+-----------------+
| Letters of Support                                  |                 |
+-----------------------------------------------------+-----------------+

+-----------------------------------------------------------------------+
| **DOCUMENTS**                                                         |
|                                                                       |
| **AVAILABLE ON SITE**                                                 |
+-----------------------------------------------------------------------+
| MANAGEMENT AND FINANCE                                                |
+-----------------------------------------------------------------------+
| Personnel Policies and Procedures                                     |
+-----------------------------------------------------------------------+
| Data Collection and Information Systems                               |
+-----------------------------------------------------------------------+
| Schedule of discounts (Sliding Fee Schedule) (If Applicable)          |
+-----------------------------------------------------------------------+
| Agreements with Medicaid and Medicare                                 |
+-----------------------------------------------------------------------+
| Billing and Collection Policies and Procedures                        |
+-----------------------------------------------------------------------+
| Procurement Policies and Procedures                                   |
+-----------------------------------------------------------------------+
| Travel Policies                                                       |
+-----------------------------------------------------------------------+
| Fee Schedule                                                          |
+-----------------------------------------------------------------------+
| Accounting Policies and Procedures Manual                             |
+-----------------------------------------------------------------------+
| Documentation of FQHC rates                                           |
+-----------------------------------------------------------------------+
| Contracts with Agencies, Vendors, etc.                                |
+-----------------------------------------------------------------------+
| CLINICAL PROGRAM                                                      |
+-----------------------------------------------------------------------+
| Patient Confidentiality Policy and Procedures                         |
+-----------------------------------------------------------------------+
| Principles of Practice (As applicable)                                |
+-----------------------------------------------------------------------+
| List of Non-Physician Supervision Protocols                           |
+-----------------------------------------------------------------------+
| Health Maintenance Protocols by Age Group                             |
+-----------------------------------------------------------------------+
| Other Clinical Protocols (Provide List)                               |
+-----------------------------------------------------------------------+
| Continuing Professional Education Policies                            |
+-----------------------------------------------------------------------+
| Patient Flow                                                          |
+-----------------------------------------------------------------------+
| Sample Medical Record                                                 |
+-----------------------------------------------------------------------+
| Clinical Information and Tracking Systems                             |
+-----------------------------------------------------------------------+
| Patient Grievance Policy and Procedure                                |
+-----------------------------------------------------------------------+
| Quality Management and/or Assurance Plan                              |
+-----------------------------------------------------------------------+
| Malpractice Coverage and/or FTCA Deeming/Malpractice Coverage         |
+-----------------------------------------------------------------------+
| OSHA Documents                                                        |
+-----------------------------------------------------------------------+
| CLIA Documents                                                        |
+-----------------------------------------------------------------------+
| Credentialing Policy and Procedures                                   |
+-----------------------------------------------------------------------+
| OTHER DOCUMENTS                                                       |
+-----------------------------------------------------------------------+
| Current or requested MUA or MUP designation                           |
+-----------------------------------------------------------------------+
| Current or requested HPSA designation                                 |
+-----------------------------------------------------------------------+
| Frontier Area Documentation                                           |
+-----------------------------------------------------------------------+
| Internal Revenue Service (IRS) Tax Exempt Certification for the       |
| Applicant, OR, if the Applicant is a public entity, the Co-Applicant  |
| Board                                                                 |
+-----------------------------------------------------------------------+

**\*\* SATELLITES: Should present information ONLY on the new access
point**

**NEW STARTS: Should present information on the entire scope of the
project**

######## FORM 2 - PROPOSED STAFF PROFILE

**YEAR 1 YEAR 2 YEAR 3**

+--------------------------+-----------+----------+---------+---------+
| **PERSONNEL BY           | **TOTAL   |          | ANNUAL  | TOTAL   |
| CATEGORY**               | FTEs      |          | SALARY  | SALARY  |
|                          | P         |          | OF      |         |
|                          | ROPOSED** |          | P       | { a \*  |
|                          |           |          | OSITION | b }     |
|                          | **{ a }** |          |         |         |
|                          |           |          | { b }   |         |
+--------------------------+-----------+----------+---------+---------+
|                          | **NEW     | **SATE   |         |         |
|                          | STARTS**  | LLITES** |         |         |
|                          |           |          |         |         |
|                          | **(All    | **(New   |         |         |
|                          | sites     | site(s)  |         |         |
|                          | included  | ONLY)**  |         |         |
|                          | in        |          |         |         |
|                          | Exhibit   |          |         |         |
|                          | B-2)**    |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| **ADMINISTRATION**       |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Executive Director     |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Finance Director       |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Chief Operating        |           |          |         |         |
| > Officer                |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Administrative Support |           |          |         |         |
| > Staff                  |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| **MEDICAL STAFF**        |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Medical Director       |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Family Practitioners   |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > General Practitioners  |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Internists             |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > OB/GYNs                |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Pediatricians          |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Psychiatrists          |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Other Specialty        |           |          |         |         |
| > Physicians (attach     |           |          |         |         |
| > list by type)          |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Physician              |           |          |         |         |
| > Assistants/Nurse       |           |          |         |         |
| > Practitioners          |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Certified Nurse        |           |          |         |         |
| > Midwives               |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Nurses (RNs)           |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Pharmacist             |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Other Medical          |           |          |         |         |
| > Personnel (attach list |           |          |         |         |
| > by type)               |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Laboratory Personnel   |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > X-ray Personnel        |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Clinical Support Staff |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| **DENTAL STAFF**         |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Dentists               |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Dental Hygienists      |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Dental Assistants,     |           |          |         |         |
| > Aides, Technicians     |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| **MENTAL HEALTH STAFF**  |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Mental Health          |           |          |         |         |
| > Specialists            |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Substance Abuse        |           |          |         |         |
| > Specialists            |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Case Managers          |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Other Professional     |           |          |         |         |
| > Personnel              |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| **OTHER STAFF**          |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Patient Education      |           |          |         |         |
| > Specialist             |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Homemaker/Aide         |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Outreach               |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Other Enabling         |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+
| > Other staff            |           |          |         |         |
+--------------------------+-----------+----------+---------+---------+

######## FORM 3 - INCOME ANALYSIS FORMAT YEAR 1 YEAR 2 YEAR 3 

+----------+----+-----+-----+------+------+------+------+---------+
| **PAYOR  | ** | **A | *   | *    | **AM | **CO | **P  | *       |
| CA       | NU | VER | *TO | *AVE | OUNT | LLEC | ROJE | *ACTUAL |
| TEGORY** | MB | AGE | TAL | RAGE | BILL | TION | CTED | ACCRUED |
|          | ER | CHA | CHA | AD   | ED** | RA   | INCO | I       |
|          | OF | RGE | RGE | JUST |      | TE** | ME** | NCOME** |
|          | VI | PER | S** | MENT | **\[ |      |      |         |
|          | SI | V   |     | PER  | c-(a | **(  | **(e | **(most |
|          | TS | ISI | *   | VIS  | \*d) | %)** | \*   | recent  |
|          | ** | T** | *(a | IT** | \]** |      | f)** | 12      |
|          |    |     | \*  |      |      |      |      | mo      |
|          |    |     | b   |      |      |      |      | nths)** |
|          |    |     | )** |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
|          | *  | *   | *   | **(  | **(  | **(  | **(  | **(h)** |
|          | *( | *(b | *(c | d)** | e)** | f)** | g)** |         |
|          | a) | )** | )** |      |      |      |      |         |
|          | ** |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **FEE    |    |     |     |      |      |      |      |         |
| FOR      |    |     |     |      |      |      |      |         |
| S        |    |     |     |      |      |      |      |         |
| ERVICE** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **M      |    |     |     |      |      |      |      |         |
| edicaid: |    |     |     |      |      |      |      |         |
| Fee for  |    |     |     |      |      |      |      |         |
| Se       |    |     |     |      |      |      |      |         |
| rvices** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **M      |    |     |     |      |      |      |      |         |
| edicaid: |    |     |     |      |      |      |      |         |
| EPSDT**  |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **M      |    |     |     |      |      |      |      |         |
| edicaid: |    |     |     |      |      |      |      |         |
| Cap      |    |     |     |      |      |      |      |         |
| itated** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **S      |    |     |     |      |      |      |      |         |
| ubtotal: |    |     |     |      |      |      |      |         |
| Me       |    |     |     |      |      |      |      |         |
| dicaid** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **M      |    |     |     |      |      |      |      |         |
| edicare: |    |     |     |      |      |      |      |         |
| Fee for  |    |     |     |      |      |      |      |         |
| Se       |    |     |     |      |      |      |      |         |
| rvices** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **M      |    |     |     |      |      |      |      |         |
| edicare: |    |     |     |      |      |      |      |         |
| Cap      |    |     |     |      |      |      |      |         |
| itated** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **S      |    |     |     |      |      |      |      |         |
| ubtotal: |    |     |     |      |      |      |      |         |
| Me       |    |     |     |      |      |      |      |         |
| dicare** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| *        |    |     |     |      |      |      |      |         |
| *Private |    |     |     |      |      |      |      |         |
| Ins      |    |     |     |      |      |      |      |         |
| urance** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **S      |    |     |     |      |      |      |      |         |
| elf-Pay: |    |     |     |      |      |      |      |         |
| 100      |    |     |     |      |      |      |      |         |
| p        |    |     |     |      |      |      |      |         |
| ercent** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **S      |    |     |     |      |      |      |      |         |
| elf-Pay: |    |     |     |      |      |      |      |         |
| Sliding  |    |     |     |      |      |      |      |         |
| Fee      |    |     |     |      |      |      |      |         |
| Scale**  |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **S      |    |     |     |      |      |      |      |         |
| elf-Pay: |    |     |     |      |      |      |      |         |
| Zero (0) |    |     |     |      |      |      |      |         |
| p        |    |     |     |      |      |      |      |         |
| ercent** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **Other: |    |     |     |      |      |      |      |         |
| Capi     |    |     |     |      |      |      |      |         |
| tation** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **Other: |    |     |     |      |      |      |      |         |
| Con      |    |     |     |      |      |      |      |         |
| tracts** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **SUB    |    |     |     |      |      |      |      |         |
| -TOTAL** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **OTHER  |    |     |     |      |      |      |      |         |
| INCOME** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **C      |    |     |     |      |      |      |      |         |
| ontribut |    |     |     |      |      |      |      |         |
| ions/Don |    |     |     |      |      |      |      |         |
| ations** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **Fund   |    |     |     |      |      |      |      |         |
| R        |    |     |     |      |      |      |      |         |
| aising** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **330    |    |     |     |      |      |      |      |         |
| BPHC     |    |     |     |      |      |      |      |         |
| Grant**  |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **Other  |    |     |     |      |      |      |      |         |
| Federal  |    |     |     |      |      |      |      |         |
| Grants** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **State  |    |     |     |      |      |      |      |         |
| Grants** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **Local  |    |     |     |      |      |      |      |         |
| S        |    |     |     |      |      |      |      |         |
| upport** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **Fo     |    |     |     |      |      |      |      |         |
| undation |    |     |     |      |      |      |      |         |
| Grants** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| *        |    |     |     |      |      |      |      |         |
| *Other** |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+
| **GRAND  |    |     |     |      |      |      |      |         |
| TOTAL**  |    |     |     |      |      |      |      |         |
+----------+----+-----+-----+------+------+------+------+---------+

######## FORM 4 - COMMUNITY CHARACTERISTICS

+------------+------------------------+-------+-------+-------+-------+
|            | **CHARACTERISTIC**     | *     |       | **T   |       |
|            |                        | *COMM |       | ARGET |       |
|            |                        | UNITY |       | POPUL |       |
|            |                        | WIDE  |       | ATION |       |
|            |                        | D     |       | D     |       |
|            |                        | ATA** |       | ATA** |       |
|            |                        |       |       |       |       |
|            |                        | **\#  |       | **\#  |       |
|            |                        | %**   |       | %**   |       |
+------------+------------------------+-------+-------+-------+-------+
| RACE       | White (non-Hispanic)   |       |       |       |       |
| /ETHNICITY |                        |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Black or               |       |       |       |       |
|            | African-American       |       |       |       |       |
|            | (non-Hispanic)         |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Hispanic               |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | American Indian or     |       |       |       |       |
|            | Alaskan Native         |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Asian                  |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Native Hawaiian or     |       |       |       |       |
|            | Other Pacific Islander |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Other                  |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Total Population       |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
| INCOME AS  | Below 100%             |       |       |       |       |
| A PERCENT  |                        |       |       |       |       |
| OF POVERTY |                        |       |       |       |       |
| LEVEL      |                        |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | 100-199 percent        |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | 200 percent and above  |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Unknown                |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
| PRIMARY    | Medicaid/Capitated     |       |       |       |       |
| THIRD      |                        |       |       |       |       |
| PARTY      |                        |       |       |       |       |
| PAYMENT    |                        |       |       |       |       |
| SOURCE     |                        |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Medicaid/Not Capitated |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Medicare               |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Other Public Insurance |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Private Insurance,     |       |       |       |       |
|            | including capitation   |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | None/Uninsured         |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
| SPECIAL    | Migrant/Agricultural   |       |       |       |       |
| P          | worker                 |       |       |       |       |
| OPULATIONS |                        |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Seasonal Agricultural  |       |       |       |       |
|            | worker                 |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Homeless People        |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | People with AIDS       |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | HIV-infected           |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Substance Abuse        |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Public Housing         |       |       |       |       |
|            | Residents              |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Low Income School      |       |       |       |       |
|            | Children/Adolescents   |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+
|            | Other                  |       |       |       |       |
+------------+------------------------+-------+-------+-------+-------+

######## FORM 5 - Part A

######## SERVICES PROVIDED

  --------------- ---------------------- ---------- ----------- ----------- ---------- ---------------- ---------- ----------- -----------
  **APPLICANT'S                                                                                                                
  NAME:**                                                                                                                      

  SERVICE TYPE                           PROVIDED   BY          BY          SERVICE                     PROVIDED   BY          BY
                                         BY GRANTEE REFERRAL/   REFERRAL/   TYPE                        BY GRANTEE REFERRAL/   REFERRAL/
                                                    GRANTEE     GRANTEE                                            GRANTEE     GRANTEE
                                                    PAYS        DOESN'T PAY                                        PAYS        DOESN'T PAY

  PRIMARY MEDICAL General Primary                                           OTHER      Environmental                           
  CARE SERVICES   Medical Care                                              SERVICES   Health                                  

                  Diagnostic Laboratory                                                Hearing                                 
                                                                                       Screening                               

                  Diagnostic X-Ray                                                     Nutrition (not                          
                                                                                       WIC)                                    

                  Diagnostic                                                           Occ./Voc.                               
                  Tests/Screens                                                        Therapy                                 

                  Urgent Medical Care                                                  Physical Therapy                        

                  24-Hour Coverage                                                     Pharmacy                                

                  Family Planning                                                      Podiatry                                

                  HIV Testing                                                          Vision Screening                        

                  Immunizations                                                        WIC                                     

                  Following Hospitalized                                    ENABLING   Case Management                         
                  Patients                                                  SERVICES                                           

  OB/GYN CARE     Gynecological Care                                                   Child Care                              

                  Obstetrical Care                                                     Discharge                               
                                                                                       Planning                                

  SPECIALTY       TB Therapy                                                           Eligibility                             
  SERVICES                                                                             Assistance                              

                  Other                                                                Emp./Ed.                                
                                                                                       Counseling                              

                  Other                                                                Food Bank/Meals                         

  DENTAL SERVICES Preventive                                                           Health Education                        

                  Restorative                                                          Homemaker/Aide                          

                  Emergency                                                            Housing                                 
                                                                                       Assistance                              

                  Other                                                                Translation                             

  MENTAL HEALTH   Treatment/Counseling                                                 Nursing Home and                        
  SERVICES                                                                             Other Placement                         

                  Developmental                                                        Outreach                                
                  Screening                                                                                                    

                  24-Hour Crisis                                                       Transportation                          

                  Other Mental Health                                                  Other:                                  

                  Substance Abuse                                                      Other:                                  

                  Other Substance Abuse                                                Other:                                  
  --------------- ---------------------- ---------- ----------- ----------- ---------- ---------------- ---------- ----------- -----------

######## FORM 5 - Part B

######## SERVICE SITES \*\*

+-----------------------------------+-----------------------------------+
| **SITE #1**                       | SITE #2                           |
+-----------------------------------+-----------------------------------+
| > G Year-Round G Seasonal         | > G Year-Round G Seasonal         |
|                                   |                                   |
| NEW START SITE: G                 | NEW START SITE: G                 |
|                                   |                                   |
| SATELLITE: EXISTING SITE: G       | SATELLITE: EXISTING SITE: G       |
| SATELLITE SITE: G                 | SATELLITE SITE: G                 |
|                                   |                                   |
| DATE OPENED/TO BE OPENED:         | DATE OPENED/TO BE OPENED:         |
|                                   |                                   |
| Name:                             | Name:                             |
|                                   |                                   |
| Address:                          | Address:                          |
|                                   |                                   |
| BPHC Funding Sources:             | BPHC Funding Sources:             |
|                                   |                                   |
| Other HRSA Funding Sources:       | Other HRSA Funding Sources:       |
+-----------------------------------+-----------------------------------+
| SITE #3                           | SITE #4                           |
+-----------------------------------+-----------------------------------+
| > G Year-Round G Seasonal         | > G Year-Round G Seasonal         |
|                                   |                                   |
| NEW START SITE: G                 | NEW START SITE: G                 |
|                                   |                                   |
| SATELLITE: EXISTING SITE: G       | SATELLITE: EXISTING SITE: G       |
| SATELLITE SITE: G                 | SATELLITE SITE: G                 |
|                                   |                                   |
| DATE OPENED/TO BE OPENED:         | DATE OPENED/TO BE OPENED:         |
|                                   |                                   |
| Name:                             | Name:                             |
|                                   |                                   |
| Address:                          | Address:                          |
|                                   |                                   |
| BPHC Funding Sources:             | BPHC Funding Sources:             |
|                                   |                                   |
| Other HRSA Funding Sources:       | Other HRSA Funding Sources:       |
+-----------------------------------+-----------------------------------+
| SITE #5                           | SITE #6                           |
+-----------------------------------+-----------------------------------+
| > G Year-Round G Seasonal         | > G Year-Round G Seasonal         |
|                                   |                                   |
| NEW START SITE: G                 | NEW START SITE: G                 |
|                                   |                                   |
| SATELLITE: EXISTING SITE: G       | SATELLITE: EXISTING SITE: G       |
| SATELLITE SITE: G                 | SATELLITE SITE: G                 |
|                                   |                                   |
| DATE OPENED/TO BE OPENED:         | DATE OPENED/TO BE OPENED:         |
|                                   |                                   |
| Name:                             | Name:                             |
|                                   |                                   |
| Address:                          | Address:                          |
|                                   |                                   |
| BPHC Funding Sources:             | BPHC Funding Sources:             |
|                                   |                                   |
| Other HRSA Funding Sources:       | Other HRSA Funding Sources:       |
+-----------------------------------+-----------------------------------+
| SITE #7                           | SITE #8                           |
+-----------------------------------+-----------------------------------+
| > G Year-Round G Seasonal         | > G Year-Round G Seasonal         |
|                                   |                                   |
| NEW START SITE: G                 | NEW START SITE: G                 |
|                                   |                                   |
| SATELLITE: EXISTING SITE: G       | SATELLITE: EXISTING SITE: G       |
| SATELLITE SITE: G                 | SATELLITE SITE: G                 |
|                                   |                                   |
| DATE OPENED/TO BE OPENED:         | DATE OPENED/TO BE OPENED:         |
|                                   |                                   |
| Name:                             | Name:                             |
|                                   |                                   |
| Address:                          | Address:                          |
|                                   |                                   |
| BPHC Funding Sources:             | BPHC Funding Sources:             |
|                                   |                                   |
| Other HRSA Funding Sources:       | Other HRSA Funding Sources:       |
+-----------------------------------+-----------------------------------+

\*\* NEW START APPLICANTS SHOULD LIST ALL SITES TO BE INCLUDED IN THE
SCOPE OF PROJECT

\*\* SATELLITE APPLICANTS SHOULD LIST ALL SITES IN THE CURRENT SCOPE OF
PROJECT AND IDENTIFY THE PROPOSED SATELLITE SITE(S)

NOTE: ADD ADDITIONAL PAGES, IF NEEDED.

######## FORM 6 -- PART A: CURRENT BOARD MEMBER CHARACTERISTICS

+--------------------+---------+-----------+--------+-----+-----------+
| **BOARD MEMBER     | **BOARD | **AREA OF | **IN   | **L | **YEARS   |
| NAME**             | OFFICE  | EX        | DICATE | IVE | OF        |
|                    | HELD**  | PERTISE** | IF     | (L) | C         |
|                    |         |           | USER   | OR  | ONTINUOUS |
|                    |         |           | OF     | W   | BOARD     |
|                    |         |           | HEALTH | ORK | SERVICE** |
|                    |         |           | CENTER | (W) |           |
|                    |         |           | SERV   | IN  |           |
|                    |         |           | ICES** | S   |           |
|                    |         |           |        | ERV |           |
|                    |         |           | **(YES | ICE |           |
|                    |         |           | /NO)** | ARE |           |
|                    |         |           |        | A** |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 1\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 2\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 3\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 4\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 5\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 6\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 7\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 8\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 9\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 10\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 11\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 12\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 13\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 14\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+

Indicate \# Board Members by Sex: F = \_\_\_\_\_\_\_ M = \_\_\_\_\_\_

Indicate \# Board Members by Race/Ethnicity:

White: \_\_\_\_\_\_\_ Hispanic or Latino: \_\_\_\_\_\_\_ Black/African
American: \_\_\_\_\_\_

Asian/Pacific Islander\_\_\_\_\_\_ American Indian & Alaska
Native:\_\_\_\_\_

**NOTES: (1) Please indicate if a board member is a special population
representative (MHC, SBHC, HCH, PHPC).**

> **(2) HCH and/or PHPC applicants requesting a waiver of the governance
> requirements must complete Form 6, Part B and must describe any
> alternative arrangement for addressing Board requirements including
> the mechanism for receiving consumer input.**
>
> **(3) Tribal entities are exempt from Governance Requirements.**
>
> **(4)** Add additional pages, if needed.

######## FORM 6 - PART B

######## REQUEST FOR WAIVER OF GOVERNANCE REQUIREMENTS

FOR HEALTH CENTERS THAT ARE SEEKING SUPPORT FOR MIGRANT HEALTH CENTER,

HEALTH CARE FOR THE HOMELESS, OR PUBLIC HOUSING FUNDING
**[ONLY]{.underline}** AS NECESSARY.

Requests for waivers will **not** be granted if applicant is also
approved and funded for CHC and/or SBHC funding.

Name of Organization:

Name of Sponsoring Organization (if different):

If existing grantee with Waiver Approval:

1\. Date of Original Governance Waiver Request:

2\. Date of Waiver Approval by BPHC Director:

3\. Date of Most Recent approval of

Continuation of Waiver Request (if different):

4\. Nature of Items Currently Approved to be Waived: \_\_\_ 51 Percent
User Majority

> \_\_\_ Monthly Meetings

5\. Are you requesting the waiver be continued? \_\_\_ Yes (Complete
questions 2. and 3. below)

\_\_\_ No (Governing Board is in Full Compliance)

If Yes is your waiver request based on arrangements \_\_\_ Yes (Complete
questions 2. below)

that are different from your original request? \_\_\_ No

All organizations Requesting Waiver:

1\. Nature of Items Requested for Waiver: \_\_\_ 51 Percent User
Majority

> \_\_\_ Monthly Meetings

2\. Describe below the arrangements that are in place to assure
appropriate user input and involvement is achieved. (See PIN 98-12 for
additional guidance).

Signature of CEO, Project Director, or designated Signatory Authority
Date

######## FORM 7 -- Page 1 of 2

######## COMPLIANCE CHECKLIST

+---+-----------------------------------------------------------+---+---+
|   |                                                           | * | * |
|   |                                                           | * | * |
|   |                                                           | Y | N |
|   |                                                           | E | O |
|   |                                                           | S | * |
|   |                                                           | * | * |
|   |                                                           | * |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Is the applicant organization a non-profit or public      |   |   |
| . | entity?                                                   |   |   |
|   |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization demonstrate the need for  |   |   |
| . | primary health care services in the community(ies) that   |   |   |
|   | make up its service area based on geographic,             |   |   |
|   | demographic, and economic factors?                        |   |   |
+---+-----------------------------------------------------------+---+---+
| 3 | Does the applicant organization serve, in whole or in     |   |   |
| . | part, a designated MUA or MUP? *(Requested, not required  |   |   |
|   | for HCH, PHPC or SBHC applicants)*                        |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 4 | Does the applicant organization have a system of care     |   |   |
| . | that contributes to the availability, accessibility,      |   |   |
|   | quality, comprehensiveness and coordination of health     |   |   |
|   | services in the service area?                             |   |   |
+---+-----------------------------------------------------------+---+---+
| 5 | Does the applicant organization provide ready access for  |   |   |
| . | all persons to all of the required primary, preventive    |   |   |
|   | and supplemental health services, including oral health   |   |   |
|   | care, mental health care and substance abuse services     |   |   |
|   | without regard to ability to pay either directly on-site  |   |   |
|   | or through established arrangements?                      |   |   |
+---+-----------------------------------------------------------+---+---+
| 6 | Does the applicant organization provide all additional    |   |   |
| . | health services as appropriate and necessary?             |   |   |
|   |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 7 | Does the applicant organization have patient case         |   |   |
| . | management services (including counseling, referral and   |   |   |
|   | follow-up services) designed to assist health center      |   |   |
|   | patients in establishing eligibility for and gaining      |   |   |
|   | access to Federal, State and local programs that provide  |   |   |
|   | or financially support the provision of medical, social,  |   |   |
|   | educational or other related services?                    |   |   |
+---+-----------------------------------------------------------+---+---+
| 8 | Does the applicant organization collaborate appropriately |   |   |
| . | with other health and social service providers in their   |   |   |
|   | area?                                                     |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 9 | Are all contracted services (including management         |   |   |
| . | agreements, administrative services contracts, etc.)      |   |   |
|   | under the governance, administration, quality assurance   |   |   |
|   | and clinical management policies of the applicant         |   |   |
|   | organization?                                             |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization arrange referrals to      |   |   |
| 0 | providers as may be appropriate to assure ready access    |   |   |
| . | for all persons to all of the required primary,           |   |   |
|   | preventive and supplemental health services without       |   |   |
|   | regard to ability to pay?                                 |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Are all services available to all persons in the service  |   |   |
| 1 | area or target population regardless of age, gender, or   |   |   |
| . | the patient's ability to pay?                             |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization maintain a core staff of  |   |   |
| 2 | primary care providers appropriate for the population     |   |   |
| . | served?                                                   |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Are the primary care providers working at the health      |   |   |
| 3 | center licensed to practice in the State where the center |   |   |
| . | is located?                                               |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Have all providers been properly credentialed and         |   |   |
| 4 | privileged according to PINs 99-08 and 2001-11?           |   |   |
| . |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Do the applicant organization's physicians have admitting |   |   |
| 5 | privileges at their referral hospital(s), or other such   |   |   |
| . | arrangement to ensure continuity of care?                 |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization use a charge schedule     |   |   |
| 6 | with a corresponding discount schedule based on income    |   |   |
| . | for persons between 100 percent and 200 percent of the    |   |   |
|   | Federal poverty level?                                    |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Is/will the new access point be open to provide services  |   |   |
| 7 | at the times that meet the needs of the majority of       |   |   |
| . | potential users?                                          |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+

######## FORM 7 -- Page 2 of 2

######## COMPLIANCE CHECKLIST

+---+-----------------------------------------------------------+---+---+
|   |                                                           | * | * |
|   |                                                           | * | * |
|   |                                                           | Y | N |
|   |                                                           | E | O |
|   |                                                           | S | * |
|   |                                                           | * | * |
|   |                                                           | * |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization provide professional      |   |   |
| 8 | coverage during hours when the center is closed?          |   |   |
| . |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization have clear lines of       |   |   |
| 9 | authority from the Board to a chief executive (President, |   |   |
| . | Chief Executive Officer or Executive Director) who        |   |   |
|   | delegates, as appropriate, to other management and        |   |   |
|   | professional staff?                                       |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have systems which        |   |   |
| 0 | accurately collect and organize data for reporting and    |   |   |
| . | which support management decision-making and which        |   |   |
|   | integrate clinical, utilization and financial information |   |   |
|   | to reflect the operations and status of the organization  |   |   |
|   | as a whole?                                               |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have accounting and       |   |   |
| 1 | internal control systems appropriate to the size and      |   |   |
| . | complexity of the organization reflecting Generally       |   |   |
|   | Accepted Accounting Principles (GAAP) and separating      |   |   |
|   | functions appropriate to organizational size to safeguard |   |   |
|   | assets?                                                   |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization maximize revenue from     |   |   |
| 2 | third party payers and from patients to the extent they   |   |   |
| . | are able to pay?                                          |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have written billing,     |   |   |
| 3 | credit and collection policies and procedures?            |   |   |
| . |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization assure that an annual     |   |   |
| 4 | independent financial audit is performed in accordance    |   |   |
| . | with Federal audit requirements?                          |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have a governing board    |   |   |
| 5 | that is composed of individuals, a majority of whom are   |   |   |
| . | being served by the organization and, who as a group,     |   |   |
|   | represent the individuals being serviced by the center?   |   |   |
|   | (May waived for HCH or PHPC applicants. See Form 6, Part  |   |   |
|   | B)                                                        |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the governing board have at least 9 but no more than |   |   |
| 6 | 25 members? (May waived for HCH or PHPC applicants. See   |   |   |
| . | Form 6, Part B)                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization's corporate bylaws        |   |   |
| 7 | demonstrate that the governing board has the required     |   |   |
| . | authority and responsibility to oversee the operation of  |   |   |
|   | the center?                                               |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Do the corporate bylaws include provisions that prohibit  |   |   |
| 8 | conflict of interest or the appearance of conflict of     |   |   |
| . | interest by board members, employees, consultants and     |   |   |
|   | those who provide services or furnish goods to the        |   |   |
|   | center?                                                   |   |   |
+---+-----------------------------------------------------------+---+---+

**I certify that the information contained herein is accurate to the
best of my knowledge.**

Signature of Governing Board Chairperson Date

Printed Name

######## FORM 8 - Page 1 of 3

######## HEALTH CENTER AFFILIATION CHECKLIST

**(MUST BE COMPLETED BY ALL NEW ACCESS POINT APPLICANTS**

**UNDER THE CHC, MHC and SBHC PROGRAMS)**

**Organization: Grant \#**

*(where applicable)*

**1. Does your organization have, or propose to establish as part of the
new access point application, any of the following arrangements with
another organization? (NOTE: You must complete a checklist for each
organization with which you have any of the following arrangements.
Copies of all applicable documents must be included with the
application.)**

YES *(Please check all that apply and proceed to question #2)*

NO *(Go to question #2)*

-   a\) Contract for a substantial portion of the approved scope of
    project

```{=html}
<!-- -->
```
-   b\) Memorandum of Understanding (MOU)/Agreement (MOA) for a
    substantial portion of the approved scope of project

-   c\) Contract with another organization or individual contract for
    core providers

-   d\) Contract with another organization for staffing health center

-   e\) Contract with another organization for the Chief Medical Officer
    (CMO) or Chief Financial Officer (CFO)

-   f\) Merger with another organization

-   g\) Parent Subsidiary Model arrangement

-   h\) Acquisition by another organization

-   i\) Establishment of a New Entity (e.g., Network corporation)

Name of Affiliating Organization:

Address:

**STAFFING**

**2) The center directly employs the CFO, CMO and the core staff of
full-time**

**primary care providers**. **YES** **NO**

**3) The center directly employs all non-provider health center staff.**
**YES** **NO**

*If NO to question 2 or 3, the applicant must submit a request for a
good cause exception. Please see PIN 98-24.*

*If NO to question 2 or 3, the CEO of the center retains the authority
to select and* **YES** **NO**

*dismiss staff assigned to the center.*

(Please cite reference document and page #.)

######## FORM 8 - Page 2 of 3

######## HEALTH CENTER AFFILIATION CHECKLIST

**1**

**GOVERNANCE:**

**4) The Governing Board structure is in compliance with all section 330
requirements. YES** **NO**

**5) The Governing Board retains its full authorities, responsibilities
and functions as**

**prescribed in legislation/regulations/BPHC guidelines in regard to the
following as YES** **NO**

**identified below.**

Reference Document Page \#

-   board composition

```{=html}
<!-- -->
```
-   executive committee function and composition

-   selection of board chairperson

-   selection of members

-   strategic planning

-   approval of the annual budget of the center

-   directly employs, selects/dismisses and evaluates the

> Chief Executive Officer (CEO)/Executive Director

-   adoption of policies and procedures for personnel

> and financial management

-   establishes center priorities

-   establishes eligibility requirements for partial

> payment of services

-   provides for an independent audit

-   evaluation of center activities

```{=html}
<!-- -->
```
-   adoption of center's health care policies including

> scope and availability of services, location, hours
>
> of operation and quality of care audit procedures

-   establishes and maintains collaborative relationships

> with other health care providers in the service area

-   existence of a conflict of interest policy

**6) The arrangements presented in the affiliation agreements, as
defined in Question 1, do not compromise the Board authorities or limit
its legislative and regulatory mandated functions and
responsibilities.** *(Examples of compromising arrangements are:
overriding approval or veto authority by another entity; dual majority
requirements; super-majority requirements; or hiring and selection of
the CEO).*

**YES** **NO**

######## FORM 8 - Page 3 of 3

######## HEALTH CENTER AFFILIATION CHECKLIST

**CONTRACTING**

**7) The center has justified the performance of the work by a third
party.** **YES** **NO**

(Please cite reference document and page #.)

**8) Written affiliation agreement(s) comply with current**

**Department of Health and Human Services (HHS) policies, i.e.:**
**YES** **NO**

Reference Document Page \#

-   contains appropriate provisions around the activities to be
    performed, time, schedules, the policies and procedures to be
    followed in carrying out the agreement, and the maximum amount of
    money for which the grantee may become liable to

the contractor under the agreement;

-   requires the contractor to maintain appropriate financial, program
    and property management systems and records in accordance with 45
    CFR Part 74 and provides the center, HHS

and the U.S. Comptroller General with access to such records;

-   requires the submission of financial and programmatic reports

to the health center;

-   complies with Federal procurement standards or grant requirements

including conflict of interest standards;

-   is subject to termination (with administrative, contractual

and legal remedies) in the event of breach by the contractor.

**PLEASE INCLUDE LIST AND COPIES OF ALL RELEVANT AND CITED DOCUMENTS**

**I certify that the information contained herein is accurate to the
best of my knowledge.**

Signature of Governing Board Chairperson Date

Printed Name

# 

# 

# SECTION VI:

# 

# EXHIBITS

######## EXHIBIT 1

######## PRIMARY CARE ASSOCIATION AND 

######## PRIMARY CARE OFFICE CONTACTS

**I. PRIMARY CARE ASSOCIATIONS**

Alabama

Al Fox

Executive Director

Alabama Primary Health Care Association

6008 E. Shirley Lane, Suite A, South

Montgomery, AL 36117-0000

\(334\) 271-7068; (334) 271-7069

AFOX@ALPHCA.COM

Alaska

Marilyn Kasmar, RNC, MBA

Executive Director

Alaska Primary Care Association, Inc.

903 W. Northern Lights Blvd., Suite 105

Anchorage, AK 99503-0000

\(907\) 929-2722; (907) 929-2734

MARILYN@ALASKAPCA.ORG

Arizona

Andrew Rinde

Executive Director

Arizona Assn of Community Health Centers, Inc.

320 E. Mcdowell Street, Suite 225

Phoenix, AZ 85004-0000

\(602\) 253-0090; (602) 252-3620

ANDYR@AACHC.ORG

Arkansas

Sip Frasier

Executive Director

Community Health Centers of Arkansas, Inc.

420-A West 4th Street

North Little Rock, AR 72114-0000

\(501\) 374-8225; (501) 374-9734

MSFRASIER@CHC-AR.ORG

California

Carmela Castellano

Executive Director

California Primary Care Association

1215 K Street, Suite 700

Sacramento, CA 95814-0000

\(916\) 440-8170; (916) 440-8172

CCASTELLANO@CPCA.ORG

Colorado

Annette Kowal

Executive Director

Colorado Community Health Network

800 Grant, Suite 505

Denver, CO 80203-0000

\(303\) 861-5165 Ex 28; (303) 861-5315

ANNETTE@CCHN.ORG

#  {#section-28 .Style1}

Colorado

Julie Hulstein

Executive Director

Comm Health Assn of the Mountains/Plains States

800 Grant, Suite 505

Denver, CO 80203-0000

\(303\) 861-5165 Ex 26; (303) 861-5315

JULIE@CHAMPSONLINE.ORG

#  {#section-29 .Style1}

#  {#section-30 .Style1}

Connecticut

Evelyn Barnum

Executive Director

Connecticut Assn of Primary Health Care Centers

90 Brainard Road, Suite 101

Hartford, CT 06114-1685

\(860\) 727-0004; (860) 727-8550

EBARNUM@CTPCA.ORG

#  {#section-31 .Style1}

District Of Columbia

Sharon Baskerville

Executive Director

District of Columbia Primary Care Association

1411 K Street, NW, Suite 400

Washington, DC 20005-0000

\(202\) 638-0252; (202) 638-4557

SBASKERVILLE@DCPCA.ORG

#  {#section-32 .Style1}

Florida

Andrew Behrman

Executive Director

Florida Association of Community Health

1203 Governor Square Blvd., Suite 302

Tallahassee, FL 32301-0000

\(850\) 942-1822; (850) 942-9902

ANDREWBEHRMAN@FACHC.ORG

#  {#section-33 .Style1}

Georgia

Duane Kavka

Executive Director

Georgia Association for Primary Health Care

41 Marietta Street, NW, Suite 505

Atlanta, GA 30303-0000

\(404\) 659-2861; (404) 659-2801

DKAVKA@GAPHC.ORG

#  {#section-34 .Style1}

Hawaii

Beth Giesting

Executive Director

Hawaii State Primary Care Association

345 Queens Street, Suite 601

Honolulu, HI 96813-4718

\(808\) 536-8442; (808) 524-0347

GIESTING@LAVA.NET

Idaho

Bill Foxcroft

Executive Director

Idaho Primary Care Association

1276 W. River Street, Suite 202

Boise, ID 83705-0000

\(208\) 345-2335; (208) 386-9945

BILLF@IDAHOPCA.ORG

#  {#section-35 .Style1}

Illinois

Bruce Johnson

Executive Director

Illinois Primary Health Care Association

225 S. College, Suite 200

Springfield, IL 62704-0000

\(217\) 541-7305; (217) 541-7306

BJOHNSON@IPHCA.ORG

#  {#section-36 .Style1}

#  {#section-37 .Style1}

Indiana

B.J. Isaacson-Chaves

Executive Director

Indiana Primary Health Care Association,

1006 E. Washington Street, Suite 200

Indianapolis, IN 46202-0000

\(317\) 630-0845; (317) 630-0849

BJCHAVES@ORI.NET

#  {#section-38 .Style1}

Iowa-Nebraska

Ted Boesen

Executive Director

Iowa-Nebraska Primary Care Association

904 Walnut Street, Suite 502

Des Moines, IA 50309-0000

\(515\) 244-9610; (515) 246-1722

IANEPCA@AOL.COM

Kansas

Joyce Volmut

Executive Director

Kansas Assn for the Medically Underserved

112 SW 6th Street, Suite 202

Topeka, KS 66603-0000

\(785\) 233-8483; (785) 233-8403

JVOLMUT@SWBELL.NET

Kentucky

Joseph E. Smith

Executive Director

Kentucky Primary Care Association

P.O. Box 751

Frankfort, KY 40602-0000

\(502\) 227-4379; (502) 223-5676

<JESMITH@MIS.NET>

**Page 2 -- Exhibit 1**

**Primary Care Associations Continued**

Louisiana

Mary Scott

Executive Director

Louisiana Primary Care Association, Inc.

P.O. Box 966

Baton Rouge, LA 70821-0966

\(225\) 383-8677; (225) 383-8678

<LPCA@LPCA.NET>

#  {#section-39 .Style1}

Maine

Kevin Lewis

Executive Director

Maine Ambulatory Care Coalition

P.O. Box 390, Route 202

Manchester, ME 04351-0000

\(207\) 621-0677; (207) 621-0577

KALMACC@MINT.NET

#  {#section-40 .Style1}

Maryland/Delaware

Miguel McInnis, MPH

Executive Director

Mid-Atlantic Assn of Community Health Ctrs

4483-B Forbes Boulevard, Forbes Ctr Bld II

Lanham, MD 20706-0000

\(301\) 577-0097; (301) 577-4789

# MIGUEL.MCINNIS@MACHC.COM {#miguel.mcinnismachc.com .Style1}

#  {#section-41 .Style1}

#  {#section-42 .Style1}

Massachusetts

Jim Hunt

Executive Director

Massachusetts League of Community Health Ctrs

100 Boylston Street, Suite 700

Boston, MA 02116-0000

\(617\) 426-2225; (617) 426-0097

JHUNT@MASSLEAGUE.ORG

#  {#section-43 .Style1}

Michigan

Kim Sibilsky

Executive Director

Michigan Primary Care Association

2369 Woodlake Drive, Suite 280

Okemos, MI 48864-0000

\(517\) 381-8000; (517) 381-8008

KSIBILSKY@MPCA.NET

#  {#section-44 .Style1}

Minnesota

Rhonda Degelau

Executive Director

Minnesota Primary Care Association, Inc.

1113 E. Franklin Ave, Suite 401

Minneapolis, MN 55404-0000

\(612\) 253-4175; (612)872-7849

MPCARD@IAXS.NET

#  {#section-45 .Style1}

Mississippi

Robert Pugh

Executive Director

Mississippi Primary Health Care Association

P.O. Box 11745

Jackson, MS 39207-1745

\(601\) 981-1817; (601) 981-1217

RMPUGH@MPHCA.COM

#  {#section-46 .Style1}

Missouri

Joseph Pierle

Executive Director

Missouri Coalition for Primary Health Care & Heartland

3325 Emerald Lane

Jefferson City, MO 65109-0000

\(573\) 636-4222; (573) 636-4585

JPIERLE@MO-PCA.ORG

#  {#section-47 .Style1}

Montana

Alan Strange, Ph.D.

Executive Director

Montana Primary Care Association

900 N. Montana Ave., Suite 3b

Helena, MT 59601-0000

\(406\) 442-2750; (406) 449-2460

ASTRANGE@MTPCA.ORG

#  {#section-48 .Style1}

Nevada

Roger Volker

Executive Director

Great Basin Primary Care Association

300 S. Curry Street, Suite 6

Carson City, NV 89703-4669

775-887-0417; 775-887-3562

VOLKER@GBPCA.ORG

#  {#section-49 .Style1}

New Hampshire

Tess Kuenning

Executive Director

Bi-State Primary Care Association

3 South Street

Concord, NH 03301-0000

\(603\) 228-2830; (603) 228-2464

TKUENNING@BISTATEPCA.ORG

#  {#section-50 .Style1}

New Jersey

Katherine Grant-Davis

Executive Director

New Jersey Primary Care Association

14 Washington Road, Suite 211

Princeton Junction, NJ 08550-1030

609-275-8886; 609-936-7247

Njpca2@Aol.Com

New Mexico

David Roddy

Executive Director

New Mexico Primary Care Association

4545 McLeod, NE, Suite D

Albuquerque, NM 87109-0000

\(505\) 880-8882; (505) 880-8885

DRODDY@NMPCA.ORG

#  {#section-51 .Style1}

New York

Mary Keane

Interim Executive Director

Community Health Center Association of New York State, Inc.

254 W. 31st Street, 9th

New York, NY 10001

\(212\) 279-9686, Ex 656; (212) 279-3851

ACS1177@AOL.COM

#  {#section-52 .Style1}

North Carolina

Sonya Bruton

Executive Director

North Carolina Primary Health Care Association

875 Walnut Street, Suite 150

Cary, NC 27511-0000

\(919\) 469-5701; (919) 469-1263

BRUTONS@NCPHCA.ORG

#  {#section-53 .Style1}

North Dakota

Janelle Johnson

Executive Director

North Dakota Branch Office

Community Health Care Association

P.O. Box 1734

Bismarck, ND 58502-1734

\(701\) 221-9824; (701) 258-3161

JANELLE@COMMUNITYHEALTHCARE.NET

Ohio

Joseph Doodan

Executive Director

Ohio Primary Care Association

51 Jefferson Ave.

Columbus, OH 43215-3840

\(614\) 224-1440; (614) 224-2320

JDOODAN@OHIOPCA.ORG

#  {#section-54 .Style1}

Oklahoma

Greta Shepherd

Executive Director

Oklahoma Primary Care Association

4300 N. Lincoln Blvd., Suite 203

Oklahoma City, OK 73105-5106

\(405\) 424-2282 Ex 101; (405) 242-1111

GSHEPHERD@OKPCA.ORG

**Page 3 -- Exhibit 1**

**Primary Care Associations Continued**

Oregon

Ian Timm

Executive Director

Oregon Primary Care Association

812 SW 10th Ave., Suite 204

Portland, OR 97205-0000

\(503\) 228-8852; (503) 228-9887

IAN@NORTHWEST.COM

#  {#section-55 .Style1}

Pennsylvania

Henry Fiumelli

Executive Director

Pennsylvania Forum for Primary Health Care

1035 Mumma Road, Suite 1

Wormleysburg, PA 17043-1147

\(717\) 761-6443; (717) 761-8730

HENRYRF@MAIL.MICROSERVE.NET

#  {#section-56 .Style1}

Puerto Rico

Lisette Rojas, Ph.D.

Executive Director

Asociacion De Salud Primaria De Puerto Rico, Inc.

Edificio La Euskalduna

Calle Navarro #56

Hato Rey, PR 00918-0000

\(787\) 758-3411; (787) 758-1736

ACSPPR@COQUI.NET

#  {#section-57 .Style1}

Rhode Island

Kerrie Jones Clark

Executive Director

Rhode Island Health Care Association

235 Promenade Street, Suite 104

Providence, RI 02908-0000

401-274-1771; 401-274-1789

KCLARK@RIHCA.ORG

#  {#section-58 .Style1}

South Carolina

Lathran Woodard

Executive Director

South Carolina Primary Care Association

2211 Alpine Road Extension

Columbia, SC 29223-0000

\(803\) 788-2778; (803) 788-8233

LATHRAN@SCPHCA.ORG

#  {#section-59 .Style1}

South Dakota

Scot Graff

Executive Director

Community Health Care Association, Inc.

1400 W. 22nd Street

Sioux Falls, SD 57105-1570

\(605\) 357-1515; (605) 357-1510

# SGRAFF@USD.EDU  {#sgraffusd.edu .Style1}

#  {#section-60 .Style1}

Tennessee

Kathy Wood-Dobbins

Executive Director

Tennessee Primary Care Association

210 25th Avenue North, Suite 1112

Nashville, TN 37203-0000

\(615\) 329-3836, Ext 16; (615) 329-3823

KATHY@TNPCA.ORG

Texas

Jose Camacho

Executive Director

Texas Association of Community Health Centers

2301 S. Capital of Texas Hwy, Building H

Austin, TX 78746-0000

\(512\) 329-5959; (512) 329-9189

JCAMACHO@TACHC.ORG

Utah

Bette Vierra

Executive Director

Association for Utah Community Health

2570 West 1700 South, Suite 153

Salt Lake City, UT 84104-0000

\(801\) 974-5522; (801) 974-5563

BETTEVIERRA@AUCH.ORG

Vermont

Tess Kuenning

Executive Director

Vermont Bi-State Primary Care Association

61 Elm Street

Montpelier, VT 05602-2818

802-229-0002; 802-223-2336

TKUENNING@BISTATEPCA.ORG

#  {#section-61 .Style1}

#  {#section-62 .Style1}

Virginia

Neal Graham

Executive Director

Virginia Primary Care Association, Inc.

10800 Midlothian Turnpike, Suite 265

Richmond, VA 23235-0000

\(804\) 378-8801 Ex 17; (804) 379-6593

NGRAHAM@VPCA.COM

#  {#section-63 .Style1}

Washington

Gloria Rodriguez

Executive Director

Washington Association of Community and Migrant Health Center Systems

19226 66th Avenue South, Suite L-102

Kent, WA 98032-0000

\(425\) 656-0848; (425) 656-0849

GROD@WACMHC.ORG

#  {#section-64 .Style1}

North West Regional

Marcia Miller

Executive Director

North West Regional Primary Care Association

6512 23rd Avenue, NW, Suite 305

Seattle, WA 98117-0000

\(206\) 783-3004; (206) 783-4311

MMMILLER@NWRPCA.ORG

West Virginia

Jill Hutchinson

Executive Director

West Virginia Association of Community Health Centers, Inc.

1219 Virginia Street East

Charleston, WV 25301-0000

\(304\) 346-0032; (304) 346-0033

BENOIT32@AOL.COM

Wisconsin

Sarah Lewis

Executive Director

Wisconsin Primary Health Care Association

49 Kessel Court, Suite 210

Madison, WI 53711-0000

\(608\) 277-7477; (608) 277-7474

SVLEWIS@WPHCA.ORG

Wyoming

Executive Director

Wyoming Primary Care Association

P.O. Box 113

Cheyenne, WY 82003-0000

\(307\) 632-5743; (307) 638-6103

WYPCA@WYPCA.ORG

**Page 4 -- Exhibit 1**

**II. PRIMARY CARE OFFICES**

Alabama

Clyde Barganier, DrPh

Director

Bureau of Planning & Resource Development

P.O. Box 303017

Montgomery, AL 36130-3017

\(334\) 206-5396; (334) 206-5434

CBARGANIER@ADPH.STATE.AL.US

Alaska

Patricia Carr

Director

Alaska Department of Health and Social Services

P.O. Box 110616

Juneau, AK 99811-0616

\(907\) 465-8618; (907) 465-6861

PAT_CARR@HEALTH.STATE.AK.US

Arizona

Patricia Tarango

Chief

Arizona Department of Health Services

1740 W. Adams, Room 302

Phoenix, AZ 85007-0000

\(602\) 542-1219; (602) 542-2011

PTARANG@HS.STATE.AZ.US

Arkansas

Bill Rodgers

Director

Arkansas Department of Health, Div of Public Health

4815 W. Markham Street, Slot 22

Little Rock, AR 72202-0000

\(501\) 661-2244; (501) 280-4706

WRODGERS@HEALTHYARKANSAS.COM

California

Earl Green

Director

Office/Statewide Health Planning & Development

1600 9th Street, Room 440

Sacramento, CA 95814-0000

\(916\) 654-2087; (916) 654-3138

EGREEN@OSHPD.STATE.CA.US

Colorado

Kitty Steven, RN, MSN

Director

Colorado Department of Health

4300 Cherry Creek Drive

Denver, CO 80246-1530

\(303\) 692-2582; (303) 782-3448

KITTY.STEVENS@STATE.CO.US

#  {#section-65 .Style1}

#  {#section-66 .Style1}

Connecticut

Beth Weinstein

Director

Family Health Division

410 Capitol Avenue, Ms #22APV

Hartford, CT 06134-0308

\(860\) 509-7832; (860) 509-7720

BETH.WEINSTEIN@PO.STATE.CT.US

Delaware

Kathy Collison

Director

Delaware State Department of Health

P.O. Box 637

Dover, DE 19903-0000

\(302\) 739-4787; (302) 739-6653

KCOLLISON@STATE.DE.US

District Of Columbia

Karyn Berry

Program Manager

Office of Health Planning & Development

825 N. Capitol St., NE, Rm. 3173

Washington, DC 20002-0000

\(202\) 442-5875; (202) 442-4824

<KARYN.BERRY@DC.GOV>

Florida

Kathy Winn

Program Administrator

Department of Health

Division of EMS & Community Health Resources

2020 Capital Circle, SE, Bin#C15

Tallahassee, FL 32388-1735

\(850\) 245-4446 Ex 2709; (850) 922-6296

KATHY_M_WINN@DOH.STATE.FL.US

Georgia

Isiah Lineberry

Director

Georgia Department of Community Health

Office of Rural Health Services

P.O. Box 310

Atlanta, GA 30310-0000

\(229\) 401-3090; (229) 401-3077

ILINEBERRY@DCH.STATE.GA.US

Hawaii

Charlene Gaspar

Grantee Contact

Hawaii State Department of Health

Family Health Services

3652 Kilauea Avenue

Honolulu, HI 96816-0000

\(808\) 733-9017; (808) 733-8369

CPGASPAR@MAIL.FHSD.HEALTH.STATE.HI.US

Idaho

Laura Rowen

Program Manager

Idaho Primary Care Program

P.O. Box 83720

Boise, ID 83720-0036

\(208\) 334-5993; (208) 332-7262

ROWENL@IDHW.STATE.ID.US

Illinois

Mary Ring

Administrator

Illinois Department of Health

535 W. Jefferson Street

Springfield, IL 62761-0000

\(217\) 782-1624; (217) 782-2547

MRING@IDPH.STATE.IL.US

Indiana

Raymond Guest

Director

Indiana State Department of Health

2 N. Meridian Street, 8th Floor

Indianapolis, IN 46204-0000

\(317\) 233-7827; (317) 233-7761

RGUEST@ISDH.STATE.IN.US

Iowa

Carl Kulczyk

Program Planner

Iowa Department of Public Health

Bureau of Community Health Development

321 E. 21st Street

Des Moines, IA 50319-0000

\(515\) 281-7223; (515) 242-6384

CKULCZYK@IDPH.STATE.IA.US

#  {#section-67 .Style1}

#  {#section-68 .Style1}

#  {#section-69 .Style1}

Kansas

Barbara Gibson

Director

Kansas Department of Health & Environment

Curtis State Office Building

1000 SW Jackson, Suite 340

Topeka, KS 66612-1365

\(785\) 296-1200; (785) 296-1231

BGIBSON@KDHE.STATE.KS.US

Kentucky

Danise Newton

Administrator

Kentucky State Department of Health

275 E. Main Street

Frankfort, KY 40621-0000

\(502\) 564-8966; (502) 564-6533

DANISE.NEWTON@MAIL.STATE.KY.US

**Page 5 -- Exhibit 1**

**Primary Care Offices Continued**

Louisiana

Kristy Nichols

Director

Louisiana Department of Health & Hospitals/Office Of Management

1201 Capitol Access Rd., 3rd Fl., Bin 30

Baton Rouge, LA 70821-0000

\(225\) 342-3814; (225) 342-0080

KNICHOLS@DHH.STATE.LA.US

Maine

Sophie Glidden

Director

Maine Department of Human Services

35 Anthony Ave., Station #11

Augusta, ME 04333-0011

\(207\) 624-5424; (207) 624-5431

SOPHIE.E.GLIDDEN@STATE.ME.US

Maryland

Antoinette Coward

Administrator

Maryland Department of Health & Mental Hygiene

Primary Care Unit

201 W. Preston Street

Baltimore, MD 21201-0000

\(410\) 767-5602; (410) 333-7501

COWARDA@DHMH.STATE.MD.US

Massachusetts

Catharine Sibble

Director

Massachusetts Department of Public Health

250 Washington Street, 5th

Boston, MA 02108-4619

\(617\) 624-6043; (617) 624-6062

CATHARINE.SIBBLE@STATE.MA.US

Michigan

Lonnie Barnett

Manager

Michigan Department of Community Health

Health Legislation & Policy Development

320 S. Walnut Street

Lansing, MI 48913-0000

\(517\) 241-2963; (517) 241-0084

BARNETTL@STATE.MI.US

#  {#section-70 .Style1}

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Minnesota

Sheila Brunelle

Director

Minnesota Department of Health

Office of Rural Health and Primary Care

P.O. Box 64975

St. Paul, MN 55164-0975

\(651\) 282-3853; (651) 297-5808

sheila.brunelle@health.state.mn.us

Mississippi

Perelia Taylor

Director

Mississippi State Department of Health

Office of Primary Care Liaison

P.O. Box 1700

Jackson, MS 39215-1700

\(601\) 576-7216; (601) 576-7230

PTAYLOR@MSDH.STATE.MS.US

Missouri

Harold Kirbey

Director

Missouri Department of Health

Division of Health Resources

P.O. Box 570

Jefferson City, MO 65102-0000

\(573\) 751-6272; (573) 526-4102

KIRBEH@MAIL.HEALTH.STATE.MO.US

Montana

Marge Levine

Director

Montana Department of Public Health

P.O. Box 202951

Helena, MT 59620-2951

\(406\) 444-4748; (406) 444-7465

MLVINE@STATE.MT.US

Nebraska

Thomas Rauner

Grantee Contact

Office of Rural Health & Primary Care

301 Centennial Mall South

Lincoln, NE 68509-5044

\(402\) 471-0148; (402) 471-0180

THOMAS.RAUNER@HHSS.STATE.NE.US

Nevada

Judy Wright

Acting Chief

Nevada Department of Human Resources

505 E. King Street, Room 203

Carson City, NV 89701-3711

\(775\) 684-4220; (775) 684-4046

JWRIGHT@GOVMAIL.STATE.NV.US

New Hampshire

Bryan Ayars

Chief

New Hampshire Primary Care Services

Community Health Institute

6 Hazen Drive

Concord, NH 03301-6527

\(603\) 271-4547; (603) 271-1517

# [**BAYARS@DHHS.STATE.NH.US**](mailto:BAYARS@DHHS.STATE.NH.US) {#bayarsdhhs.state.nh.us .Style1}

#  {#section-72 .Style1}

New Jersey

Linda Anderson

Division of Family Health Services

50 E. State Street

Trenton, NJ 08625-0364

\(609\) 292-1495; (609) 292-9599

LANDERSON@DOH.STATE.NJ.US

New Mexico

Harvey Licht

Chief

New Mexico Dept of Health, Public Health Division

P.O. Box 26110

Santa Fe, NM 87502-6110

\(505\) 827-0642; (505) 827-0924

HARVEY.LICHT@ACCESS.GOV

New York

Barry Gray

Director

Workforce Planning, Policy & Resources Devlp

E.S.P. Corning Tower, Rm. 1084

Albany, NY 12237-0053

\(518\) 473-7019; (518) 474-0572

BMG01@HEALTH.STATE.NY.US

North Carolina

Serge Dihoff

Office of Rural Health & Resources Development

311 Ashe Avenue

Raleigh, NC 27606-0000

\(919\) 733-2040; (919) 733-8300

SERGEDIHOFF@NCMAIL.NET

North Dakota

Gary Garland

Director

Office of Community Assistance and Primary Care

600 E. Boulevard Avenue

Bismarck, ND 58505-0200

\(701\) 328-4839; (701) 328-1890

GGARLAND@STATE.ND.US

Ohio

Joel Mariotti

Administrator

Office of Rural Health

246 N. High Street, 6th Floor

Columbus, OH 43215-0000

\(614\) 644-8508; (614) 644-9850

JMARIOTT@GW.ODH.STATE.OH.US

#########  {#section-73 .unnumbered}

**Page 6 -- Exhibit 1**

**Primary Care Offices Continued**

Oklahoma

Michael Brown

Oklahoma State Department of Health

1000 NE 10th Street, Room 1113

Oklahoma City, OK 73117-1299

\(405\) 271-8428; (405) 271-1225

MIKEBR@HLTH.STATE.OK.US

#  {#section-74 .Style1}

#  {#section-75 .Style1}

Oregon

Joel Young

Director

Office of Community Services

800 NE Oregon Street, Suite 930

Portland, OR 97232-0000

\(503\) 731-4017; (503) 731-4078

JOEL.YOUNG@STATE.OR.US

#  {#section-76 .Style1}

#  {#section-77 .Style1}

Pennsylvania

Joseph May

Director

Pennsylvania Department of Health

P.O. Box 90, Rm. 709

Harrisburg, PA 17108-0000

\(717\) 772-5298; (717) 705-6525

JMAY@STATE.PA.US

Puerto Rico

Nadia Gardana

Puerto Rico Dept of Health, Office of Federal Affairs

P.O. Box 70139

San Juan, PR 00936-8139

\(787\) 274-7735; (787) 759-6552

NGARDANA@SALUD.GOV.PR

Rhode Island

Mary Ann Miller

Chief

Rhode Island Dept of Health, Preventive Health

3 Capitol Hill, Rm. 408

Providence, RI 02908-0000

\(401\) 222-1171; (401) 222-4415

MARYANNEM@DOH.STATE.RI.US

#  {#section-78 .Style1}

South Carolina

Mark Jordan

Director

South Carolina Dept of Health & Environment Control

P.O. Box 101106

Columbia, SC 29211-0000

\(803\) 898-0766; (803) 898-0445

JORDANMA@COLUMB61.DHEC.STATE.SC.US

South Dakota

Bernard Osberg

South Dakota Dept of Health, Office Of Rural Health

445 E. Capitol

Pierre, SD 57501-0000

\(605\) 773-3364; (605) 773-5904

BERNIEO@DOH.STATE.SD.US

Tennessee

Susan Veale

Tennessee Dept of Health, Access & Rural Health

710 Hart Lane

Nashville, TN 37247-0000

\(615\) 227-7070; (615) 262-6139

SVEALE@MAIL.STATE.TN.US

#  {#section-79 .Style1}

#  {#section-80 .Style1}

Texas

Connie Berry

Director

Texas Department of Health

Community Oriented Primary Care

1110 W. 49th Street

Austin, TX 78756-0000

\(512\) 458-7518; (512) 458-7235

CONNIE.BERRY@TDH.STATE.TX.US

Utah

Marilyn Haynes-Brokopp

Bureau of Primary Care & Rural Health

P.O. Box 142005

Salt Lake City, UT 84114-2005

\(801\) 538-6113; (801) 538-6387

MBROKOPP@UTAH.GOV

#  {#section-81 .Style1}

#  {#section-82 .Style1}

Vermont

Craig Stevens

Contact

Vermont Department of Health

Office of Primary Care

P.O. Box 70

Burlington, VT 05402-0070

\(802\) 863-7606; (802) 651-1634

CSTEVEN@VDH.STATE.VT.US

#  {#section-83 .Style1}

Virgin Islands

Pamela A. Eckstein

Director

Virgin Islands Department of Health

21-22 Kongens Gade

Government House

St. Thomas, VI 00802

\(340\) 693-4315; (340) 693-4374

IRIEASSOCINC@EARTHLINK.NET

Virginia

Chandra Shrestha, Ph.D.

Virginia Department of Health

Center for Primary Care and Rural Health

1500 E. Main Street, Suite 227

Richmond, VA 23219-0000

\(804\) 786-4767; (804) 371-0116

CSHRESTHA@VDH.STATE.VA.US

Washington

Mary Looker

Director

Washington Department of Health

Office of Community & Rural Health

P.O. Box 47834

Olympia, WA 98504-7834

\(360\) 705-6764; (360) 664-9273

MARY.LOOKER@DOH.WA.GOV

West Virginia

Phil Schenk

Director

Bureau of Public Health

Office of Community and Rural Health

350 Capitol Street, Rm. 515

Charleston, WV 25301-3716

\(304\) 558-4007; (304) 558-1437

PHILSCHENK@WVDHHR.ORG

Wisconsin

Mary Erikson

Chief

Wisconsin Department of Health

Division of Public Health

P.O. Box 2659

Madison, WI 53701-2659

\(608\) 267-7121; (608) 266-8925

ERIKSM@DHFS.STATE.WI.US

Wyoming

Daniel Stackis

Administrator

Wyoming Department of Health

Primary Care Office

2020 Carey Avenue, 8th Floor

Cheyenne, WY 82002-0000

\(307\) 777-6918; (307) 777-7127

<DSTACK@STATE.WY.US>

########  {#section-84 .unnumbered}

######## EXHIBIT 2

######## DEFINITIONS FOR NEW ACCESS POINTS 

######## -- FISCAL YEAR 2004

**ALTERATION/RENOVATION:** Alteration and renovation (A&R) is defined as
work required to change the interior arrangements or other physical
characteristics of an existing facility or installed equipment so that
it may be more effectively utilized for its currently designated purpose
or adapted to an alternative use to meet a programmatic requirement. A&R
costs that do not constitute construction are allowable charges to PHS
supported projects and activities. Section 330 grant funds may not be
used to support construction of facilities

**FULL OPERATIONAL CAPACITY:** relates to the number of projected
providers and the number of patients within the designated target
population that the center can realistically serve after two years of
Federal funding of the project. This capacity should be determined using
the projected provider levels required by the center to operate at its
full level of services (i.e., at the

full-range of services required by section 330 statute, regulations and
Health Center Program Expectations). **It is expected that full
operational capacity will be achieved within 2 years of receiving
Federal section 330 support.**

**For CHCs and MHCs**, full operational capacity for a center can be
calculated based on the projected staffing levels for the new access
point(s). In general applicants may use a physician to population ratio
of 1:1,500 as a guide to calculate their appropriate full operational
patient capacity. For midlevel practitioners (e.g., nurse practitioners,
physician assistants, and certified nurse midwives), applicants may use
a 1:750 provider to patient ratio. For example, a practice with a team
of two full-time physicians and a full-time nurse practitioner would
have a full operational capacity of 3 full-time equivalent (FTE)
providers and 3,750 patients.

In general, for **CHCs and MHCs** in urban areas, it is recommended that
a minimum of five full-time equivalent (5 FTEs) providers be available
to provide services to patients as appropriate and reasonable based on
the population and service delivery plan proposed. In rural areas, it is
recommended that three full-time equivalent (3 FTEs) providers be
available to provide services to patients as appropriate and reasonable
based on the population and service delivery plan proposed. (**Note**:
**This recommendation does not preclude a more limited provider level
for a new access point application**.)

**HOMELESS:** A homeless individual means an individual who lacks
housing (without regard to whether the individual is a member of a
family), including an individual whose primary residence is a supervised
public or private facility that provides temporary accommodations and an
individual who is a resident in transitional housing.

**MIGRATORY AND SEASONAL AGRICULTURAL WORKERS:** Migratory agricultural
worker means an individual whose principal employment is in agriculture,
who has so been employed within the last 24 months, and who establishes
for the purposes of such employment a temporary abode. Seasonal
agricultural worker means an individual whose principal employment is in
agriculture on a seasonal basis and who is not a migrant agricultural
worker.

**Page 2 -- EXHIBIT 2**

**NEW ACCESS POINT:** A new access point is a new delivery site for the
provision of comprehensive primary and preventive health care services.
The two types of new access points referenced in this application
guidance are (1) new starts and (2) satellites. (These are described
below.) Every competitive new access point will demonstrate compliance
with the applicable requirements of section 330 of the PHS Act, the
implementing regulations and BPHC Program Expectations. To be
competitive, new access point applications will:

> \(a\) demonstrate that all persons will have ready access to the full
> range of required primary, preventive, enabling (see Exhibit 2, page
> [83](#exhibit-2), for a definition) and supplemental health services,
> including oral health care, mental health care and substance abuse
> services, either directly on-site or through established arrangements
> without regard to ability to pay;
>
> \(b\) demonstrate compliance at the time of application (or a plan for
> compliance within 120-days of a grant award) with the requirements of
> section 330, its guidelines and regulations;
>
> \(c\) demonstrate how section 330 funds will expand services and
> increase the number of people served through the establishment of a
> new service delivery site(s) and/or at an existing site(s) not
> currently within a BPHC funded scope of project;
>
> \(d\) demonstrate that the site(s) will be operational and services
> will be initiated within 120 days of a grant award; and
>
> \(e\) emonstrate how section 330 funds will augment already available
> funds and in-kind resources to expand existing primary health care
> service capacity to currently underserved populations.

**NEW STARTS:** A new start applicant is an organization that
**currently DOES NOT RECEIVE Federal grant support under the
Consolidated Health Center Program authorized under section 330 of the
PHS Act**. A new start application should address the entire scope of
the project being proposed for Federal support. New start applicants may
submit an application for Federal support for a single site or a
multi-site operation and may request funding for one or multiple types
of health centers authorized under section 330 based on the
population(s) to be served.

**SATELLITES:** A satellite applicant is an organization **that
CURRENTLY RECEIVES grant support under under the Consolidated Health
Center Program authorized under section 330 of the PHS Act.** All
satellite applicants must propose to establish a new access point(s) to
serve a new patient population that is outside the applicant's approved
scope of project (i.e., not listed on the applicant's most recently
submitted Exhibit B "Service Sites" from the continuation application or
Change in Scope request under any section 330 program). A satellite
application should address **ONLY** the service area and target
population of the proposed new access point(s) (i.e., only the new
site(s) and service area proposed in the satellite application, not all
of the sites or the entire service area of the applicant) in terms of
need, population to be served and the new delivery system being
proposed. Satellite applicants may submit an application for Federal
support to establish a single new access point or multiple access points
(outside of their approved scope of project under any section 330
program) and may request funding for one or multiple types of health
centers authorized under section 330 based on the population(s) to be
served. Satellite applicants may not request funding to support the
expansion/addition of services/programs/staff at a site(s) that is
currently listed as being a part of their approved scope of project
under the Consolidated Health Center Program.

**Page 3 -- EXHIBIT 2**

**SCHOOL BASED HEALTH CENTER:** is defined as a health center located in
a school or on school grounds that provides on-site comprehensive
primary and preventative health services, including referrals, tracking
and follow-up, throughout the school year or year round with signed
agreements with the host school and local school district. The SBHC is
expected to operate at least 30 hours per week and provide 24-hour per
day/7 days per week (on-site or through referral) backup coverage to all
students and users enrolled in the SBHC. Some SBHC services may be
provided off site through established arrangements within the applicant
organization. SBHCs may serve other community members in addition to the
students attending the school(s) where the SBHC is located, in other
locations operated by the applicant organization.

**SERVICE AREA:** is defined as a geographic area with precise
boundaries that is federally-

designated, in whole or in part, as a MUA or a MUP. The size of the
service area should be appropriate to provide services in a timely and
appropriate fashion. Within the service area, barriers to care should be
overcome to the extent possible and the applicant must provide access to
anyone who seeks services. The delineation of the service area should
conform to relevant boundaries (such as political subdivision, school
districts, health and social service programs) and should include a
description of the service area population.

**SPARSELY POPULATED RURAL AREAS:** Given the unique needs of sparsely
populated rural and frontier areas, preference will be given to new
access point applications from these areas. Organizations applying under
the sparsely populated rural areas classification should describe their
proposed service area in terms of population density, travel distance to
the nearest provider and geographic isolation. Using the frontier
definition as a starting point (i.e., geographic area with less than 7
people per square mile), applicants must clearly demonstrate why their
proposed service area should be classified as sparsely populated.

In terms of project plan requirements, it is recognized that the
recommended level of staffing and/or services may not be supportable in
sparsely populated areas. Therefore alternative methods of providing
necessary support for isolated providers, including participation in
rural service delivery networks may be considered appropriate. For
example, health centers that by themselves may not be able to meet the
staffing recommendations and/or service requirements may, through formal
agreements regarding clinical and referral arrangements or strong
collaborative relationships with other local providers, be considered to
have met the staffing level recommendations and/or service requirements.

In addition, applicants from sparsely populated rural or frontier areas
may request a waiver from the governing board requirements (section
330(j)(3)(H))under section 330(l)(3)(H). However, such applicants must
clearly demonstrate why any or all of the governing board requirements
cannot be met and must provide a documented plan for soliciting
community input in the development and operation of the new service
delivery site.

**TARGET POPULATION:** A target population is usually a subset of the
entire service area population but may include all residents of the
service area. The description of the target population

**Page 4 -- EXHIBIT 2**

should include the major health problems of the target population and
should serve as the basis for the center\'s service delivery plan. The
target population for a center may be composed of a particular
ethnic/socio-economic group or may be composed of a variety of different
ethnic/socio-economic groups. A target population may also be a sparsely
populated rural or frontier area. It may not, however, be limited in
terms of age or gender.

-   **For CHCs** target population refers to the individuals within the
    service area to whom the center will direct its service delivery
    plan.

-   **For MHCs** the target population refers to the migratory and
    seasonal farmworker individuals within the service area to whom the
    center will direct its service delivery plan.

-   **For HCHs** the target population refers to the homeless
    individuals within the service area to

-   whom the center will direct its service delivery plan.

-   **For PHPCs** the target population refers to the residents of one
    or more public housing developments and the surrounding areas as
    appropriate.

-   **For SBHCs** the target population refers to the students and other
    family members of students of a particular school or schools, and
    the surrounding areas as appropriate.

All health centers must provide access to the full-range of required
services for all life cycle groups. This requirement does not preclude a
more limited target population or range of services for a particular
service delivery site. In such a case, assurance must be provided that
all patients have access to the full-range of required services and
necessary supplemental services within the health center\'s current
service delivery capacity.

.

# 

# ATTACHMENTS

# 

######### ATTACHMENT A

######## ELIGIBILITY CRITERIA FOR 

######## NEW ACCESS POINTS - FISCAL YEAR 2004

**(MUST MEET ALL OF THESE REQUIREMENTS)**

A. Applicant is a public or private, nonprofit entity, including
faith-based and community-based organizations.

B.  Applicant has requested section 330 funds to establish a new access
    point(s) for the provision of comprehensive primary and preventive
    health care services;

C.  Applicant proposes to serve a defined geographic area that is
    federally-designated, in whole or in part, as a Medically
    Underserved Area (MUA) or a Medically Underserved Population (MUP).
    \[If the area is not currently federally-designated, in whole or in
    part as a MUA or MUP, the applicant must provide documentation that
    the request has been submitted in order for timely processing prior
    to a final BPHC funding decision on the FY 2004 New Start or
    Satellite application\]. **NOTE: MHC, HCH and PHPC sites do not need
    to have MUA/MUP designation.**

D.  Applicant has submitted a request for annual Federal section 330
    funding in Year 1, Year 2, or Year 3 that, as presented on Budget
    Form SF 424A with accompanying Budget Narrative, **DOES NOT exceed
    the established cap on annual Federal funding** available for
    section 330 new access points.

E.  Applicant does not propose a new access point(s) to provide a single
    service, such as dental, mental health or prenatal services.

F.  Applicant does not propose a new access point(s) to serve a single
    age group (i.e., children) or lifecycle (i.e., geriatric only)
    except in the case of organizations applying under section 330(h) to
    target services for homeless children or adolescents and/or children
    and youth at risk of homelessness.

G.  Applicant is not designated as an exceptional/high risk grantee at
    the time of application.

H.  *(Satellite Applicants Only)* Applicant does not request funding to
    support the relocation of a site(s) already in their approved scope
    of project (i.e., a site listed on the applicant's most recently
    approved Exhibit B "Service Sites" from the Single Grant Award) to a
    new location/facility.

I.  *(Satellites Applicants Only)* Applicant does not propose the
    expansion of capacity (additional providers, new services, etc.) at
    a site(s) already in their approved scope of project (i.e., not
    listed on the applicant's most recently approved Exhibit B "Service
    Sites" from the continuation application or approved Change in Scope
    request) under any section 330 program including applications
    requesting funding to establish a new type of health center (i.e.,
    CHC, MHC, HCH, PHPC, SBHC) at sites already listed under the
    organization's Federal scope of project.

######### ATTACHMENT B

######## 

######## AWARDING FACTORS FOR 

######## NEW ACCESS POINTS -- FISCAL YEAR 2004

HRSA intends to achieve a wide geographic distribution of New Access
Point awards in FY 2004**.** The need for primary health care services
within a Federally defined county along the United States/Mexico Border
has been identified as an area of high need. Therefore, we strongly
encourage all eligible applicants in these areas to submit an
application under this announcement.

**I. FUNDING PREFERENCE**

A funding preference is defined as the funding of a specific category or
group of approved applications ahead of other categories or groups of
applications. There is one funding preference for New Access Points.

> A. SPARSELY POPULATED RURAL AREAS
>
> Preference will be given to organizations proposing to serve sparsely
> populated rural or frontier areas (See Exhibit 2, page
> [83](#exhibit-2) for a definition).

**II. GENERAL AWARD FACTORS:**

A. RURAL/URBAN DISTRIBUTION OF AWARDS:

> Aggregate awards in FY 2004 to serve rural and urban areas will be
> made to ensure that no more than 60 percent and no fewer than 40
> percent of the people served come from either rural or urban areas.

B. GEOGRAPHIC CONSIDERATION:

> The goal of the HRSA in making this funding announcement is to expand
> the current safety net on a national basis by creating new access
> points in areas not currently served by a funded health center.
> Therefore, the HRSA will consider geographic distribution when
> deciding which applications to fund.
>
> C. PERFORMANCE UNDER SECTION 330 PROGRAM EXPECTATIONS:
>
> Current grantees found to be out of compliance with section 330
> program expectations may not be considered for funding.

######### ATTACHMENT C

######## NEED FOR ASSISTANCE CRITERIA FOR

######## NEW ACCESS POINTS -- FISCAL YEAR 2004

As part of the application, applicants MUST COMPLETE AND SUBMIT the Need
for Assistance Worksheet found in Attachment D. Applicants that score 70
or higher on the need for assistance component of the application will
have the merits of the application evaluated by reviewers using
published review criteria with points assigned up to a maximum of 100
points.

The scoring of Need for Assistance will be based on data about both the
proposed service area and target population. **New start applicants**
are expected to provide data for the proposed scope of project.
**Satellite applicants** are expected to provide data for the **proposed
new service delivery site ONLY.** If more than one site or target
population is included in the proposal, the Need for Assistance
worksheet is expected to provide data on the combined data for all
target populations and sites.(i.e., only one comprehensive Need for
Assistance Worksheet will be accepted). If target population data are
not available for any of the following rating criteria, the applicant
may provide service area data only. Applicants are expected to provide
the most recently available data.

The following guidelines are in place for completing the Need for
Assistance Worksheet. If the responses to the Need for Assistance
Worksheet are not presented appropriately, as described below, the
applicant may receive the minimum points allowed for the applicable
question.

> 1\. All responses must be given in the format requested (i.e., if a
> percentage is requested, the response must be a percentage; if a rate
> is requested, the response must be a rate).
>
> 2\. Documentation of the source of the data is required.
>
> 3\. Data cited must be the most recent data available.
>
> 4\. Data must be from a reliable and independent source including:
> Census data; Service area data; Local or State-level data; and/or
> National data, where no other data is available.
>
> NOTE: Applicants should use the most geographically focused data
> available. Applicants may not use data generated by their own internal
> data systems to complete the Need for Assistance Worksheet.
>
> 5\. Each response must clearly address the target population(s) to be
> served. If an applicant proposes to serve multiple sites or service
> areas, the Need for Assistance Worksheet should include responses that
> represent the total targeted populations/areas. No more than one
> response should be submitted for each question.
>
> 6\. All responses must be finite numbers (i.e., 212) and cannot be
> presented as ranges (i.e., 31-35).
>
> 7\. In completing the Health Disparities section, a response must be
> presented for the target population as well as for the benchmark area.
> A different response, such as County, State, National or other
> established reporting area, must also be provided be used as a point
> of comparison for the target population. As with item #4, applicants
> should use the most geographically focused data available for both the
> target population and the benchmark area.
>
> 8\. Only one response may be provided under the Health Disparity
> Factor "2bb. Other".

Eligible applicants will be evaluated in accordance with the following
criteria (total 100 points):

1.  BARRIERS AND ACCESS TO CARE: each applicant must respond to **FIVE**
    of the following: (maximum 70 points)

\(a\) **Geographic barriers** based on average travel time/distance by
the means most commonly used by the target population (e.g., car, public
transportation, walking, etc.) from home/shelter/ camp to the nearest
source of primary care that is accessible to the target population
(e.g., a physician willing to accept new Medicaid patients and/or has a
published sliding fee schedule for people below 200 percent of poverty).

0 -- 20 minutes 0 points

21 -- 29 minutes 6 points

30 -- 44 minutes 8 points

45 -- 59 minutes 10 points

60 -- 74 minutes 12 points

75 + minutes 14 points

**or**

0 -- 10 miles 0 points

11 -- 19 miles 6 points

20 -- 29 miles 8 points

30 -- 49 miles 10 points

50 -- 59 miles 12 points

60 + miles 14 points

\(b\) **Length of waiting time** for public housing and Section 8
certificates in the proposed service area:

> Less than 90 days 0 points
>
> 3 -- 5 months 6 points

6 -- 12 months 8 points

> 13 -- 18 months 10 points
>
> 19 -- 24 months 12 points
>
> Greater than 25 months 14 points

\(c\) Percentage of population 5 years or older who speak a **language
other than English** at home:

\<1 % 0 points

1 -- 2 % 6 points

3 -- 4 % 8 points

5 -- 7 % 10 points

8 -- 12 % 12 Points

13 + % 14 points

\(d\) **Shortage of primary care physicians** necessary to meet the
needs of the target population = Designation of the service area as a
Federal Health Professional Shortage Area (HPSA):

NO 0 points

YES 14 points

\(e\) **Percentage of Individuals Below 200 percent** of the Federal
Poverty Index in the Target Population

> 0 - 9% 0 points
>
> 10 - 19% 6 points
>
> 20 - 29% 8 points
>
> 30 - 39% 10 points
>
> 40 - 49% 12 points
>
> 50+ % 14 points

\(f\) **Life Expectancy Rate** (based on life expectancy at birth in
years):

> 82+ years 0 points
>
> 77 -- 81 years 8 points
>
> 73 -- 76 years 10 points
>
> 68 -- 72 years 12 points
>
> 0 -- 67 years 14 points

\(g\) **Percentage of Uninsured Individuals** in the Target Population
\[If information is unavailable, use number of individuals below 200
percent of poverty minus the number of Medicaid beneficiaries\]

> 0 - 9% 0 points

10 - 14% 8 points

> 15 - 24% 10 points
>
> 25 - 34% 12 points
>
> 35+ % 14 points

\(h\) **Unemployment rate** in the target population

> 0 -- 1 % 0 points
>
> 2 -- 3.5 % 6 points
>
> 3.6 -- 5.0 % 8 points
>
> 5.1 -- 6.5 % 10 points
>
> 6.6 -- 8.0 % 12 points
>
> 8.1+ % 14 points

2\. HEALTH DISPARITY FACTORS: Each applicant must respond to **ten**
(**10**) of the following items. Responses must be based on the
rate/percentage/etc., in the proposed TARGET POPULATION. If information
is not available for the target population, service area data may be
substituted. If the application proposes to serve a special population
group, responses in this section should demonstrate the unique Health
Disparities of the special population. (3 points each - maximum 30
points)

> 2a. Cancer rate (age adjusted death rate for all cancers per 100,000
> people)
>
> 2b. Low birthweight rate (per 1,000 live births)
>
> 2c. Infant mortality rate (per 1,000 live births)
>
> 2d. Rate of exposure (i.e., hypothermia, heat stroke, etc.)
>
> 2e. Asthma rate
>
> 2f. Diabetes rate
>
> 2g. Nutrition rate (e.g., hunger, malnutrition, etc.)
>
> 2h. Coronary heart disease rate (age adjusted death rate for all
> cancers per 100,000 people)
>
> 2i. Rate of occupational (e.g., pesticide) and environmental hazard
> exposures
>
> 2j. Skin disorders rate (e.g., acne, eczema, ring worm, etc.)
>
> 2k. Dental disease rate (e.g., caries, lack of teeth, periodontal
> disease)
>
> 2l. Teen pregnancy rate
>
> 2m. Late entry into prenatal care
>
> 2n. Obesity rate
>
> 2o. Depression rate
>
> 2p. Suicide rate
>
> 2q. Hypertension rate
>
> 2r. HIV/AIDS/STDs rate
>
> 2s. Unintentional injury rate
>
> 2t. Percent of elderly
>
> 2u. Substance abuse rate
>
> 2v. ADD/ADHD rate
>
> 2w. Rate of respiratory infection
>
> 2x. Immunization rate
>
> 2y. Rate of school absenteeism
>
> 2z. Percent of minority populations
>
> 2aa. Rate of serious mental illness (e.g., schizophrenia, bi-polar,
> etc.)
>
> 2bb. Other (must be health related): *ONE RESPONSE ONLY*

######### ATTACHMENT D

######## NEED FOR ASSISTANCE WORKSHEET FOR 

######## NEW ACCESS POINTS -- FISCAL YEAR 2004

***MUST BE COMPLETED AND INCLUDED WITH THE GRANT APPLICATION***

All responses in this section must be given in the format requested
(i.e., if a percentage is requested, the response must be a percentage;
if a rate is requested, the response must be a rate). ***If the response
is not provided in the requested format, the applicant will receive the
minimum points allowed for that question.***

Documentation of the source of the data is required. ***If there is no
source documented, the applicant will only receive the minimum points
allowed for that question.***

**Applications that score 70 or higher on the need for assistance
component of the application will have the merits of the application
evaluated by an Independent Review Committee.**

See Attachment C, page [90](#attachment-c), for scoring of the Need for
Assistance Worksheet**.**

+-----+-------------------+-------+---+---+---+----------+-------------+
| **R |                   |       |   |   |   |          |             |
| esp |                   |       |   |   |   |          |             |
| ond |                   |       |   |   |   |          |             |
| to  |                   |       |   |   |   |          |             |
| f   |                   |       |   |   |   |          |             |
| ive |                   |       |   |   |   |          |             |
| (5) |                   |       |   |   |   |          |             |
| of  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| Ba  |                   |       |   |   |   |          |             |
| rri |                   |       |   |   |   |          |             |
| ers |                   |       |   |   |   |          |             |
| and |                   |       |   |   |   |          |             |
| Acc |                   |       |   |   |   |          |             |
| ess |                   |       |   |   |   |          |             |
| to  |                   |       |   |   |   |          |             |
| C   |                   |       |   |   |   |          |             |
| are |                   |       |   |   |   |          |             |
| que |                   |       |   |   |   |          |             |
| sti |                   |       |   |   |   |          |             |
| ons |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| A   |                   |       |   |   |   |          |             |
| tta |                   |       |   |   |   |          |             |
| chm |                   |       |   |   |   |          |             |
| ent |                   |       |   |   |   |          |             |
| C,  |                   |       |   |   |   |          |             |
| S   |                   |       |   |   |   |          |             |
| ect |                   |       |   |   |   |          |             |
| ion |                   |       |   |   |   |          |             |
| 1   |                   |       |   |   |   |          |             |
| .** |                   |       |   |   |   |          |             |
| Ple |                   |       |   |   |   |          |             |
| ase |                   |       |   |   |   |          |             |
| wr  |                   |       |   |   |   |          |             |
| ite |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| Qu  |                   |       |   |   |   |          |             |
| est |                   |       |   |   |   |          |             |
| ion |                   |       |   |   |   |          |             |
| \#  |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| fi  |                   |       |   |   |   |          |             |
| rst |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn, |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| qu  |                   |       |   |   |   |          |             |
| est |                   |       |   |   |   |          |             |
| ion |                   |       |   |   |   |          |             |
| s   |                   |       |   |   |   |          |             |
| ubj |                   |       |   |   |   |          |             |
| ect |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| for |                   |       |   |   |   |          |             |
| mat |                   |       |   |   |   |          |             |
| ion |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| sec |                   |       |   |   |   |          |             |
| ond |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn, |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| app |                   |       |   |   |   |          |             |
| lic |                   |       |   |   |   |          |             |
| ant |                   |       |   |   |   |          |             |
| re  |                   |       |   |   |   |          |             |
| spo |                   |       |   |   |   |          |             |
| nse |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| th  |                   |       |   |   |   |          |             |
| ird |                   |       |   |   |   |          |             |
| col |                   |       |   |   |   |          |             |
| umn |                   |       |   |   |   |          |             |
| and |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| sou |                   |       |   |   |   |          |             |
| rce |                   |       |   |   |   |          |             |
| for |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| re  |                   |       |   |   |   |          |             |
| spo |                   |       |   |   |   |          |             |
| nse |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| fou |                   |       |   |   |   |          |             |
| rth |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn. |                   |       |   |   |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| Que | Question Subject  |       |   | R |   | >        |             |
| st. | information       |       |   | e |   | Identify |             |
| \#  | (e.g.,            |       |   | s |   | > Source |             |
|     | "Geographic       |       |   | p |   | > and    |             |
|     | barriers")        |       |   | o |   | > Date   |             |
|     |                   |       |   | n |   |          |             |
|     |                   |       |   | s |   |          |             |
|     |                   |       |   | e |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| 1\. |                   |       |   |   |   |          |             |
| ( ) |                   |       |   |   |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| 1\. |                   |       |   |   |   |          |             |
| ( ) |                   |       |   |   |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| 1\. |                   |       |   |   |   |          |             |
| ( ) |                   |       |   |   |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| 1\. |                   |       |   |   |   |          |             |
| ( ) |                   |       |   |   |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| 1\. |                   |       |   |   |   |          |             |
| ( ) |                   |       |   |   |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| **R |                   |       |   |   |   |          |             |
| esp |                   |       |   |   |   |          |             |
| ond |                   |       |   |   |   |          |             |
| to  |                   |       |   |   |   |          |             |
| ten |                   |       |   |   |   |          |             |
| (   |                   |       |   |   |   |          |             |
| 10) |                   |       |   |   |   |          |             |
| of  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| Hea |                   |       |   |   |   |          |             |
| lth |                   |       |   |   |   |          |             |
| Di  |                   |       |   |   |   |          |             |
| spa |                   |       |   |   |   |          |             |
| rit |                   |       |   |   |   |          |             |
| ies |                   |       |   |   |   |          |             |
| lis |                   |       |   |   |   |          |             |
| ted |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| A   |                   |       |   |   |   |          |             |
| tta |                   |       |   |   |   |          |             |
| chm |                   |       |   |   |   |          |             |
| ent |                   |       |   |   |   |          |             |
| C   |                   |       |   |   |   |          |             |
| .** |                   |       |   |   |   |          |             |
| Ple |                   |       |   |   |   |          |             |
| ase |                   |       |   |   |   |          |             |
| wr  |                   |       |   |   |   |          |             |
| ite |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| I   |                   |       |   |   |   |          |             |
| tem |                   |       |   |   |   |          |             |
| \#  |                   |       |   |   |   |          |             |
| f   |                   |       |   |   |   |          |             |
| rom |                   |       |   |   |   |          |             |
| A   |                   |       |   |   |   |          |             |
| tta |                   |       |   |   |   |          |             |
| chm |                   |       |   |   |   |          |             |
| ent |                   |       |   |   |   |          |             |
| C   |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| fi  |                   |       |   |   |   |          |             |
| rst |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn, |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| orr |                   |       |   |   |   |          |             |
| esp |                   |       |   |   |   |          |             |
| ond |                   |       |   |   |   |          |             |
| ing |                   |       |   |   |   |          |             |
| Hea |                   |       |   |   |   |          |             |
| lth |                   |       |   |   |   |          |             |
| Dis |                   |       |   |   |   |          |             |
| par |                   |       |   |   |   |          |             |
| ity |                   |       |   |   |   |          |             |
| Fac |                   |       |   |   |   |          |             |
| tor |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| sec |                   |       |   |   |   |          |             |
| ond |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn, |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| d   |                   |       |   |   |   |          |             |
| ata |                   |       |   |   |   |          |             |
| (   |                   |       |   |   |   |          |             |
| rat |                   |       |   |   |   |          |             |
| e/p |                   |       |   |   |   |          |             |
| erc |                   |       |   |   |   |          |             |
| ent |                   |       |   |   |   |          |             |
| /et |                   |       |   |   |   |          |             |
| c.) |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| tar |                   |       |   |   |   |          |             |
| get |                   |       |   |   |   |          |             |
| p   |                   |       |   |   |   |          |             |
| opu |                   |       |   |   |   |          |             |
| lat |                   |       |   |   |   |          |             |
| ion |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| th  |                   |       |   |   |   |          |             |
| ird |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn, |                   |       |   |   |   |          |             |
| d   |                   |       |   |   |   |          |             |
| ata |                   |       |   |   |   |          |             |
| (   |                   |       |   |   |   |          |             |
| rat |                   |       |   |   |   |          |             |
| e/p |                   |       |   |   |   |          |             |
| erc |                   |       |   |   |   |          |             |
| ent |                   |       |   |   |   |          |             |
| /et |                   |       |   |   |   |          |             |
| c.) |                   |       |   |   |   |          |             |
| for |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| omp |                   |       |   |   |   |          |             |
| ari |                   |       |   |   |   |          |             |
| son |                   |       |   |   |   |          |             |
| f   |                   |       |   |   |   |          |             |
| rom |                   |       |   |   |   |          |             |
| Nat |                   |       |   |   |   |          |             |
| ion |                   |       |   |   |   |          |             |
| al, |                   |       |   |   |   |          |             |
| Sta |                   |       |   |   |   |          |             |
| te, |                   |       |   |   |   |          |             |
| Cou |                   |       |   |   |   |          |             |
| nty |                   |       |   |   |   |          |             |
| or  |                   |       |   |   |   |          |             |
| ot  |                   |       |   |   |   |          |             |
| her |                   |       |   |   |   |          |             |
| es  |                   |       |   |   |   |          |             |
| tab |                   |       |   |   |   |          |             |
| lis |                   |       |   |   |   |          |             |
| hed |                   |       |   |   |   |          |             |
| rep |                   |       |   |   |   |          |             |
| ort |                   |       |   |   |   |          |             |
| ing |                   |       |   |   |   |          |             |
| a   |                   |       |   |   |   |          |             |
| rea |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| fou |                   |       |   |   |   |          |             |
| rth |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn, |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| sou |                   |       |   |   |   |          |             |
| rce |                   |       |   |   |   |          |             |
| and |                   |       |   |   |   |          |             |
| d   |                   |       |   |   |   |          |             |
| ate |                   |       |   |   |   |          |             |
| for |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| d   |                   |       |   |   |   |          |             |
| ata |                   |       |   |   |   |          |             |
| for |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| tar |                   |       |   |   |   |          |             |
| get |                   |       |   |   |   |          |             |
| p   |                   |       |   |   |   |          |             |
| opu |                   |       |   |   |   |          |             |
| lat |                   |       |   |   |   |          |             |
| ion |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| fi  |                   |       |   |   |   |          |             |
| fth |                   |       |   |   |   |          |             |
| col |                   |       |   |   |   |          |             |
| umn |                   |       |   |   |   |          |             |
| and |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| sou |                   |       |   |   |   |          |             |
| rce |                   |       |   |   |   |          |             |
| and |                   |       |   |   |   |          |             |
| d   |                   |       |   |   |   |          |             |
| ate |                   |       |   |   |   |          |             |
| for |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| d   |                   |       |   |   |   |          |             |
| ata |                   |       |   |   |   |          |             |
| for |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| omp |                   |       |   |   |   |          |             |
| ari |                   |       |   |   |   |          |             |
| son |                   |       |   |   |   |          |             |
| d   |                   |       |   |   |   |          |             |
| ata |                   |       |   |   |   |          |             |
| in  |                   |       |   |   |   |          |             |
| the |                   |       |   |   |   |          |             |
| fi  |                   |       |   |   |   |          |             |
| nal |                   |       |   |   |   |          |             |
| c   |                   |       |   |   |   |          |             |
| olu |                   |       |   |   |   |          |             |
| mn. |                   |       |   |   |   |          |             |
+-----+-------------------+-------+---+---+---+----------+-------------+
| I   | Health Disparity  | T     | C |   | > |          | > Source    |
| tem | Factor            | arget | o |   |   |          | > and date  |
| \#  |                   | Popul | m |   | S |          | > for       |
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|     |                   | data  | a |   | u |          |  comparison |
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+
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+-----+-------------------+-------+---+---+---+----------+-------------+