Bureau of Primary Health Care (BPHC)

UNIFORM DATA SYSTEM

Calendar Year 2004

UDS Reporting Instructions

for Section 330 Grantees

For help contact: 866-837-4357 (866-UDS-HELP) or udshelp330@bphcdata.net
BPHC UDS MANUAL

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BUREAU OF PRIMARY HEALTH CARE

BPHC UNIFORM DATA SYSTEM MANUAL

2004 REVISION

For use with Calendar Year 2004 UDS Data

BUREAU OF PRIMARY HEALTH CARE

4350 EAST WEST HIGHWAY ¦ BETHESDA, MARYLAND 20814
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UNIFORM DATA SYSTEM - REVISED MANUAL 2004

CONTENTS

 Page

INTRODUCTION ....... ....................................................................................................... 5

GENERAL INSTRUCTIONS ..................................................................................................8

INSTRUCTIONS FOR CENTER/GRANTEE PROFILE COVER SHEET ........................14

• CENTER/GRANTEE PROFILE COVER SHEET (PART I) ..................................19

• CENTER/GRANTEE PROFILE COVER SHEET (PART II) .................................20

• CENTER/GRANTEE PROFILE COVER SHEET (PART III) ................................21

• CENTER/GRANTEE PROFILE COVER SHEET (PART IV) ................................22

INSTRUCTIONS FOR TABLE 2 ................................................................................23

• TABLE 2: SERVICES OFFERED AND DELIVERY METHOD ...........................25

INSTRUCTIONS FOR TABLE 3A AND TABLE 3B ....................................................30

• TABLE 3A: USERS BY AGE AND GENDER ..................................................33

• TABLE 3B: USERS BY RACE/ETHNICITY AND LINGUISTIC 

PREFERENCE ..............................................................................................33

INSTRUCTIONS FOR TABLE 4 .............................................................................. 34

• TABLE 4: SOCIOECONOMIC CHARACTERISTICS ................................ 38

INSTRUCTIONS FOR TABLE 5 .............................................................................. 40

• TABLE 5: STAFFING AND UTILIZATION.................................................... 47

INSTRUCTIONS FOR TABLE 6 .............................................................................. 49

• TABLE 6: STAFFING AND UTILIZATIONNDERED ....................................53

INSTRUCTIONS FOR TABLE 7 .............................................................................. 56

• TABLE 7: PERINATAL PROFILE ................................................................ 61

INSTRUCTIONS FOR TABLE 8A ............................................................................ 63

• TABLE 8A: COSTS ......................................................................................68

INSTRUCTIONS FOR TABLE 8B ............................................................................ 69

TABLE 8B: ENABLING SERVICES ............................................................. 71

INSTRUCTIONS FOR TABLE 9C ............................................................................ 72

• TABLE 9C: MANAGED CARE ................................................................... 78 

INSTRUCTIONS FOR TABLE 9D ............................................................................ 81

• TABLE 9D: PATIENT SERVICE REVENUE ...............................................88
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INSTRUCTIONS FOR TABLE 9E ..............................................................................90

• TABLE 9E: OTHER REVENUE ............................................................... 93

APPENDIX A: PERSONNEL BY MAJOR SERVICE CATEGORY ...................................... 94

APPENDIX B: SERVICE DEFINITIONS .......................................................................... 99

NOTE: TABLE 1, TABLE 9A AND TABLE 9B, WHICH WERE INCLUDED IN THE ORIGINAL UDS, 

HAVE BEEN DELETED.

PUBLIC BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 24 hours per response for the Universal Report and 16 

hours per response for the Grant Report, including the time for reviewing instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate 

or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS Reports Clearance Officer; 

Paperwork Reduction Project (0915-0193); Room 737-F; Humphrey Building; 200 Independence Ave., SW; Washington, DC 20201. OMB 

No. 0915-0193;- Expiration 2/28/05
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INTRODUCTION

This ninth edition of the Bureau of Primary Health Care’s User Manual: Uniform Data System (UDS) 

updates all instructions and modifications issued since the first UDS reporting year (1996). This 

Manual supersedes all previous manuals, including instructions provided on the BPHC 

Web site prior to October 2004.

The Manual includes a brief introduction to the Uniform Data System, a set of General Instructions for 

completing the UDS and detailed instructions for completing each table. The General Instructions 

include definitions which are used to insure consistent data are collected for many of the parameters. 

 Where relevant, the table-specific instructions also include a set of “Questions and Answers”,

addressing frequently raised issues in completing the tables. 

The UDS is an integrated reporting system used by all grantees of the following primary care

programs administered by the Bureau of Primary Health Care (BPHC), Health Resources and Services 

Administration:

- Community Health Center, as defined in Section 330(e) of the Health Centers Consolidation 

Act; 

- Migrant Health Center, as defined in Section 330(g) of the Health Centers Consolidation Act;

- Health Care for the Homeless, as defined in Section 330(h) of the Health Centers

Consolidation Act;

- Public Housing Primary Care, as defined in Section 330(i) of the Health Centers

Consolidation Act.

BPHC collects data on its programs to ensure compliance with legislative mandates and to report to 

Congress, OMB, and other policy makers on program accomplishments. To meet these objectives, 

BPHC requires a core set of information collected annually that is appropriate for monitoring and 

evaluating performance and for reporting on annual trends. The UDS is the vehicle used by BPHC to 

obtain this information. 

The UDS includes two components:

- The Universal Report is completed by all grantees. This report provides data on services, 

staffing, and financing across all four programs. The Universal Report is the source of 

unduplicated data on BPHC programs. 

- The Grant Reports are completed by a sub-set of grantees who receive multiple BPHC grants. 

 These reports repeat four of the Universal Report tables to provide comparable data for that 

portion of their program that falls within the scope of a project funded under a particular 

grant. Separate grant reports are required for the Migrant Health Center, Homeless Health 

Care, Public Housing Primary Care and School Based Clinics grantees unless a grantee funded 

under one specific program receives no other BPHC funding.

Exhibit A outlines the contents of UDS reports, identifying tables included in the Universal Report and 

those included in Grant Reports. The Exhibit lists tables that have been deleted from the UDS since 

the system was initiated in 1996. No further reference to any of the deleted tables is made in this 

Manual.

The UDS report is always a calendar year report. Agencies whose funding begins, either in whole or 

in part, after the beginning of the year, or whose funding is terminated, again either in whole or in 
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part, before the end of the year, are nonetheless requested to report on the entire year to the best of 

their ability.
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EXHIBIT A: UDS

OVERVIEW OF UNIVERSAL AND GRANT REPORTS

TABLE UNIVERSAL 

REPORT

GRANT 

REPORTS

CENTER/GRANTEE PROFILE

Cover Sheet Grantee and Service Delivery 

Location Information

X

Table 1: NO LONGER REPORTED

Table 2: Services Offered X

USER PROFILE

Table 3(A-B): User Demographics X X

Table 4: Socioeconomic Characteristics X X

STAFFING AND UTILIZATION

Table 5: Staffing and Utilization X

<partial>

Table 6: Selected Diagnoses and Services X X

Table 7: Perinatal Profile X

FINANCIAL

Table 8(A-B): Costs X

Table 9(A-B): NO LONGER REPORTED

Table 9(C-E) Managed Care and Revenue X
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GENERAL INSTRUCTIONS

This section provides basic definitions and instructions for completing the UDS. These instructions 

should be used in conjunction with the instructions for completing specific tables, and are crossreferenced as appropriate. 

SCOPE OF ACTIVITIES INCLUDED IN REPORTS

The Universal Report provides a comprehensive picture of all activities within the scope of BPHCsupported projects. In this report grantees should report on the total unduplicated number of users 

and activities within the scope of projects supported by any of the four BPHC primary care programs 

covered by the UDS. 

For Grant Reports, grantees provide data on the users and activities within that part of their program 

which is funded under a particular grant. Because a user can receive services through more than one 

type of BPHC grant, and not all grants are reported separately, totals from the Grant Reports cannot 

be aggregated to generate totals in the Universal Report.

Grantees that receive only one BPHC grant are required to complete only the Universal Report. 

Agencies with multiple BPHC grants complete a Universal Report for the combined projects and a 

separate grant report for each Migrant, Homeless, School Based Clinics (formerly known as Healthy 

Schools Healthy Communities,) and/or Public Housing program grant. Examples include the 

following: 

- A CHC grantee (Section 330e) that has a Health Care for the Homeless grant (Section 330h) 

completes a Universal Report and a Homeless Grant Report--but does not complete a Grant 

Report for the CHC grant.

- A CHC grantee (Section 330e) that also has Migrant Health (Section 330g) and Homeless 

(Section 330h) grants, completes a Universal Report, a Grant Report for the Homeless grant, 

and a grant report for the Migrant grant.

- A Homeless grantee (section 330h) that also has a School Based Clinic grant completes a 

Universal Report, a Grant Report for the Homeless grant and a Grant Report for the School 

Based Clinics grant. 

NOTE: The reporting software will automatically identify the reports which must be filed and 

prompt the grantee if one is left out. 

If the reporting grantee is a contractor to another organization that is the direct recipient of a BPHC 

grant, both entities report the users, utilization, costs and revenues associated with those users.
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DEFINITION OF ENCOUNTERS

Encounter definitions are needed both to determine who is counted as a user (Tables 3A, 3B , 4 & 6) 

and to report total encounters by type of provider staff (Table 5). Encounters are defined to include a 

documented, face-to-face contact between a user and a provider who exercises independent

judgment in the provision of services to the individual. To be included as an encounter, services 

rendered must be documented. Appendix A provides a list of health center personnel and the usual 

status of each as a provider or non-provider for purposes of UDS reporting. Encounters which are 

provided by contractors, and paid for by the grantee, such as Migrant Voucher encounters or outpatient or in-patient specialty care associated with an at-risk managed care contract, are considered to 

be encounters to the extent that they meet all other criteria.

Further explanation of the definitions and criteria for defining and reporting encounters are below.

1. To meet the criterion for “independent judgment”, the provider must be acting on his/her 

own when serving the patient and not assisting another provider. For example, a nurse 

assisting a physician during a physical examination by taking vital signs, taking a history or 

drawing a blood sample is not credited with a separate encounter. 

2. To meet the criterion for “documentation”, the service (and associated patient information)

must be recorded in written form. The patient record does not have to be a full and complete 

health record in order to meet this criterion. For example, if an individual receives services 

on an emergency basis and these services are documented, the documentation criterion is met 

even though a complete health record is not created. Mass screenings at health fairs or mass 

immunization drives for children or elderly do not result in encounters.

3. When a provider renders services to several patients simultaneously, the provider can be 

credited with an encounter for each person only if the provision of services is noted in each

person's health record. Examples of "group encounters" include: family therapy or

counseling sessions and group mental health counseling during which several people receive 

services and the services are noted in each person's health record. In such situations, each

patient is normally billed for the service. Medical visits must be provided on an individual 

basis. Patient education or health education classes (e.g., smoking cessation) are not credited 

as encounters.

4. An encounter may take place in the health center or at any other location in which projectsupported activities are carried out. Examples of other locations include mobile vans,

hospitals, patients' homes, schools, homeless shelters, and extended care facilities. Encounters 

also include contacts with patients who are hospitalized, where health center medical staff 

member(s) follow the patient during the hospital stay, as physician of record or where they 

provide consultation to the physician of record. A provider may not generate more than one 

inpatient encounter per patient per day.

5. Such services as drawing blood, collecting urine specimens, performing laboratory tests, 

taking X-rays, and filling/dispensing prescriptions, in and of themselves, do not constitute 

encounters. 

6. A patient may have more than one encounter with the health center per day. The number of 

encounters per service delivery location per day is limited as follows:
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- One medical encounter (physician, nurse practitioner, physicians assistant, certified nurse midwife, 

or nurse);

- One dental encounter (dentist or hygienist); 

- One “other health” encounter for each type of “other health” provider (nutritionist, podiatrist, 

speech therapist, acupuncturist, optometrist, etc.).

- One enabling service (case management or health education) encounter; 

- One mental health encounter; and

- One substance abuse encounter

7. A provider may be credited with no more than one encounter with a given patient during that 

patient's visit to the center in a single day, regardless of the type or number of services

provided. 

8. The encounter criteria are not met in the following circumstances:

- When a provider participates in a community meeting or group session that is not designed to 

provide clinical services. Examples of such activities include information sessions for prospective 

users, health presentations to community groups (high school classes, PTA, etc.), and information 

presentations about available health services at the center.

- When the only health service provided is part of a large-scale effort, such as a mass immunization 

program, screening program, or community-wide service program (e.g., a health fair).

- When a provider is primarily conducting outreach and/or group education sessions, not providing 

direct services.

- When the only services provided are lab tests, x-rays, immunizations, Tb tests and/or prescription 

refills.

Further definitions of encounters for different provider types follow:

PHYSICIAN ENCOUNTER – An encounter between a physician and a user. 

NURSE PRACTITIONER/PHYSICIANS ASSISTANT ENCOUNTER – An encounter between a Nurse Practitioner 

or Physicians Assistant and a user in which the practitioner acts as an independent provider.

CERTIFIED NURSE MIDWIFE ENCOUNTER – An encounter between a Certified Nurse Midwife and a 

user in which the practitioner acts as an independent provider.

NURSE ENCOUNTER (Medical) – An encounter between an R.N., L.V.N. or L.P.N. and a user in 

which the nurse acts as an independent provider of medical services exercising independent 

judgment, such as in a triage encounter. The service may be provided under standing orders of a 

physician, under specific instructions from a previous visit, or under the general supervision of a 

physician or Nurse Practitioner/Physicians Assistant/Certified Nurse Midwife (NP/PA/CNM) who 

has no direct contact with the patient during the visit. (Note that some states prohibit an LVN or 

an LPN to exercise independent judgment, in which case no encounters would be counted for 

them. Note also that, under no circumstances are services provided by Medical Assistants or 

other non-nursing personnel counted as nursing visits.)

DENTAL SERVICES ENCOUNTER – An encounter between a dentist or dental hygienist and a user for 

the purpose of prevention, assessment, or treatment of a dental problem, including restoration. 

NOTE: A dental hygienist is credited with an encounter only when (s)he provides a service 

independently, not jointly with a dentist. Two encounters may not be generated during a 

patient's visit to the dental clinic in one day, regardless of the number of clinicians who provide 
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services or the volume of service provided.

MENTAL HEALTH ENCOUNTER – An encounter between a licensed mental health provider

(psychiatrist, psychologist, LCSW, and certain other Masters Prepared mental health providers 

licensed by specific states) and a user, during which mental health services (i.e., services of a 

psychological, psychosocial, or crisis intervention nature) are provided.

SUBSTANCE ABUSE ENCOUNTER – An encounter between a substance abuse provider (e.g.,

credentialed substance abuse counselor, rehabilitation therapist, psychologist) and a user during 

which alcohol or drug abuse services (i.e., assessment and diagnosis, treatment, aftercare) are 

provided.

OTHER PROFESSIONAL ENCOUNTER – An encounter between a provider, other than those listed above 

and a user during which health services are provided. Examples are provided in Appendix A.

CASE MANAGEMENT ENCOUNTER – An encounter between a case management provider and a user 

during which services are provided that assist patients in the management of their health and 

social needs, including patient needs assessments, the establishment of service plans, and the 

maintenance of referral, tracking, and follow-up systems. 

EDUCATION ENCOUNTER – An encounter between an education provider and a user in which the 

services rendered are of an educational nature relating to health matters and appropriate use of 

health services (e.g., family planning, HIV, nutrition, parenting, and specific diseases). Classes are 

not counted as encounters.

DEFINITION OF A PROVIDER

A provider is the individual who assumes primary responsibility for assessing the patient and 

documenting services in the patient's record. Providers include only individuals who exercise 

independent judgment as to the services rendered to the patient during an encounter. The 

provider who exercises independent judgment is credited with the encounter, even when two or 

more providers are present and participate. If two or more providers of the same type divide up 

the services for a patient (e.g., a family practitioner and a pediatrician both seeing a child) only 

one may be credited with an encounter. Where health center staff are following a patient in the 

hospital, the primary responsible center staff person is the provider (and is credited with an 

encounter), even if other staff from the health center and/or hospital are present. (Appendix A 

provides a listing of personnel, indicating whether or not they are considered a provider who can 

generate encounters for purposes of UDS reporting.)

If contract providers who are part of the scope of the approved grant-funded program and are 

paid with grant funds or program income, serve center users and document their services in the 

center's records, they are considered providers. Also, contract providers paid with grant funds or 

program income who report encounters of users to the direct recipient of a BPHC grant (e.g., 

under a migrant voucher program or contractors with homeless grantees) are considered

providers and their activities are to be reported by the direct recipient of the BPHC grant.
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DEFINITION OF A USER

Users are individuals who have at least one encounter during the year, as defined above. 

As described under "Scope of Activities Included in Reports," tables in the Universal Report include 

as users all individuals who have at least one encounter during the year within the scope of activities 

supported by any BPHC grant covered by the UDS. In the Universal Report, each user is counted 

once and only once, even if s/he received more than one type of service or services supported by 

more than one BPHC grant. For each Grant Report, users include individuals who have at least one 

encounter during the year within the scope of project activities supported by the specific BPHC grant. 

Users never include individuals who only have encounters such as outreach, community education 

services, and other types of community-based services not documented on an individual basis. Also, 

persons who only receive services from large-scale efforts such as mass immunization programs, 

screening programs, and health fairs are not users. Persons whose only contact with the grantee is to 

receive WIC counseling and vouchers are not users and the contact does not generate an encounter. 

See "Definition of Encounters" for further discussion of contacts included as encounters.

WHO SUBMITS REPORTS AND REPORTING PERIODS 

Reports should be submitted by the BPHC grantee. The grantee is the direct recipient of one or more 

BPHC grants. All grantees are expected to report for the entire calendar year, even if they were 

funded, in whole or in part, for less than the full year. The one exception to this rule is for grantees 

who are funded for the first time after October 1st of the year and who have had no other BPHC funds 

during the year. The following information is reported on all UDS Tables (and is completed

automatically in electronic UDS software): 

 DATE OF SUBMISSION – The date the report is submitted.

REPORTING PERIOD – The time period covered by the report. All reports cover an entire calendar 

year. The reporting period is January 1` through December 31 of each reporting year. 

UDS NUMBER – The identifying number assigned to the grantee by the BPHC. 

DUE DATES AND REVISIONS TO REPORTS

Initial submissions of all UDS reports are due by February 15th of each calendar year. Submission is 

electronic, by disk or email, as instructed in the reporting software. 

If revisions to your tables are needed after your data have been exported from the software, you will 

need to contact the toll free UDS support line at (866) UDS-HELP (866-837-4357). If you have 

already been contacted by a UDS data editor, coordinate all data changes with that individual. 

For revision of Prior Year UDS Reports, you will need to contact the toll free UDS support line at 

(866) UDS-HELP (866-837-4357) for instructions.

WHERE TO SUBMIT THE DATA
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- Grantees will submit their data electronically. If a grantee has difficulty in submitting the 

data electronically, the grantee will need to contact the UDS support line: (866) UDSHELP. 

- Grantee will submit the data, electronically to: submit330uds@bphcdata.net

BPHC UDS Data

P.O. Box 333

Concord, NH 03302-0333
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INSTRUCTIONS FOR 

CENTER/GRANTEE PROFILE COVER SHEET

The content of this table has not changed since the 2003 Reporting period.

The cover sheet provides basic identifying information about the grantee, its leadership and the 

address of its service delivery locations.

GRANTEE LEGAL NAME AND ADDRESS OF GRANTEE ADMINISTRATIVE OFFICES: 

• Provide the legal name and address of the recipient of the BPHC grant. If administrative 

offices are located separately from the clinical service delivery locations, use the address 

of the administrative offices. 

• Provide the 9-digit zip code. The zip code is separated into two cells. The first cell 

contains the first five digits and the second cell contains the last four digits.

CEO/EXECUTIVE DIRECTOR OR PROJECT DIRECTOR: 

• Provide the name of the CEO, Executive Director, or Project Director of the grantee

organization. Public health departments or other public entities should list the individual 

responsible for directing the BPHC-funded project. 

• Provide the phone number and e-mail address of the CEO, Executive or Project Director.

CMO/CLINICAL DIRECTOR: 

• Provide the name of the Clinical Director for the grantee organization. Organizations 

with both Medical and Dental Clinical Directors should list the Medical Director. 

• Provide the phone number and e-mail address of the Clinical Director.

CHAIRPERSON OF THE GOVERNING BOARD, HEALTH OFFICER, OR OTHER ACCOUNTABLE INDIVIDUAL (E.G. 

CHAIR OF THE BOARD OF SUPERVISORS, PRESIDENT OF THE BOARD OF TRUSTEES, ETC.) 

• Provide the name of the Chair of the grantee organization's Governing Board. State and 

local health departments receiving grants that do not include requirements for a

Governing Board (e.g., Health Care for the Homeless grantees) should provide the name 

of the State Health Officer or Local Health Officer or other accountable individual, as 

appropriate. 

GRANTEE CONTACT PERSON: 

• Provide the name of the grantee staff person with primary responsibility for preparing the 

UDS report (do not list consultants, contractors or contracted employees). Two names 

may be listed if they prepare separate tables, but the first name listed should be the one 

for whom the phone number is provided.

• Provide the address with 9-digit zip code, phone/fax numbers, including area code, and email address for the Grantee Contact Person.

SCHOOL HEALTH COORDINATOR:

• Provide the name of the grantee staff person with primary responsibility for any schoolbased health center activities managed by the grantee, regardless of whether or not BPHC 

funding supports the activities.

HOMELESS PROGRAM COORDINATOR:
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• Provide the name of the grantee staff person with primary responsibility for any homeless 

program managed by the grantee, regardless of whether or not BPHC funding supports the 

activities.

PUBLIC HOUSING PROGRAM COORDINATOR:

• Provide the name of the grantee staff person with primary responsibility for any public 

housing program managed by the grantee, regardless of whether or not BPHC funding 

supports the activities.

MEDICAID PROVIDER BILLING NUMBER: 

• If your agency has a single billing number, which you use for all Medicaid billing, enter it 

here. If you have multiple service delivery locations, which use separate Medicaid billing 

numbers, record these numbers on the following pages with the data for each individual 

service delivery location. If each provider uses their own number, report one number 

only, usually the Clinic Director’s, or lead clinician’s, for each service delivery location.

MEDICAID PHARMACY NUMBER: 

• If your agency has a single billing number that you use for all Medicaid pharmacy billing, 

enter it here. If you do not have a separate identifier for pharmacy services, enter your 

Medicaid medical provider number. If there are individual service delivery location 

numbers, record them on the following pages with each individual service delivery

location listing.

 NUMBER OF SERVICE DELIVERY LOCATIONS. 

• Report the total number of service delivery locations supported by BPHC grant(s). This 

should match the number of boxes used on the following pages.. Do not include 

administration-only locations.

NUMBER OF NHSC ASSIGNEES. 

• Report the total number of National Health Service Corps Assignees working at your 

service delivery location(s) as of December 31st of the reporting period.

GRANTEE PARTICIPATION IN AN INTEGRATED SERVICES NETWORK: 

• Report if the grantee participates in an integrated services network. Grantees will check 

one box only for participation in a horizontal network, a vertical network, or both. 

Grantees that do not participate in a network will check 'No ISN Participation'. An 

integrated services network is defined as a group of safety net providers collaborating 

through the redesign of practices to integrate services, optimize patient outcomes, and/or 

negotiate managed care contracts on behalf of the participating collaborators. Vertical 

integration is the collaboration of different providers, such as health centers, hospitals, 

and physician offices. Horizontal integration is collaboration occurring across the same 

type of provider, i.e. several health centers. 

• Report if the network received Integrated Services Development Initiative (ISDI) funds 

from BPHC by checking the ISDI box whether or not the grantee is the direct recipient of 

the funds and regardless of whether the original grant may have expired.

FEDERAL TORT CLAIMS ACT (FTCA) 

• Check the box indicating whether or not you were 'deemed' under the FTCA for any 
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portion of the reporting period.

DRUG PRICING PARTICIPATION

• Check the box indicating whether or not you participated in the 340(b) drug pricing 

program during the reporting period.

• Check the box if you participate in an alternate drug pricing program. (Alternative drug 

pricing programs are programs, often sponsored by health care consortiums, designed to 

lower the cost of pharmaceuticals to members by facilitating group purchasing activities.) 

SERVICE DELIVERY LOCATIONS. 

• A service delivery location is defined as a permanent unit providing services to a defined 

geographic service area or population. 

- Locations where individual patients may be visited by providers but where the 

grantee has not established a permanent unit (e.g., private homes, hospitals and 

nursing homes) are NOT service delivery locations.

- Locations where the grantee has established a permanent unit are service

delivery locations (e.g., a hospital OPD, homeless shelter or nursing home 

where the grantee has established and staffed a clinic). 

- Mobile vans providing health care services are service delivery locations; the 

service area is the area the van(s) cover.

- Vans, homeless shelter, migrant camps, and other similar locations can be 

grouped if the area they cover is the same. Generally multiple shelters, camps 

and other locations visited by a mobile service delivery team should be grouped 

together unless services are delivered at the site more than 50 days a year.

- A special population's service area may be a larger geographic area but focus on 

a specific population within that area.

Report the name and address of each service delivery location, including the 9-digit zip code. For 

each service delivery location, also:

1. Include your service delivery location alpha identifier, as assigned by BPHC. (If 

you do not have the alpha identifiers for your service delivery locations, leave the 

fields blank. Do not make up your own alpha identifiers!)

2. Indicate whether the service delivery location operates year-round or on a seasonal 

basis.

3. Indicate the location or type(s) of facility, using codes in the drop-down menu. 

These codes provide information on the type of facility in which the service

delivery location is located, NOT the specific services offered at the service delivery 

location. Examples of coding are shown below.

- A community-based primary care service delivery location not 

located in a health department or substance abuse treatment 

clinic/facility should be coded as "1".

- A primary care service delivery location located in a health 

department should be coded "5" -- Health Department clinic.

- A primary care service delivery location located in a substance 

abuse clinic should be coded "6".

- A community-based homeless grantee service delivery location 

located in a mental health clinic operated by a local health 
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department should be coded "5" and "8".

4. Define the service area by listing the census tracts, whole or partial counties, or Minor 

Civil Divisions included in it.

5. Provide, if relevant, individual service delivery location Medicaid provider and pharmacy 

billing numbers. 
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QUESTIONS AND ANSWERS FOR CENTER/GRANTEE PROFILE COVERSHEET

1) Are there any changes to this table?

NO
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

CENTER/GRANTEE PROFILE

COVER SHEET (Part I)

GRANTEE LEGAL NAME

Address of Grantee Administrative Offices Street

City

State

9-Digit zip code (required) -

Name

Phone Extension

CEO/Executive Director or Project Director

E-Mail

Name

Phone Extension

Clinical Director

E-Mail

Chairperson, Governing Board, Health 

Officer, or other Accountable Individual (e.g. 

Chair of Board of Supervisors, President of 

the Board of Trustees, etc.)

Name

Name

Street

City

State Zip -

Phone Extension

Fax

Grantee Contact Person

(Person completing report):

E-mail

School Health Coordinator Name

Homeless Program Coordinator Name

Public Housing Program Coordinator Name

Medicaid Provider Billing Number: 

(Organization Wide Only)

Medicaid Pharmacy Number: 

(Organization Wide Only)
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

CENTER/GRANTEE PROFILE

COVER SHEET (Part II)

# service delivery locations supported by 

BPHC Grant(s)

Number of NHSC Assignees as of 12/31

CHECK ONE BOX:

o Horizontal Network o Vertical Network

o Both (Horizontal & Vertical Integration) o No ISN 

Participation

Grantee Participation in an Integrated 

Services Network

If participation in a network was indicated above, did the network 

receive ISDI funding from BPHC at any time in the past? 

o Yes o No

 Federal Tort Claims Act (FTCA) Deemed? o Yes o No

340(b) Drug Pricing Participation? o Yes o No

Alternative drug discounting program? o Yes o No
BPHC UDS MANUAL

2004 Revision

21

UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

CENTER/GRANTEE PROFILE

COVER SHEET (Part III)

NOTE: Use Location Codes listed below to describe the type of facility in which the service delivery 

location is located. More than one location code may apply for a given service delivery location. Use 

Medicaid numbers for service delivery locations only if applicable. For location code 11, School-based 

health center, include name of school in service delivery location name.

service delivery location # 1: service delivery location #2:

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

service delivery location #3 service delivery location #4

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

Location Codes for service delivery 

location Locations:

1. Community-based Primary Care Clinic

2. Hospital or worksite clinic

3. Fully equipped mobile health van

4. Community-based social service center 

5. Health Department Clinic

6. Substance Abuse treatment clinic/facility

 7. HIV/AIDS medical care clinic/facility

 8. Mental Health Clinic

 9. Public Housing

10. Migrant camp

11. School-Based Health Center 

12. Homeless shelter

13. Soup Kitchen

14. Other-Specify
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2002 through December 31, 2002 o Initial Submission o Revision

CENTER/GRANTEE PROFILE

COVER SHEET (Part IV)

service delivery location # service delivery location #

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

service delivery location # service delivery location #

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

Year Round Seasonal 

UDS # + alpha 

Name:

Address:

 Zip(9) (required)

Location Code(s): 

Service Area

Medicaid Number:

Medicaid Pharmacy Number:

Location Codes for service delivery 

location Locations:

1. Community-based Primary Care Clinic

2. Hospital or worksite clinic

3. Fully equipped mobile health van

4. Community-based social service center

5. Health Department Clinic

6. Substance Abuse treatment clinic/facility

 7. HIV/AIDS medical care clinic/facility

 8. Mental Health Clinic

 9. Public Housing

10. Migrant camp

11. School-Based Health Center

12. Homeless

13. Soup Kitchen

14. Other-Specify
BPHC UDS MANUAL

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INSTRUCTIONS FOR TABLE 2 –

SERVICES OFFERED AND DELIVERY METHOD

The content of this table has changed slightly since the 2003 reporting period to include 1 new line.

This table indicates the types of services provided by the grantee and reports whether these services 

are provided directly or through formal referral arrangements. Table 2 is only included in the 

Universal Report. Only services included within the scope of the federally-approved project(s) should 

be reported. This table is a compilation of the wide array of services provided through different 

BPHC grants. Individual grantees will rarely provide or refer for all of the services listed in this table. 

Also, since more than one delivery method may apply for a given service there may be notations in 

more than one of the columns.

1. SERVICE TYPE. This table lists medical, dental, behavioral, and enabling services that may be 

provided by BPHC grantees. Service definitions appear in Appendix B. 

2. DELIVERY METHOD. Mark the delivery method(s) applicable to the particular service type. If the 

service is not offered, leave the row blank.

• PROVIDED BY GRANTEE – Includes services rendered by salaried employees, contracted 

providers, National Health Service Corps Staff, volunteers and others such as outstationed eligibility workers who render services in the grantee's name.

• BY REFERRAL – GRANTEE PAYS - Includes services provided by another organization under 

a formal arrangement, only when the grantee pays for provision of the service, though 

the grantee may also bill the patient or a third party payor for the service. The 

arrangement may involve discounted payment (i.e., payment less than cost). These 

services are generally provided off site.

• BY REFERRAL – GRANTEE DOES NOT PAY – Includes services that are provided by another 

organization or individual under a formal referral arrangement where the grantee 

DOES NOT pay for or bill for the service.

A formal referral arrangement means either a written agreement or the ability to document the service 

in the patient record.
BPHC UDS MANUAL

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QUESTIONS AND ANSWERS FOR TABLE 2

1. Are there any changes to this table?

Yes – a new line, 33a Comprehensive mental health / Substance abuse screening, has been added.
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 2 –

SERVICES OFFERED AND DELIVERY METHOD (Part I of V)

SERVICE TYPE

NOTE: NOT ALL CENTERS WILL PROVIDE ALL SERVICES

 (See Appendix B for definitions)

DELIVERY METHOD

Mark (X) if Applicable

[More than one method may apply for a given service]

PROVIDED BY

GRANTEE

(a)

BY REFERRAL/

GRANTEE PAYS

(b)

BY REFERRAL/ 

GRANTEE 

DOESN'T PAY

(c)

PRIMARY MEDICAL CARE SERVICES

1. General Primary Medical Care (other than listed below)

2. Diagnostic Laboratory (technical component)

3. Diagnostic X-Ray Procedures (technical component)

4. Diagnostic Tests/Screenings (professional component)

5. Emergency medical services

6. Urgent medical care

7. 24-hour coverage

8. Family Planning

9. HIV testing and counseling

10. Testing for Blood Lead Levels

11. Immunizations

12. Following hospitalized patients

OBSTETRICAL AND GYNECOLOGICAL CARE

13. Gynecological Care 

14. Prenatal care

15. Antepartum fetal assessment

16. Ultrasound

17. Genetic counseling and testing

18. Amniocentesis

19. Labor and delivery professional care

20. Postpartum care
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 oInitial Submission o Revision

TABLE 2 –

SERVICES OFFERED AND DELIVERY METHOD (Part II of V)

SERVICE TYPE

NOTE: NOT ALL CENTERS WILL PROVIDE ALL SERVICES

(See Appendix B for definitions)

DELIVERY METHOD

Mark (X) if Applicable

[More than one method may apply for a given service]

PROVIDED BY

GRANTEE

(a)

BY REFERRAL/

GRANTEE PAYS

(b)

BY REFERRAL/ 

GRANTEE 

DOESN'T PAY

(c)

SPECIALTY MEDICAL CARE

21. Directly observed TB therapy

22. Respite Care

23. Other Specialty Care

DENTAL CARE SERVICES

24. Dental Care – Preventive

25. Dental Care – Restorative

26. Dental Care – Emergency 

27. Dental Care – Rehabilitative

MENTAL HEALTH/SUBSTANCE ABUSE SERVICES

28. Mental Health Treatment/Counseling

29. Developmental Screening

30. 24-hour Crisis Intervention/Counseling

31. Other Mental Health Services

32. Substance Abuse Treatment/Counseling

33. Other Substance Abuse Services

33a. Comprehensive mental health / Substance abuse 

screening

OTHER PROFESSIONAL SERVICES

34. Hearing Screening

35. Nutrition Services Other Than WIC

36. Occupational or Vocational Therapy

37. Physical Therapy

38. Pharmacy – Licensed Pharmacy staffed by 

Registered Pharmacist

39. Pharmacy – Provider Dispensing
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 2 –

SERVICES OFFERED AND DELIVERY METHOD (Part III of V)

SERVICE TYPE

NOTE: NOT ALL CENTERS WILL PROVIDE ALL SERVICES

(See Appendix B for definitions)

DELIVERY METHOD

Mark (X) if Applicable

[More than one method may apply for a given service]

PROVIDED BY

GRANTEE

(a)

BY REFERRAL/

GRANTEE PAYS

(b)

BY REFERRAL/ 

GRANTEE 

DOESN'T PAY (c)

40. Vision Screening

41. Podiatry

42. Optometry

ENABLING SERVICES

43. Case management

44. Child Care (during visit to center)

45. Discharge planning

46. Eligibility Assistance 

47. Environmental Health Risk Reduction 

(via detection and/or alleviation)

48. Health Education

49. Interpretation/Translation services

50. Nursing home and assisted-living placement

51. Outreach

52. Transportation

53. Out Stationed Eligibility Workers

54. Home Visiting

55. Parenting Education
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 2 -

SERVICES OFFERED AND DELIVERY METHOD (Part IV of V)

SERVICE TYPE

NOTE: NOT ALL CENTERS WILL PROVIDE ALL SERVICES

(See Appendix B for definitions)

DELIVERY METHOD

Mark (X) if Applicable

[More than one method may apply for a given service]

PROVIDED BY

GRANTEE

(a)

BY REFERRAL/

GRANTEE PAYS

(b)

BY REFERRAL/ 

GRANTEE 

DOESN'T PAY

(c)

56. Special Education Program

57. Other (specify:____________________________)

PREVENTIVE SERVICES RELATED TO TARGET CLINICAL AREAS

I. Cancer

58. Pap smear

59. Fecal occult blood test

60. Sigmoidoscopy 

61. Colonoscopy

62. Mammograms

63. Smoking cessation program

II. Diabetes

64. Glycosylated hemoglobin measurement for people 

with diabetes

65. Urinary microalbumin measurement for people 

with diabetes

66. Foot exam for people with diabetes

67. Dilated eye exam for people with diabetes

II. Cardiovascular Disease

68. Blood pressure monitoring

69. Weight reduction program
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 2 -

SERVICES OFFERED AND DELIVERY METHOD (Part V of V)

SERVICE TYPE

NOTE: NOT ALL CENTERS WILL PROVIDE ALL SERVICES

 (See Appendix B for definitions)

DELIVERY METHOD

Mark (X) if Applicable

[More than one method may apply for a given service]

PROVIDED BY

GRANTEE

(a)

BY REFERRAL/

GRANTEE PAYS

(b)

BY REFERRAL/ 

GRANTEE 

DOESN'T PAY

(c)

70. Blood cholesterol screening

IV. HIV/AIDS

See line 9. HIV testing and counseling

V. Infant Mortality

71. Follow-up testing and related health care services 

for abnormal newborn bloodspot screening

See line 14. Prenatal Care

VI. Immunizations

See line 11. Immunizations

OTHER SERVICES

72. WIC services

73. Head Start services

74. Food banks / Delivered meals

75. Employment / Educational Counseling

76. Assistance in obtaining housing
BPHC UDS MANUAL

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INSTRUCTIONS FOR TABLES 3A and 3B –

USERS BY AGE, GENDER, RACE/ETHNICITY 

and LINGUISTIC PREFERENCE

The content of Table 3B has had a minor change since the 2002 Reporting period. Table 3A is 

unchanged. Please see a guide to changes in the Questions and Answers Section below.

Tables 3A and 3B provide demographic data on users of the program and are included in both the 

Universal Report and the Grant Reports. 

For the Universal Report, include as users all individuals receiving at least one face-to-face encounter 

for services within the scope of the four programs covered by UDS. Each user is to be counted only 

once, regardless of the number or types of services received. 

The Grant Reports include only individuals who received at least one face-to-face encounter within 

the scope of the program in question. Users are to be reported only once in each report filed, 

however the if the same user is served in more than one program, they will be reported on the grant 

report for each program that served them.

An encounter is a face-to-face contact between a client and a provider who exercises independent 

judgment in the provision of services to the individual, and the services rendered must be

documented to be counted as an encounter. See the General Instructions for additional detail on the 

definition of encounters.

TABLE 3A: USERS BY AGE AND GENDER

Report the number of total users by appropriate categories for age and gender. For reporting 

purposes, use the individual's age on June 30 of the reporting period.

TABLE 3B: USERS BY RACE/ETHNICITY AND LINGUISTIC PREFERENCE

RACE/ETHNICITY:

• This table requests the number of users in each racial/ethnic category. The total on 

Table 3B line 7 must equal the total on Table 3A, line 39 Columns A + B. 

LINGUISTIC PREFERENCE:

• Table 3B requests the number of users who are best served in a language other than 

English or with sign language. 

• Include those users who were served by a bilingual provider and those who may have 

brought their own interpreter. 

NOTE: Data reported on line 8, Linguistic preference, only may be estimated if the health center does 

not maintain actual data in its MIS. Wherever possible, the estimate should be based on a sample.
BPHC UDS MANUAL

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QUESTIONS AND ANSWERS FOR TABLE 3A and 3B

1. How do we report individuals who receive different types of services or use more than one of 

the grantee’s service delivery locations? For example, a person who receives both medical and 

dental services or a woman who receives primary care from one clinic, but gets prenatal care at 

another.

UDS Table 3A provides an unduplicated count of users. Grantees are required to report each 

user once and only once on this table, regardless of the type or number of services they 

receive or where they receive them. Each person who has received one or more encounter 

that is reported on Table 5 is to be counted once and only once on Table 3A. Encounters are 

defined in detail in the General Instructions. Note the following: 

• Persons who only receive WIC services and no other services at the agency are not to 

be counted as users or reported on Table 3A.

• Persons who only receive lab services or whose only service was an immunization or 

screening test as part of a community wide health promotion/disease prevention effort 

are not to be counted as users or reported on Table 3A.

NOTE: The sum of Table 3A, Line 39, Column A + B must equal Table 4, Line 6 and Line 

12, Column A + B. The sum of Table 3A, Lines 1-20, Column A + B must equal Table 4, 

Line 12, Column A.

2. Are there changes to these tables for 2004?

Yes. On Table 3B, grantees now report actual numbers of users by linguistic

preference rather than percentages.

3. Do we need to collect information on and report on the race and ethnicity of all of our

patients?

Yes. According to the Office of Management and Budget (OMB) this information 

must be collected for all users. Users may refuse to provide the information and there 

is a line for this now on table 3B. 
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: ____________________________ 

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 3A – USERS BY AGE AND GENDER

AGE GROUPS MALE USERS (a) FEMALE USERS (b)

NUMBER OF USERS

1 Under age 1

2 Age 1

3 Age 2

4 Age 3

5 Age 4

6 Age 5

7 Age 6

8 Age 7

9 Age 8

10 Age 9

11 Age 10

12 Age 11

13 Age 12

14 Age 13

15 Age 14

16 Age 15

17 Age 16

18 Age 17

19 Age 18

20 Age 19

21 Age 20

22 Age 21

23 Age 22

24 Age 23

25 Age 24

26 Ages 25 – 29

27 Ages 30 – 34

28 Ages 35 – 39

29 Ages 40 – 44

30 Ages 45 – 49

31 Ages 50 – 54

32 Ages 55 – 59

33 Ages 60 – 64

34 Ages 65 – 69

35 Ages 70 – 74

36 Ages 75 – 79

37 Ages 80 – 84

38 Age 85 and over

39 TOTAL USERS (SUM LINES 1-38)
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 3B –

USERS BY RACE/ETHNICITY/LANGUAGE

RACE/ETHNICITY/LANGUAGE NUMBER

(a)

PROPORTION OF USERS

1a. Asian

1b. Native Hawaiian

1c. Other Pacific Islander

 1. TOTAL ASIAN/PACIFIC ISLANDER (SUM LINES 1A + 1B + 1C)

 2. Black/African American (not Hispanic or Latino)

 3. American Indian/Alaska Native

 4. White (not Hispanic or Latino)

 5. Hispanic or Latino (all races)

 6. Unreported / Refused to report

 7. TOTAL USERS (SUM LINES 1 - 6)

 8. Users best served in a language other than English 

• Asian, Native Hawaiian and Pacific Islander users should be reported separately in lines 1a, 1b and 

1c. The total of Asian, Native Hawaiian and Pacific Islander users should equal the sum of lines 1a, 

1b and 1c. This should be reported on line 1.
BPHC UDS MANUAL

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INSTRUCTIONS FOR TABLE 4 –

SOCIOECONOMIC CHARACTERISTICS

INSTRUCTIONS FOR TABLE 4 SOCIOECONOMIC CHARACTERISTICS

Table 4 provides descriptive data on socioeconomic status of users. The table is included in both the 

Universal Report and the Grant Reports.

For the Universal Report, include as users all individuals receiving at least one face-to-face encounter 

for services within the scope of any of the programs covered by UDS. The Grant Reports include 

only individuals who received at least one face-to-face encounter that was within the scope of the 

program in question. Users are to be reported only once in each report filed.

INCOME AS PERCENT OF POVERTY LEVEL, LINES 1 - 6

Grantees are expected to collect income data on all users, but are not required to collect this

information more frequently than once during the year. If income information is updated during the 

year, report the most current information available. Users for whom the information was not 

captured must be reported on line 5 as unknown.

Income is defined in ranges relative to the federal poverty guidelines (e.g., < 100% of the federal 

poverty level). In determining a user's income relative to the poverty level, grantees should use 

official poverty line guidelines defined and revised annually. The official Poverty Guidelines are 

published in the Federal Register in February/March of each year. 

PRINCIPAL THIRD PARTY INSURANCE SOURCE, LINES 7 - 12

This portion of the table provides data on users by principal source of insurance for primary medical 

care services. Users are divided into two age groups (a) 0 - 19 and (b) age 20+. 

DEFINITIONS OF INSURANCE LINES

MEDICAID – State-run programs operating under the guidelines of Title XIX of the Social Security 

Act. Medicaid includes programs called by state-specific names (e.g., California’s Medi-Cal 

program). While Medicaid coverage is generally funded by Federal and State funds, some states 

also have “state-only” programs covering individuals ineligible for Federal matching funds (e.g., 

general assistance recipients).

NOTE: Individuals who are enrolled in Medicaid but who receive services through a private 

managed care plan that contracts with the state Medicaid agency should be reported as 

Medicaid, not privately insured. 
BPHC UDS MANUAL

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MEDICARE – Federal insurance program for the aged, blind and disabled (Title XVIII of the Social 

Security Act).

PRIVATE INSURANCE – Health insurance provided by commercial and non-profit companies. 

Individuals may obtain insurance through employers or on their own. 

OTHER PUBLIC INSURANCE – Federal, State and/or local government programs providing a broad set 

of benefits for eligible individuals. Do not include uninsured individuals whose visit may be 

covered by a public source with limited benefits such as the Early Prevention, Screening,

Detection and Treatment (EPSDT) program or the Breast and Cervical Cancer Control Program, 

(BCCCP), etc. An example of an “other public insurance” program would be a State Based

Children’s Health Insurance Program (S-CHIP) run outside of the Medicaid program. 

CHIP – The Child Health Insurance Program (also known as S-CHIP) provides primary health care 

coverage for children and, on a state by state basis, others – especially parents of these children. 

CHIP coverage can be provided through the state’s Medicaid program and/or through contracts 

with private insurance plans. In some states it is difficult to distinguish between regular Medicaid 

and CHIP-Medicaid. In other states the distinction is readily apparent (e.g., they may have different 

cards). Where it is not obvious, CHIP may be identifiable from a “plan” code or some other 

embedded code in the membership number. This may also vary from county to county within a 

state. Obtain information from the state and/or county on their coding practice. If there is no way 

to distinguish between them, classify all covered users as “regular” Medicaid. In those states where 

CHIP is contracted through a private third party payor, participants are to be classified as “other 

public-CHIP” rather than as private on Table 4.

SPECIFIC INSTRUCTIONS FOR REPORTING USERS BY SOURCE OF 

INSURANCE

Grantees should report the user's principal health insurance covering primary medical care, if any, as 

of the last visit during the reporting period. Principal insurance is defined as the insurance

plan/program that the grantee would bill first for services rendered. 

NOTE: Users who have both Medicare and Medicaid, would be reported as Medicare users because 

Medicare is billed before Medicaid. The exception to the Medicare first rule is the Medicare-eligible 

person who is still working and insured by both an employer-based plan and Medicare. In this case, 

the principal health insurance is the employer-based plan, which is billed first.

Patients whose services are subsidized through State/local government “indigent care programs” are 

uninsured. Examples of state government “indigent care programs” include Massachusetts Free Care 

Pool, New Jersey Uncompensated Care Program, NY Public Goods Pool Funding, and Colorado 

Indigent Care Program. 

For both Medicaid and Other Public Insurance, the table distinguishes between “regular” enrollees 

and enrollees in CHIP.

MEDICAID = Line 8b includes Medicaid-CHIP enrollees only; Line 8a includes all other enrollees; 

and Line 8 is the sum of 8a + 8b.
BPHC UDS MANUAL

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OTHER PUBLIC = Line 10b includes CHIP enrollees who are covered by a plan other than Medicaid 

only; Line 10a includes all other persons with other public insurance; and Line 10 is the sum of 

10a + 10b.

SELECTED USER CHARACTERISTICS, PAGE 2 - LINES 13 - 23

MIGRANT OR SEASONAL AGRICULTURAL WORKERS AND THEIR DEPENDENTS, LINES 13 - 15

All grantees are required to report on Line 15 the combined total number of users during the 

reporting period who were either migrant or seasonal agricultural workers or their

dependents. Only section 330(g) grantees are asked to provide separate totals for migrant and 

for seasonal agricultural workers on Lines 13 and 14. For Section 330(g) grantees, Lines 13 + 

14 = 15

DEFINITIONS OF MIGRANT AND SEASONAL AGRICULTURAL WORKERS

MIGRANT AGRICULTURAL WORKERS – Defined by Section 330(g) of the Public Health Service Act, a 

migrant agricultural worker is an individual whose principal employment is in agriculture on a 

seasonal basis (as opposed to year-round employment) and who establishes a temporary home 

for the purposes of such employment. Migrant agricultural workers are usually hired laborers 

who are paid piecework, hourly or daily wages. The definition includes those individuals who 

have been so employed within the past 24 months and their dependent family members who 

have also used the center. The dependent family members may or may not move with the 

worker or establish a temporary home. Note that agricultural workers who leave a community 

to work elsewhere are equally eligible to be classified as migrant as are those who migrate to a 

community to work there.

SEASONAL AGRICULTURE WORKERS – Seasonal agricultural workers are individuals whose principal 

employment is in agriculture on a seasonal basis (as opposed to year-round employment) and 

who do not establish a temporary home for purposes of employment. Seasonal agricultural 

workers are usually hired laborers who are paid piecework, hourly, or daily wages. The 

definition includes those individuals who have been so employed within the past 24 months and 

their dependent family members who have also used the center.

For both categories of workers, agriculture is defined as farming of the land in all its branches, 

including cultivation, tillage, growing, harvesting, preparation, and on-site processing for market 

or storage. Aquaculture, lumbering, poultry processing, cattle ranching etc. are not included.

HOMELESS USERS, LINES 16 - 22

All grantees are to report the total number of users known to be homeless at some time during the 

reporting period on Line 22. Only section 330(h) Homeless Program grantees will provide separate 

totals for homeless program users by type of shelter arrangement. The shelter arrangement reported is 

their arrangement as of the first visit during the reporting period. “Street” includes living outdoors, in 

a car, in an encampment, in makeshift housing/shelter or in other places generally not deemed safe or 

fit for human occupancy. Persons who spent the prior night incarcerated or in a hospital should be 

reported based on where they intend to spend the night after their encounter. If they do not know, 
BPHC UDS MANUAL

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37

code as “street”. Section 330(h) Homeless Program grantees should report previously homeless 

persons now housed but still eligible for the program on Line 20. 

DEFINITION OF A HOMELESS INDIVIDUAL

HOMELESS INDIVIDUALS – Defined as individuals who lack housing (without regard to whether the 

individual is a member of a family), including individuals whose primary residence during the 

night is a supervised public or private facility that provides temporary living accommodations, 

and individuals who reside in transitional housing.

SCHOOL-BASED HEALTH CENTER USERS, LINE 23

All grantees that identified a school-based health center as a service delivery location on the UDS 

Cover Sheet are to report the total number of users of primary health care services delivered at the 

school service delivery location(s). 

A school-based health center is a health center located on or near school grounds, including preschool, kindergarten, and primary through secondary schools that provides on-site comprehensive 

preventive and primary health services. 

NOTE: The sum of Table 3A, Line39, Column A + B (total users by age and gender) must equal 

Table 4, Line 6 (users by income) and Line 12, Column A + B (users by insurance status.) The sum of 

Table 3A, Lines 1-20, Column A + B must equal Table 4, Line 12, Column A.
BPHC UDS MANUAL

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38

UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 4 –

SOCIOECONOMIC CHARACTERISTICS

CHARACTERISTIC NUMBER OF USERS

(a)

INCOME AS PERCENT OF POVERTY LEVEL

1. 100% and below

2. 101 - 150%

3. 151 - 200%

4. Over 200%

5. Unknown

6. TOTAL (SUM LINES 1 - 5)

PRINCIPAL THIRD PARTY INSURANCE SOURCE 0-19

(a)

20 AND OLDER

(b)

7. NONE/ UNINSURED

8a. Regular Medicaid (Title XIX)

8b. CHIP Medicaid 

8. TOTAL MEDICAID (LINE 8A + 8B)

9. MEDICARE (TITLE XVIII)

10a. Other Public Insurance Non-CHIP 

10b. Other Public Insurance CHIP

10. TOTAL PUBLIC INSURANCE (LINE 10A+LINE 10B)

11. PRIVATE INSURANCE

12. TOTAL (SUM LINES 7 + 8 + 9 +10 +11)

NOTE: Lines 8a and 8b distinguish between CHIP enrollees and all other Medicaid enrollees; Line 8 equals 

the sum of 8a and 8b. Lines 10a and 10b distinguish between CHIP enrollees covered through a nonMedicaid state plan and other enrollees in public insurance programs; Line 10 equals the sum of lines 10a 

and 10b.
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 4 –

SOCIOECONOMIC CHARACTERISTICS

SELECTED USER CHARACTERISTICS

CHARACTERISTIC NUMBER OF USERS 

(a)

13. Migrant (330g grantees only)

14. Seasonal (330g grantees only)

15. TOTAL MIGRANT/SEASONAL AGRICULTURAL WORKER OR DEPENDENT (ALL 

GRANTEES REPORT THIS LINE)

16. Homeless Shelter (330h grantees only)

17. Transitional (330h grantees only)

18. Doubling Up (330h grantees only)

19. Street (330h grantees only)

20. Other (330h grantees only)

21. Unknown (330h grantees only)

22. TOTAL HOMELESS (ALL GRANTEES REPORT THIS LINE)

23. TOTAL SCHOOL BASED HEALTH CENTER USERS

(ALL GRANTEES REPORT THIS LINE)
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INSTRUCTIONS FOR TABLE 5 –

STAFFING AND UTILIZATION

The content of this table has changed significantly since the 2002 Reporting period, please see a guide 

to changes in the Questions and Answers Section below. As of 2004, Grant Reports are required on 

Table 5 as well as the Universal Report

For the Universal Report, all staff, all encounters and all users are reported in Columns A, B and C. 

For the Grant Reports, only Columns B and C are to be completed. Every eligible encounter must be 

counted on the Universal Report. Grant Reports report on encounters and users supported by funds 

which are within the scope of one of the non-CHC grants. This could include both BPHC and nonBPHC funds. 

As a rule, all encounters for persons reported on Homeless Table 4 will be reported on Homeless 

Table 5; encounters for persons reported on Migrant Table 4 will be reported on Migrant Table 5, 

encounters for persons reported on School Based Clinics Table 4 will be reported on School Based 

Clinics Table 5, and encounters for persons reported on Public Housing Table 4 will be reported on 

Public Housing Table 5.

This table provides a profile of grantee staff, the number of encounters they render and the number of 

users served. Unlike Tables 3 and 4, where an unduplicated count of users is reported, Table 5 is 

designed to produce an unduplicated user figure within each of six major personnel categories:

medical, dental, mental health, substance abuse, other professional services, and enabling. The 

staffing information in Table 5 is designed to be compatible with approaches used to describe staff for 

financial/cost reporting, while ensuring adequate detail on staff categories for program planning and 

evaluation purposes.

INSTRUCTIONS FOR COMPLETING TABLE 5- COLUMN A - FTES

This table includes information on all individuals who work in programs and activities that are within 

the scope of the project for the four types of projects included in the UDS. All staff are to be 

reported in terms of Full-Time Equivalents (FTEs). A person who works 20 hours per week (i.e., 50% 

time) is reported as “0.5 FTE.” This example is based on a 40 hour work week. Positions with less 

than a 40 hour base, especially clinicians, should be calculated on whatever they have as a base for 

that position. Similarly, an employee who works four months out of the year would be reported as 

“0.33 FTE”. 

Staff may provide services on behalf of the grantee on a regularly scheduled basis under many 

different arrangements including, but not limited to: salaried full-time, salaried part-time, hourly 

wages, National Health Service Corps assignment, under contract, under capitation, block time, or 

donated time. Individuals who are paid by the grantee on a fee-for-service basis only are not counted 

as FTEs since there is no basis for determining their hours. The FTE column is only completed on the 

Universal Report. Staff are not separated according to the different BPHC funding streams.
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All staff time is to be allocated by function among the major service categories listed. For example, a 

full-time nurse who works solely in provision of direct medical services would be counted as 1.0 FTE 

on Line 11 (Nurses). If that nurse provided case management services for 10 hours per week, and 

provided medical care services for the other 30 hours per week, time would be allocated 0.25 FTE 

case manager (Line 24) and 0.75 FTE nurse (Line 11). 

Time for clinicians should be allocated to the appropriate clinical personnel category except when 

such personnel perform corporate administrative duties not directly connected with provision of 

clinical services. The time spent by clinicians for charting, reviewing lab test results, writing

prescriptions, returning phone calls, arranging for referrals, etc. is not considered administrative and 

should be reported as “medical care services.” However, time for a physician/medical director should

be allocated between medical care services and administration. 

An individual who is hired as a full-time clinician must be counted as 1.0 FTE regardless of the 

number of “direct patient care” or “face-to-face hours” they provide. Providers who have released 

time to compensate for on-call hours or who receive leave for continuing education or other reasons 

are still considered full-time if this is how they were hired. The time spent by providers doing 

administrative work such as charting, reviewing labs, filling prescriptions, returning phone calls, 

arranging for referrals, etc. is not to be adjusted. The one exception to this rule is when a Medical 

Director is engaged in corporate administrative activities, in which case time can be allocated to 

administration. This does not, however, include clinical administrative activities including chairing 

or attending clinical meetings, supervising staff, etc.

PERSONNEL BY MAJOR SERVICE CATEGORY – Staff are distributed into categories that reflect the types 

of services they provide. Major service categories include: medical care services, dental 

services, mental health services, substance abuse services, other professional health services, 

pharmacy services, enabling services, other program related services staff, and administration 

and facility. Whenever possible, the contents of major service categories have been defined to 

be consistent with definitions used by Medicare. The following summarizes the personnel 

categories; a detailed list appears in Appendix A. 

• MEDICAL CARE SERVICES 

- Physicians - M.D.s and D.O.s, except psychiatrists, pathologists and 

radiologists 

- Nurse Practitioners

- Physician Assistants

- Certified Nurse Midwives 

- Nurses - registered nurses, licensed practical and vocational nurses, 

home health and visiting nurses, clinical nurse specialists, and public 

health nurses

- Laboratory Personnel - pathologists, medical technologists,

laboratory technicians and assistants, phlebotomists

- X-ray Personnel - radiologists, X-ray technologists, and X-ray 

technicians

- Other Medical Personnel - medical assistants, nurses aides, and all 

other personnel providing services in conjunction with services

provided by a physician, nurse practitioner, physician assistant,

certified nurse midwife, or nurse
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• DENTAL SERVICES

- Dentists - general practitioners, oral surgeons, periodontists, and

pediodontists

- Dental Hygienists 

- Other Dental Personnel - dental assistants, aides, and technicians

• MENTAL HEALTH SERVICES

- Psychiatrists, 

- Other licensed clinicians, including psychiatric nurses, psychiatric social

workers, clinical psychologists, clinical social workers, and family therapists

- Other individuals providing counseling, treatment or support services related 

to mental health professionals. 

• SUBSTANCE ABUSE SERVICES - Psychiatric nurses, psychiatric social workers, mental health 

nurses, clinical psychologists, clinical social workers, and family therapists and other 

individuals providing counseling and/or treatment services related to substance abuse.

• ALL OTHER PROFESSIONAL HEALTH SERVICES - Occupational and physical therapists,

podiatrists, optometrists and other staff professionals providing health services. Note: 

WIC nutritionists and others working in WIC programs are now reported on Line 29a, 

Other Program Related Staff. (A more complete list is included in Appendix A.)

• PHARMACY SERVICES - Pharmacists , pharmacist assistants and others supporting

pharmaceutical services including individuals assisting in applying for free drugs from 

pharmaceutical companies.

• ENABLING SERVICES

- Case Managers - staff who provide services to aid patients in the management of 

their health and social needs, including assessment of patient medical and/or 

social services needs, and maintenance of referral, tracking and follow-up 

systems. Case managers may provide eligibility assistance, if performed in the 

context of other case management functions. Staff may include nurses, social 

workers and other professional staff.

- Education Specialists - health educators, family planning, HIV specialists, and 

others who provide information about health conditions and guidance about 

appropriate use of health services that are not otherwise classified under

outreach.

- Outreach Workers - individuals conducting case finding, education or other 

services to identify potential clients and/or facilitate access/referral of clients to 

available services. 

- Personnel Performing Other Enabling Service Activities - all other staff

performing services listed in Appendix B as enabling services, such as child 

care, eligibility assistance, referral for housing assistance, interpretation and 

translation. 

• OTHER PROGRAM RELATED SERVICES STAFF
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Some grantees, especially “umbrella agencies,” operate programs which, while 

within their scope of service, are not directly a part of their medical or social 

health services. These include WIC programs, job training programs, head start 

or early head start programs, shelters, housing programs, etc. The staff for these 

programs are reported under Other Related Services. The cost of these

programs are reported on Table 8A on line 12.

• ADMINISTRATION AND FACILITY

- Administration - executive director, medical director, physicians or nurses with 

corporate (not clinical) administrative responsibilities, secretaries, fiscal and 

billing personnel, all other support staff and staff with administrative

responsibilities.

- Facility - staff with facility support and maintenance responsibilities, including 

custodians, housekeeping staff, and other maintenance staff.

- Patient Services Support Staff - intake staff and medical/patient records.

NOTE: The Administration and Facility category for this report is more comprehensive than that 

used in some other program definitions and includes all personnel working in a BPHCsupported program, whether or not that individual's salary was supported by the BPHC grant. 

Note also: Tables 8A and 8B have data relating to cost centers. Staff classifications should be 

consistent with classifications on other tables. The staffing on Table 5 is routinely compared to 

the costs on Table 8A and 8B during the editing process. If there is a reason why such a 

comparison would look strange (e.g., volunteers on Table 5 resulting in no cost on Table 8A) be 

sure to include an explanatory note on Table 8A .

INSTRUCTIONS FOR COMPLETING TABLE 5 COLUMN B (ENCOUNTERS) AND 

COLUMN C (USERS)

ENCOUNTERS – An encounter is a documented, face-to-face contact between a user and a provider 

who exercises independent professional judgment in the provision of services to the individual. (See 

General Instructions for further detail on the definition of encounters). Grantees are to report 

encounters rendered by identified staff during the reporting period. No encounters are reported for 

personnel who are not “providers who exercise independent professional judgment” within the 

meaning of the definition above; in Column B, the cells applicable to these staff are blocked out. 

Encounters that are purchased from non-staff providers on a fee-for-service basis are also counted in 

this column, even though no corresponding FTE are included in Column A. To be counted, the 

service must meet the following criteria:

1) the service was provided to a patient of the Grantee by a provider that is not part of 

the grantee's staff (neither salaried nor contracted on the basis of time worked), 

2) the service was paid for by the grantee, and 

3) the service otherwise meets the above definition of an encounter. 

This category does not include unpaid referrals or referrals for services that would otherwise not be 

counted as encounters.
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USERS – A user is an individual who has at least one encounter during the year. Report the number of 

users for each of the six separate services listed below. Within each category, an individual can only 

be counted once as a user. A person who receives multiple types of services should be counted once 

for each service. For example, a person receiving only medical services is reported once (as a 

medical user) regardless of the number of encounters made.

A person receiving medical, dental and enabling services is reported once as a medical user (Line 15), 

once as a dental user (Line 19) and once as an enabling user (Line 29), but is counted only once each 

time in column C, regardless of the number of visits reported in column B. An individual patient may 

be counted once (and only once) in each of the following categories:

• Medical care services users (Line 15)

• Dental services users (Line 19)

• Mental health services users (Line 20)

• Substance abuse services users (Line 21)

• Users of other professional services (Line 22)

• Enabling services users (Line 29)

Though it would be relatively uncommon, an individual whose only contact with the clinic was 

through a paid referral (e.g., a patient who was referred in December and seen in January of the next 

year) would also be counted as a user here as well as on Tables 3A, 3B, and 4.

If you show encounters in Column B for any of these six categories, you are required to show the 

unduplicated number of persons who received these encounters. Since users must have at least one 

documented encounter, it is not possible for the number of users to exceed the number of encounters. 
BPHC UDS MANUAL

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QUESTIONS AND ANSWERS FOR TABLE 5

1. Are there changes to this table?

Several changes to the table have been made:

1) Line 9, which previously reported “Nurse Practitioners / Physician Assistants” has 

been replaced by line 9a “Nurse Practitioners” and line 9b “Physician Assistants.”

2) Line 6, Psychiatrists, has been eliminated. Psychiatrists will now be reported as 

Mental Health providers as they were in past years.

3) Line 20, “Mental Health Services”, is now a total line, and we have added three 

new lines: Line 20a Psychiatrists, Line 20b Other Licensed Mental Health

Providers, and Line 20c: Other Mental Health staff, including all non-licensed 

and support staff. Line 20 is the sum of Lines 20a + 20b + 20c.

4) Table 5 is now reported for grants as well as for the universal report, though staff 

FTE are not reported separately for the grant reports.

2. How do I count participants in a group session?

If you have group treatment sessions (e.g., for substance abuse or mental health) you must 

record the encounter in each participant’s chart and then record an encounter for each 

participant. If an encounter is not recorded in a participant’s chart, that participant may not 

be counted as a user. No group medical encounters are counted on the UDS. Though in 

some instances they may be billable as counseling services, the UDS specifically does not 

count as encounters activities in such sessions.

3. How do I report the FTEs for a clinician who regularly sees patients 75 percent of the time 

and covers after-hours call the remaining 25 percent of his/her time?

An individual who is hired as a full-time clinician must be counted as 1.0 FTE regardless of 

the number of “direct patient care” or “face-to-face hours” they provide. Providers who have 

released time to compensate for on-call hours or hours spent on clinical committees, or who 

receive leave for continuing education or other reasons are still considered full-time if this is 

how they were hired. The time spent by providers doing administrative work such as

charting, reviewing labs, filling prescriptions, returning phone calls, arranging for referrals, 

etc. is not to be adjusted for. The one exception to this rule is when a Medical Director is 

engaged in corporate administrative activities, in which case time can be allocated to

administration. This does not, however, include clinical administrative activities including 

chairing or attending meetings, supervising staff, supervising. Note that UGS, the FQHC 

Medicare intermediary, has different definitions for full time providers. These UGS definitions

are not to be used in reporting on the UDS,

4. Is it appropriate for the total number of users reported on Table 3A to be equal to the sum 

of the several types of users on Table 5?

Not usually. On Table 5, the grantee reports users of each type of service, with the user 

counted once for each type of service received. Thus a person who receives both medical 

and dental services would be counted once as a medical user on Line 15 and once as a dental 

user on Line 19. Because there are six different types of users identified on Table 5, a patient 

who is counted only once on Table 3A may be counted up to six different places on Table 5.

On the other hand, grantees which provide only medical services will report the same 

number of total users on Table 3A as they do medical users on Table 5 (Line 15). But where 
BPHC UDS MANUAL

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an agency has more than one type of user (e.g., medical and dental or medical and enabling) 

these numbers are not the same. 

5. If I report case management services on Table 2 or costs for them on Tables 8A and 8B, do I 

have to report case managers on Table 5?

Yes. There should be a logical consistency between Table 5 and Tables 2 and 8A and 8B. If 

a grantee reports that case management services are provided by the grantee (i.e., Table 2, 

Column A is marked), one would expect to see case managers reported on Table 5. For 

example, if nurses also have case management duties, their time (FTEs) should be split.
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 5 –

STAFFING AND UTILIZATION

Personnel by Major Service Category FTEs

(a)

Clinic Encounters

(b)

Users

(c)

1 Family Practitioners

2 General Practitioners

3 Internists

4 Obstetrician/Gynecologists

5 Pediatricians

7 Other Specialty Physicians

8

Total Physicians

(Total lines 1 through 7)

9a Nurse Practitioners

9b Physician Assistants

10 Certified Nurse Midwives

11 Nurses

12 Other Medical personnel

13 Laboratory personnel

14 X-ray personnel

15 Total Medical Care Services

(Total Lines 8 through 14)

16 Dentists

17 Dental Hygienists

18 Dental Assistants, Aides, Techs

19 Total Dental Services

(Lines 16 through 18)
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 5 –

STAFFING AND UTILIZATION

Personnel by Major Service Category FTEs

(a)

Clinic Encounters

(b)

Users

(c)

20a Psychiatrists

20b Other Licensed Mental Health 

Providers

20c Other Mental Health Staff

20 Mental Health Services

(Lines 20a + 20b + 20c)

21 Substance Abuse Services

22 Other Professional Services

23 Pharmacy Personnel

24 Case Managers

25 Education Specialists

26 Outreach Workers

27 Transportation Staff

28 Other Enabling Services

29 Total Enabling Services

(Lines 24 through 28)

29a Other Programs and Services

 (see instructions)

30 Administrative Staff

31 Facility Staff

32 Patient Support Staff

33 Total Administration and Facility

(Lines 30 through 32)

34

Total (Lines 

15+19+20+21+22+23+29+29a

+33)
BPHC UDS MANUAL

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INSTRUCTIONS FOR TABLE 6 –

SELECTED DIAGNOSES AND SERVICES RENDERED

The content of this table has changed significantly since the 2002 Reporting period, please see a guide 

to changes in the Questions and Answers Section below.

This table reports data on selected diagnoses and services rendered. It is designed to provide 

information on diagnoses and services of greatest interest using data maintained for billing purposes. 

As a subset of diagnoses, Table 6 is not expected to reflect the full range of diagnoses and services 

rendered by a grantee. The selected conditions and services represent those that are prevalent among 

BPHC users or a sub-group of users or are generally regarded as sentinel indicators of access to 

primary care. 

The table is included in both the Universal Report and Grant Reports. 

• The Universal Report reports on encounters in the indicated diagnostic or service categories 

and a count of all individuals who had at least one encounter in the indicated diagnostic or 

service category within the scope of any and all BPHC - supported projects included in the 

UDS.

• The Grant Report reports only those encounters and those individuals which were provided 

or served within the scope of the program in question.

SELECTED DIAGNOSES – Lines 1 through 20 present the name and applicable ICD-9CM codes for the 

diagnosis or diagnostic range/group. Wherever possible, diagnoses have been grouped into code 

ranges. Where a range of ICD-9CM codes is shown, grantees should report on all of the diagnoses 

included in the range/group.

SELECTED TESTS/SCREENINGS/PREVENTIVE SERVICES – Lines 21 through 26 present the name and applicable 

ICD-9CM and/or CPT procedure codes for selected tests, screenings, and preventive services which 

are particularly important to the populations served. On several lines both CPT codes and IC9 codes 

are provided. Grantees should use either the CPT codes or the ICD9 codes for any given line, not 

both!

INSTRUCTIONS FOR REPORTING ENCOUNTERS - COLUMN (A).

LINES 1 – 20: Diagnostic Data.

ENCOUNTERS BY SELECTED DIAGNOSES (Lines 1-20): Report the total number of encounters during the 

reporting period where the indicated diagnosis is listed on the encounter/billing records as the 

primary diagnosis only. If an encounter is attributed to one of the many diagnoses not listed on 

Table 6, it is not reported. Note that, while most encounters are not reported on this table, those 

which are counted, are reported for only the primary diagnosis on lines 1 through 20. All visits 

are entered into the computer in order, with one diagnosis listed as primary and successive 

diagnoses listed as secondary, tertiary, etc.

LINES 21 – 34: Service Data.
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ENCOUNTERS BY SELECTED TESTS/SCREENINGS/PREVENTIVE AND DENTAL SERVICES (Lines 21-34) – Report the 

total number of encounters for the listed diagnostic tests/screenings/preventive services. Note that 

codes for these services may either be diagnostic (ICD-9) codes or procedure (ADA or CPT-4) codes. 

During one encounter there may be more than one test/screening or preventive service.

• One encounter may involve more than one of the indicated services and all should be 

reported. For example, if during an encounter both a PAP smear and an HIV test were 

conducted then an encounter would be reported on both lines 21 and 23. 

• If a client receives multiple immunizations at one visit, only one encounter should be 

reported. 

• Services may be reported in addition to diagnoses. A hypertensive patient who also 

receives an HIV test would be counted once on the hypertension line 11 and 

once on line 21, HIV test.

• If a patient had more than one tooth filled, only one encounter for restorative services 

should be reported.

INSTRUCTIONS FOR REPORTING USERS - COLUMN (B) 

LINES 1 – 20: Diagnostic Data.

USERS BY DIAGNOSIS – For Column B report each individual who had one or more encounter during 

the year where the primary diagnosis was the indicated diagnosis (e.g., a user with one or more 

encounters for hypertension (Line 11, Column A). A user is counted once and only once regardless of 

the number of encounters made for that specific diagnosis. Any one user may have encounters with 

different primary diagnoses, for example, one for hypertension and one for diabetes on different days. 

 In this case, the user would be reported once for each diagnosis used during the year.

LINES 21 – 26: Services Data.

USERS BY SELECTED DIAGNOSTIC TESTS/SCREENINGS/PREVENTIVE SERVICES -- Report users who have had at least 

one encounter during the reporting period for the selected diagnostic tests, screenings, and/or 

preventive services listed on Lines 21-26. If a user had a PAP smear and contraceptive management 

during the same encounter, this user would be counted on both Lines 23 and 25 in Column B.

LINES 27 – 34: Dental Services Data.

USERS BY SELECTED DENTAL SERVICES -- Report users who have had at least one encounter during the 

reporting period for the selected dental services listed on Lines 27-34. If a user had two teeth repaired 

and sealants applied during one encounter, this user would be counted once (only) on both Lines 30 

and 32 in Column B.
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QUESTIONS AND ANSWERS FOR TABLE 6

1. Are there any changes to the table this year?

Several critical changes have been made to the table:

• Some of the CPT codes and ICD9 codes have been updated. Be sure to check with your 

software vendor to ensure that the appropriate codes are included. 

• There are several new categories for mental health codes,

• Service categories have been added for dental services.

• Some of the immunizations on the list have been changed adding, for example, the 

inactivated polio vaccine and the DTaP (diptheria, tetanus and acellular pertusis) vaccine.

2. Some diagnostic and/or procedure codes in my system are different from the codes listed. What 

do I do?

It is possible that several items on Table 6 are not available in the requested form because of 

idiosyncrasies in state or clinic billing systems. Generally, these involve situations where (a) the 

state uses unique billing codes, other than the normal CPT code, for state billing purposes (e.g., 

EPSDT) or (b) internal or state confidentiality rules mask certain diagnostic data. The following 

provides examples of problems and solutions. 

LINE # PROBLEM POTENTIAL SOLUTION

1 and 2 HIV diagnoses are kept confidential and 

alternative diagnostic codes are used.

Include the alternative codes used at your center on these lines 

as well.

26

Well child visits are charged to the state 

EPSDT program using a special code

(often starting with W, X, Y or Z).

Add these special codes to the other codes listed and count all 

such visits as well. Do not count EPSDT follow-up visits in this 

category. 

3. The instructions specifically say that the source of information for Table 6 is “billing systems.” 

There are some services for which I do not pay and there are no encounters in my system. What 

do I do? 

While grantees are only required to report data derived from billing systems, the reported data 

will understate services in the circumstances described. In order to more accurately reflect your 

level of service, grantees are encouraged to use other sources of information (e.g., referral or 

tracking logs), although there is no requirement to do so. The following provides examples of 

these sources. 

LINE 

#

PROBLEM POTENTIAL SOLUTION

21

HIV Tests are processed and paid for by 

the State and do not show on the

encounter form or in the billing system.

Use other data sources such as logs of HIV tests conducted or 

reports to Ryan White programs and use this number of tests.

22

Mammograms are paid for, but are

conducted by a contractor and do not 

show in the billing system for individual 

patients.

Use the bills from the independent contractor to identify the 

total number of mammograms conducted during the course of 

the year and report this number.

23

Pap smears are processed and paid for by 

the State and do not show on the

encounter form or in the billing system.

Use other data sources such as logs of PAP tests conducted and 

use this number of tests.

24 Flu shots are not counted because they 

are obtained at no cost by the center.

Use the Medicare cost report data on influenza vaccination 

reimbursements as an estimate for the number of actual

encounters where flu shots were administered.

25 Contraceptive management is funded

under Title X or a state family planning 

Use records developed for the Title X or state family planning 

program to count the number of family planning visits. Take 
BPHC UDS MANUAL

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program and does not have a V-25 

diagnosis attached to it.

care not to count the same visit twice.
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 6 –

SELECTED DIAGNOSES AND SERVICES RENDERED

DIAGNOSTIC CATEGORY

APPLICABLE

ICD-9-CM

CODE

NUMBER OF 

ENCOUNTERS BY PRIMARY 

DIAGNOSIS

 (A)

NUMBER OF USERS WITH 

PRIMARY DIAGNOSIS

(B)

SELECTED INFECTIOUS AND PARASITIC DISEASES

1. Symptomatic HIV 042.xx

2. Asymptomatic HIV V08

3. Tuberculosis 010.xx – 018.xx

4. Syphilis and other venereal 

diseases 090.xx – 099.xx

SELECTED DISEASES OF THE RESPIRATORY SYSTEM

5. Asthma 493.xx

6. Chronic bronchitis and 

emphysema

490.xx – 492.xx

496.xx

SELECTED OTHER MEDICAL CONDITIONS

7. Abnormal breast findings, female 174.xx; 198.81; 233.0x; 

793.8x

8. Abnormal cervical findings 180.xx; 198.82; 

233.1x; 795.0x

9. Diabetes mellitus 250.xx; 775.1x; 

790.2

10. Heart disease (selected) 391.xx – 392.0x

410.xx – 429.xx

11. Hypertension 401.xx – 405.xx; 

12. Contact dermatitis and other 

eczema

692.xx

13. Dehydration 276.5x 

14. Exposure to heat or cold 991.xx – 992.xx
BPHC UDS MANUAL

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 6 –

SELECTED DIAGNOSES AND SERVICES RENDERED

DIAGNOSTIC CATEGORY

APPLICABLE

ICD-9-CM

CODE

NUMBER OF ENCOUNTERS 

BY PRIMARY DIAGNOSIS

 (A)

NUMBER OF USERS WITH 

ANY DIAGNOSIS

(B)

SELECTED CHILDHOOD CONDITIONS

15. Otitis media and eustachian tube 

disorders 381.xx – 382.xx

16. Selected perinatal medical 

conditions

770.xx; 771.xx; 773.xx; 

774.xx – 779.xx 

(excluding 779.3x)

17.

Lack of expected normal 

physiological development (such 

as delayed milestone; failure to 

gain weight; failure to thrive)--does 

not include sexual or mental 

development; Nutritional 

deficiencies

260.xx – 269.xx;

779.3x;

783.3x – 783.4x;

SELECTED MENTAL HEALTH AND SUBSTANCE ABUSE CONDITIONS

18. Alcohol related disorders 291.xx, 303.xx; 305.0x

357.5x

19. Other substance related disorders 

(excluding tobacco use disorders)

292.1x – 292.8x 304.xx, 

305.2x – 305.9x 357.6x, 

648.3x

20a. Depression and other mood 

disorders

296.xx, 300.4

301.13, 311.xx

20b Anxiety disorders including PTSD

300.0x, 300.21, 300.22, 

300.23, 300.29, 300.3, 

308.3, 309.81

20c Attention deficit and disruptive 

behavior disorders

312.8x, 312.9x, 313.81, 

314.xx

290.xx

 293.xx – 302.xx 

(excluding 296.xx, 

300.0x, 300.21, 300.22, 

300.23, 300.29, 300.3, 

20d 300.4, 301.13);

Other mental disorders, excluding 

drug or alcohol dependence 

(includes mental retardation)

306.xx - 319.xx

(excluding 308.3, 309.81, 

311.xx, 312.8x, 

312.9x,313.81,314.xx)
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 6 –

SELECTED DIAGNOSES AND SERVICES RENDERED

SERVICE CATEGORY

APPLICABLE

ICD-9-CM 

OR CPT-4 CODE(S)

NUMBER OF 

ENCOUNTERS

(A)

NUMBER OF USERS

(B)

SELECTED DIAGNOSTIC TESTS/SCREENING/PREVENTIVE SERVICES

21. HIV test

CPT-4: 86689;

86701-86703;

87390-87391

22. Mammogram CPT-4: 76090-76092

ICD-9: V76.1x

23. Pap Smear

CPT-4: 88141-88155; 

88164-88167

ICD-9:V72.3; V76.2

24. Selected Immunizations:

CPT-4: 90633-90634, 

90645 – 90648; 

90657 – 90660; 90669; 

90700 – 90702;

90704 – 90716; 90718; 

90720 – 90723, 

90743 – 90744; 90748

25. Contraceptive management ICD-9: V25.xx

26. Health supervision of infant or 

child (ages 0 through 11)

CPT-4: 99391-99393; 

99381-99383;

99431-99433

ICD-9: V20.xx; V29.xx

SELECTED DENTAL SERVICES

27. I. Emergency Services ADA: 09110

28. II. Oral Exams ADA: 00120

29. Prophylaxis – adult or child ADA: 01110, 01120

30. Sealants ADA: 01351

31. Fluoride treatment ADA: 01203

32. III. Restorative Services ADA: 021xx, 023xx, 

027xx

33. IV Oral Surgery 

 (extractions only)

ADA: 07111, 07140, 

07210, 07220, 07230, 

07240, 07241, 07250, 

07260, 07261, 07270, 

07272, 07280, 07281

34. V. Rehabilitative services 

 (Endo, Perio, Prostho, Ortho)

ADA: 03xxx, 04xxx, 

05xxx, 06xxx, 08xxx

Note: x denotes any number including the absence of a number in that place.

I International Classification of Diseases, 9th Revision, 6th Edition, Clinical Modification, Volumes 1 and 2, 2004. 

Reston, VA: St. Anthony Publishing. Codes for HIV Infection reflect revisions published in MMWR Volume 43, No. 

RR-12, September 30, 1994.

II Physicians' Current Procedural Terminology, 4th edition, CPT 2004. American Medical Association.

III Current Dental Terminology, CDT 4, 2002. American Dental Association.
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INSTRUCTIONS FOR TABLE 7 –

PERINATAL PROFILE

The content of this table has changed since the 2002 Reporting period, please see a guide to changes 

in the Questions and Answers Section below.

This table provides detail on pregnant and postpartum women users and their newborn infants, as 

well as services rendered by grantees that provide prenatal care. Table 7 is included in the Universal 

Report only.

DATA REPORTED BY ALL GRANTEES

TOTAL USERS KNOWN TO BE PREGNANT – NO LONGER REPORTED

TOTAL USERS KNOWN TO BE HIV-POSITIVE AND PREGNANT (Line 2) – Report the total number of users 

known to have been both pregnant and infected with HIV at some time during the reporting 

period, regardless of whether the woman received services from the grantee directly related to the 

pregnancy or to HIV infection.

NOTE: All grantees, whether or not they provide or assume primary responsibility for a client's 

perinatal care services, complete Line 2. Requesting this information does not mean that the 

grantee must provide pregnancy or HIV testing if those services are not in the scope of their 

services.

DATA REPORTED ONLY BY GRANTEES WHO PROVIDE PRENATAL CARE

Only grantees that provide or assume primary responsibility for a client's prenatal care services, 

whether or not the grantee does the delivery, complete the remaining sections of Table 7. All data 

reported apply only to users who received prenatal care services during the reporting period.

DEMOGRAPHIC CHARACTERISTICS OF PRENATAL CARE USERS

AGE OF PRENATAL CARE USERS (Lines 3-8) – Report the total number of users who received 

prenatal care services at any time during the reporting period by age group. Be sure to 

include women who began prenatal care during the previous reporting period and continued 

into this reporting period as well as women who began their care in this reporting period but 

will not /did not deliver until the next year. To determine the appropriate age group, use the 

woman's age on June 30 of the reporting period.

RACE / ETHNICITY OF PRENATAL CARE USERS (Lines 9-15) – Report the number of prenatal care 

users during the reporting period in each race / ethnicity category. The total women reported 

on line 15 must equal the total by age reported on line 8 above. Data on race / ethnicity may 

be estimated where not fully known. Asian, Native Hawaiian and Other Pacific Islander users 

should be reported separately on Lines 9a, 9b and 9c; the total percentage of Asian, Native 

Hawaiian and Other Pacific Islander users should be reported on Line 9.
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TRIMESTER OF ENTRY INTO PRENATAL CARE

TRIMESTER OF FIRST VISIT (Lines 16-18) – Report the total number of pregnant women users who 

received prenatal care during the reporting period, by trimester of pregnancy when they 

began prenatal care either at one of the grantee's service delivery locations or with another 

provider. A woman is counted only once regardless of the number of trimesters during 

which she receives care. A woman who begins her prenatal care at another provider and 

then comes to the center, is counted once and only once Column B. Prenatal care is

considered to have begun at the time the patient has her first visit with the obstetrical care 

giver, not when she registers for care at the center or has lab tests done.

• FIRST TRIMESTER – Includes women who received prenatal care during the

reporting period and whose pregnancy at the time of enrollment was estimated 

to be anytime less than 13 weeks after conception. 

• SECOND TRIMESTER – Includes women who received prenatal care during the 

reporting period and whose pregnancy at the time of enrollment was estimated 

to be between the 13th and through the 26th week after conception.

• THIRD TRIMESTER – Includes women who received prenatal care during the 

reporting period and whose pregnancy at the time of enrollment was estimated 

to be 27 weeks or more after conception.

NOTE: Line 8 (total prenatal care users by age) and the sum of Lines 16-18 (total prenatal 

care users by trimester) must be the same.

DELIVERY, POSTPARTUM AND WELL CHILD CARE

This section reports on deliveries, infant birthweight, and infant and postpartum visits. All 

data except line 19a, center deliveries, are to be reported by race / ethnicity subcategories to 

enable BPHC to account for impact on racial disparities.

PRENATAL CARE USERS WHO DELIVERED DURING THE YEAR (Line 19) – Report the total number of 

women who both received prenatal care from the grantee during the reporting period and

delivered during the year, even if the delivery was done by another provider. Include all 

deliveries, regardless of the outcome.

NOTE: Line 8 (total prenatal care users by age) and Line 19, Column H (total prenatal 

care users who deliver during the year) should not be identical. 

DELIVERIES BY CENTER CLINICIANS (Line 19a) – Report the total number of deliveries performed by 

center clinicians during the reporting period in column H. (This line is not reported by the 

race / ethnicity of the women delivered.) On this line ONLY, include deliveries of women 

who were not part of the grantee’s prenatal care program during the calendar year. This 

would include such circumstances as the delivery of another doctor’s patients when the clinic 

provider participates in a call group and is on call at the time of delivery; emergency 

deliveries when the clinic provider is on-call for the emergency room; and deliveries of “un-
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doctored” patients who are assigned to the provider as a requirement for privileging at a 

hospital.

BIRTHWEIGHT OF INFANTS BORN TO PRENATAL CARE USERS DURING THE YEAR (Lines 20-22) – Report 

the total number of live births during the reporting period for women who received prenatal 

care from the grantee or referral provider during the reporting period, according to the 

appropriate birthweight group. NOTE: Grantees must report deliveries and the birth-weight 

of children delivered for all women who were in their prenatal care program and who 

delivered during the reporting period, regardless of whether the grantee did the delivery 

themselves or referred the delivery to another provider.

PRENATAL CARE USERS WHO RETURNED FOR POSTPARTUM CARE DURING THE YEAR (Line 23) – Report 

the total number of women who: 

• received prenatal care from the grantee during the reporting period, 

• delivered during the reporting period,

• and returned to the grantee within 8 weeks of delivery for postpartum care during 

the reporting period 

•

INFANTS WHO RECEIVED A NEWBORN VISIT (Line 24). Report the total number of infants who

• were born during the reporting period 

• to women who received prenatal care from the grantee during the reporting 

period 

• who also received a newborn care visit from the grantee during the reporting 

period.

• And who did so during the first 4 weeks after birth)

WIC ENROLLEES

This section of Table 7 tracks enrollment of prenatal care users in the Special Supplemental 

Food Program for Women, Infants and Children (WIC). Report the total number of users in 

the following three categories:

• PRENATAL CARE USERS – Line 25 reports only women who are enrolled in the prenatal 

care program, not a grantee’s total WIC program. It asks how many of the women 

reported on Line 8 (total prenatal care users by age) were also enrolled in WIC, either 

at your center or elsewhere. The number is never more than the number reported on 

Line 8.

• INFANTS – Line 26 reports only children born in a grantee’s prenatal care program, not 

a grantee’s total WIC program. It asks how many of the children reported on Lines 

20-22 (infants by birthweight) were also enrolled in WIC, either at your center or 

elsewhere. It is never more than the sum of these lines.

• POSTPARTUM CARE USERS. – Line 27 reports only women in the prenatal care program 

who delivered during the year, not a grantee’s total WIC program. It asks how many 

of the women reported on Line 19 Column H as having delivered this year were also 

enrolled in WIC, either at your center or elsewhere. It is never more than the number 

reported on Line 19.
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NOTE: Grantees are expected to provide case management for their perinatal care patients 

and to track whether or not they received WIC services. Report on all successful referrals 

regardless of whether or not the grantee actually operates the WIC program the woman was 

referred. NOTE ALSO that a woman may be reported in more than one category (i.e., a 

woman may be reported as having been both a prenatal and a postpartum WIC program 

enrollee).
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QUESTIONS AND ANSWERS FOR TABLE 7

1. Are there changes to the table this year?

Yes. Two changes have been implemented. The number of women served by race and 

ethnicity is now being reported as a number, not as a percentage. And the total number of 

deliveries by center providers are now reported on line 19a.

2. If a prenatal user in one year (e.g., 2004) gives birth in the next year (i.e., 2005) without having 

prenatal care in that year (i.e., 2005), is the delivery reported for that year (i.e., 2005)?

The delivery is NOT reported in 2005, nor was it to be reported in 2004. The table only 

includes data on women who received prenatal care during the year.

3. Are deliveries by women who are not in the grantee's prenatal care program excluded from 

Table 7?

Except for line 19a, the answer is “Yes”. For example, women who are delivered by a center 

provider as a result of being in a call group or staffing the emergency room, are not reported 

on this form as a user, as a delivery, or as a postpartum visit. 

4. Are birth outcomes of prenatal care users delivered by a non-grantee provider to be reported?

Yes. Comprehensive prenatal care includes case management and thus case tracking is a 

responsibility of all grantees. 
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 7 –

PERINATAL PROFILE

SECTION 1: ALL GRANTEES

CHARACTERISTICS

NUMBER OF USERS

(a)

1. Total Users Known to be Pregnant THIS LINE NO LONGER REPORTED

2. Total Users Known to be HIV+ Pregnant Women

*** ONLY CONTINUE IF YOU PROVIDE PRENATAL SERVICES ***

SECTION II: GRANTEES WHO PROVIDE PRENATAL CARE

A. DEMOGRAPHIC CHARACTERISTICS OF PRENATAL CARE USERS 

AGE Number of Users

(a)

3. Less than 15 years

4. Ages 15-19

5. Ages 20-24

6. Ages 25-44

7. Ages 45 and Over

8. TOTAL USERS 

(SUM LINES 3 – 7)

RACE/ETHNICITY Number of Users

(a)

9a. Asian

9b. Native Hawaiian

9c. Other Pacific Islander

9. TOTAL ASIAN/NATIVE HAWAIIAN/PACIFIC ISLANDER

(Sum Lines 9a through 9c)

10. Black/African American

(not Hispanic or Latino)

11. American Indian/Alaska Native

12. White (not Hispanic or Latino)

13. Hispanic or Latino (all races)

14. Unreported / Refused to Report

15. TOTAL NUMBER OF USERS

(Sum Lines 9 through14)
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 7 –

PERINATAL PROFILE

B. TRIMESTER OF ENTRY INTO PRENATAL CARE

Trimester of First Known Visit for Women Receiving 

Prenatal Care During Reporting Year

Women Having First 

Visit with Grantee

(a)

Women Having First Visit 

with Another Provider

(b)

16. First Trimester

17. Second Trimester

18. Third Trimester

C. DELIVERY, POSTPARTUM AND INFANT UTILIZATION DURING THE CALENDAR YEAR 

Asian

(a)

Native 

Hawaiian 

(b1)

Pacific 

Islander 

(b2)

Black/ 

African 

American 

(c)

American 

Indian/ 

Alaska 

Native 

(d)

White (not 

Hispanic 

or Latino) 

(e)

Hispanic 

or Latino 

(all races) 

(f)

Unreported/ 

Refused to

Refused

(g)

Total

(h)

19

Prenatal Care users 

who delivered during 

the year

19a

Deliveries performed 

by grantee provider

20 Births less than 1,500 

grams (very low)

21 Births 1,501 to 2,500 

grams (low)

22 Births more than 

2,500 grams (normal)

23

Prenatal care users 

who received postpartum care within 8 

weeks of delivery

24

Infant delivered who 

received newborn 

visit within 4 weeks 

of birth

D. ENROLLMENT OF PRENATAL CARE USERS AND THEIR INFANTS IN WIC

(Only Patients Who Receive Prenatal Services From The Grantee)

Number of Users (a)

25. Prenatal Care Users

26. Infants

27. Postpartum Care Users
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INSTRUCTIONS FOR TABLE 8A – COSTS

The content of this table has changed since the 2002 Reporting period, please see a guide to changes 

in the Questions and Answers Section below.

Table 8A must be completed by all BPHC grantees. It is included only in the Universal Report. The 

table covers the total cost of all activities, which are within the scope of the project(s) supported, in 

whole or in part, by any of the four BPHC grants covered by the UDS. All costs are to be reported on 

an accrual basis. These are the costs attributable to the period, including depreciation, regardless of 

when actual payments were made. 

DIRECT AND LOADED COSTS (COLUMN DEFINITIONS)

Column A : This column reports the accrued direct costs associated with each of the services listed. 

See Line Definitions for costs to be included in each category. Column A also reports the total cost of 

administration and facility (Overhead) separately on Lines 14 -16. 

Column B : This column shows the allocation of overhead costs (from lines 14-15, Column A) to 

each of the direct cost centers. The total of facility and administration costs, reported in Column A, 

lines 14-15, are to be distributed in Column B. The total amounts entered in Column B will thus 

equal the amount reported on Line 16, Column A. NOTE: for Lines 1-3, it is acceptable to report all 

medical overhead on Line 1 only if a more appropriate allocation is not available. It is also 

reasonable to allocate all pharmacy overhead to the non-supply line, and no overhead costs to 

pharmaceutical supplies (line 9a) 

The allocation of administration and facility costs should be done as follows, unless your center has a 

more accurate system:

FACILITY COSTS should be allocated based on the amount of square footage utilized for 

Medical, Dental, Mental Health, Substance Abuse, Pharmacy, Other Professional, Enabling, 

or Other Program Related Services. Square Footage refers to the portion of the grantee's 

facility space used in the operation of the organization, not including common spaces such 

as hallways, rest rooms, and utility closets. For reporting purposes, the square footage 

associated with space owned by the grantee and leased or rented to other parties should not 

be included if it is considered to be outside of the scope of the project. If it has been 

included inside the scope of project, it should allocated to Other Program Related Services 

(Row 12) and the rent received should be included on Table 9E under Other Revenues (Line 

10). 

ADMINISTRATIVE COSTS should be allocated after facility cost has been allocated, and should 

include the facility costs allocated to it. Administrative cost is allocated based on a straight 

line allocation method. The proportion of total cost (excluding administrative cost) that is 

attributable to each service category should be used to allocate administrative cost. For 

example, if medical staff account for 50 percent of total cost (excluding administration) then 

50 percent of administrative cost is allocated to medical staff. If you have an alternative 

method that provides more accurate allocations, it may be used, but save your paper work 

for review and explain the methods used in the table note.

Column C : This column shows the loaded cost of each of the cost centers listed on Lines 1 - 13. The 
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loaded cost is the sum of the direct cost, reported in Column A, plus the allocation of overhead, 

reported in Column B. The Total Accrued Cost reported on Line 17 should be the same in Column A 

and Column C. Column C also shows the value of any donated services and supplies on Line 18. 

Donations should be reflected as a positive number, and are not included in any of the lines above. 

Line 19, Column C is the total cost including the value of donations. 

BPHC MAJOR SERVICE CATEGORIES (LINE DEFINITIONS)

A. MEDICAL CARE SERVICES (Lines 1- 4) – This category includes costs for medical care staff personnel; 

services provided under agreement; X-ray and laboratory; and other direct costs wholly

attributable to medical care (e.g., equipment depreciation, supplies, or professional dues and 

subscriptions). It does not include costs associated with pharmacy, dental care, substance abuse 

specialists, or clinical psychologist and clinical social worker services. 

STAFF COSTS (Line 1) – Include all staff costs, including salaries and fringe benefits 

for personnel supported directly or under contract, for medical care staff except lab 

and x-ray staff. The costs of medical records and billing and collections are 

considered administrative and should be included on Line 15 and allocated in 

Column B. Include the cost for vouchered or contracted medical services on line 

1.

LAB AND X-RAY COSTS (Line 2) – Include all costs for lab and x-ray, including salaries 

and fringe benefits for personnel supported directly or under contract, for lab and 

x-ray staff; and all other direct costs including, but not limited to, supplies,

equipment depreciation, related travel, contracted or vouchered lab and x-ray 

services, etc. The costs of medical records, billing and collections are considered 

administrative and should be included on Line 15 and allocated in Column B.

OTHER DIRECT COSTS (Line 3) – Include all other direct costs for medical care 

including, but not limited to, supplies, equipment depreciation, related travel, etc. 

TOTAL MEDICAL (Line 4) – The sum of lines 1 + 2 + 3. 

B. OTHER CLINICAL SERVICES (Lines 5 - 10) – This category includes staff and related costs for dental, 

mental health, substance abuse services, pharmacy, and other services rendered by professional 

personnel (e.g., optometrists, occupational and physical therapists, and podiatrists).

DENTAL (Line 5) – Report all costs for the provision of dental services including but 

not limited to staff, fringe benefits, supplies, equipment depreciation, related travel, 

contracted dental lab services and dental x-ray. Corporate administrative and 

facility costs should be included on Line 15 Column A and allocated in Column B.

MENTAL HEALTH (Line 6) – Report all direct costs for the provision of mental health 

services, other than substance abuse services, including but not limited to staff, 

fringe benefits, supplies, equipment depreciation, and related travel. Corporate 

administrative and facility costs should be included on Line 15 Column A and 

allocated in Column B.
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SUBSTANCE ABUSE (Line 7) – Report all direct costs for the provision of substance 

abuse services including but not limited to staff, fringe benefits, supplies,

equipment depreciation, and related travel. Corporate administrative and facility 

costs should be included on Line 15 Column A and allocated in Column B.

PHARMACY (NOT INCLUDING PHARMACEUTICALS) (Line 8a) – Report all direct costs for 

the provision of pharmacy services including but not limited to staff, fringe

benefits, non-pharmaceutical supplies, equipment depreciation, related travel,

contracted purchasing services, etc. Corporate administrative and facility costs

should be included on Line 15 Column A and allocated in Column B.

PHARMACEUTICALS (Line 8b) – Report all direct costs for the purchase of

pharmaceuticals. Do not include other supplies. Do not include the value of 

donated pharmaceutical supplies (these are recorded on Line 18, Column 

C.) Overhead costs are not allocated to pharmaceuticals.

OTHER PROFESSIONAL (Line 9) – Report all direct costs for the provision of other 

professional and ancillary health care services including but not limited to:

optometry, podiatry, chiropractic, occupational and physical therapy, etc. (A more 

complete list appears at Appendix A.) Included in direct costs are staff, fringe 

benefits, supplies, equipment depreciation, related travel, and contracted services. 

Corporate administrative and facility costs should be included on Line 15 Column 

A and allocated in Column B.

TOTAL OTHER CLINICAL (Line 10) – The sum of lines 5 + 6 + 7 + 8a + 8b + 9. 

C. ENABLING AND OTHER PROGRAM RELATED SERVICES (Lines 11 - 13) – This category includes enabling 

staff and related costs for case management, outreach, transportation, translation and

interpretation, education, environmental risk reduction and other services that support and assist 

in the delivery of primary medical services and facilitate patient access to care. The cost of these 

services are also reported on Table 8B. For definitions of specific enabling services, see Appendix 

B. 

It also includes the staff of other program related services such as WIC, day care, job training, 

delinquency prevention and other activities not included in other BPHC categories. 

ENABLING (Line 11) – Enabling services include a wide range of services which 

support and assist primary medical care and facilitate patient access to care. A 

non-exclusive list of 15 such services is included in Appendix B. Report all direct 

costs for the provision of enabling services including but not limited to costs such 

as staff, fringe benefits, supplies, equipment depreciation, related travel, and

contracted services. Corporate administrative and facility costs should be included 

on Line 15 Column A and allocated in Column B.

OTHER PROGRAM RELATED (Line 12) – Report all direct costs for the provision of 

services not included in any other category here. This includes services such as 

WIC, childcare centers, and training programs. Report all direct costs for staff, 

fringe benefits, supplies, equipment depreciation, related travel and contracted 
BPHC UDS MANUAL

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services. (Staff for these programs are now reported on line 29a of Table 5.) 

Corporate administrative and facility costs should be included on Line 15 Column 

A and allocated in Column B.

TOTAL ENABLING AND OTHER PROGRAM RELATED SERVICES (Line 13) – The sum of lines 

11 + 12.

D. FACILITY AND ADMINISTRATIVE COSTS (Lines 14 - 16) – This includes all traditional overhead costs 

that are later allocated to other cost centers. Specifically:

FACILITY COSTS (Line 14) – Facility costs include rent or depreciation, interest

payments, utilities, security, grounds keeping, maintenance, janitorial services, and 

all other related costs.

ADMINISTRATIVE COSTS (Line 15) – Administrative costs include the cost of all

corporate administrative staff, billing and collections staff, medical records and

intake staff, and the costs associated with them including, but not limited to,

supplies, equipment depreciation, travel, etc. In addition, include other corporate 

costs (e.g., purchase of insurance, audits, Board of Directors’ costs, etc.) The cost of 

all patient support services (e.g., medical records and intake) should be included in 

Administrative Costs. Most notably, the “cost” of bad debts is NOT to be included 

in administrative costs or shown on this table in any way. Instead, the UDS reduces 

income by the amount of patient bad debt on table 9D. 

NOTE: Some grant programs have limitations on the proportion of funds that may be 

used for administration. Limits on administrative costs for those programs is not to 

be considered in completing lines 14 and 15. The Administration and Facility 

categories for this report includes all administrative costs and personnel working in a 

BPHC-supported program, whether or not that cost was identified as administrative 

in any specific grant application. 

TOTAL OVERHEAD (Line 16) – The sum of lines 14 + 15.

 TOTAL ACCRUED COST (Line 17) – It is the sum of lines 4 + 10 +13 + 16

VALUE OF DONATED FACILITIES, SERVICES AND SUPPLIES (Line 18) - Include here the total imputed 

value of all in-kind and donated services, facilities and supplies applicable to the reporting 

period that are within your scope of project, using the methodology discussed below. In-kind 

services and donations include all services (generally volunteers, but sometimes paid staff 

donated to the grantee by another organization), supplies, equipment, space, etc that are 

necessary and prudent to the operation of your program that you do not pay for directly and 

which you included in your budget as donated. Line 18 reports the estimated reasonable 

acquisition cost of donated personnel, supplies, services, space rental, and depreciation for 

the use of donated facilities and equipment. The value of these services should not be 

included in the lines above.

The estimated reasonable acquisition cost should be calculated according to the cost that 

would be required to obtain similar services, supplies, equipment or facilities within the 

immediate area at the time of the donation. Donated pharmaceuticals, for example, would 

be shown at the price that would be paid under the federal drug pricing program, not the 

manufacturer’s suggested retail price. Donated value should only be recognized when the 
BPHC UDS MANUAL

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intent of the donating parties is explicit and when the services, supplies, etc., are both prudent 

and necessary to the grantee's operation.

The full market value of National Health Service Corps (NHSC) Federal assignee(s) should also 

be included in this category. NHSC-furnished equipment, including dental operatories, 

should be capitalized at the amount shown on the NHSC Equipment Inventory Document, 

and the appropriate depreciation expense should be shown in this category for the reporting 

period.

 TOTAL WITH DONATIONS (Line 19) – It is the sum of lines 17 and 18, column C.

CONVERSION FROM FISCAL TO CALENDAR YEAR

Grantees whose cost allocation system permits them to provide accurate accrued cost data should use 

that system. Grantees whose fiscal year does not correspond to the calendar year and whose 

accounting system is unable to provide accurate accrued cost data may calculate calendar year costs, 

using the following straight-line allocation methodology:

Step 1: Calculate the proportion of the calendar reporting period covered by the cost report 

and use that ratio to calculate the proportion of cost in each category attributable to the 

calendar year. Example: A grantee whose fiscal year ends March 31, 2003, allocates 25% 

of costs in each cost category to the 2003 calendar year.

Step 2: Using the trial balance for the end of December, determine the total cost for the 

remainder of the calendar year for each column. For example, a grantee whose fiscal year 

ends March 31, 2003 would use the nine-month trial balance for December 31. (Note:

Grantees who do not accrue depreciation monthly should adjust depreciation to an annual 

total.)

Step 3: Sum results of Steps 1 and 2 and enter the total in Column A. 
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 8A –

FINANCIAL COSTS

ACCRUED COST

( a )

ALLOCATION OF 

FACILITY AND 

ADMINISTRATION

( b )

TOTAL COST 

AFTER 

ALLOCATION OF 

FACILITY AND 

ADMINISTRATION

( c )

FINANCIAL COSTS FOR MEDICAL CARE

1. Medical Staff

2. Lab and X-ray

3. Medical/Other Direct

4. TOTAL MEDICAL CARE SERVICES 

(SUM LINES 1 THROUGH 3)

FINANCIAL COSTS FOR OTHER CLINICAL SERVICES

5. Dental 

6. Mental Health

7. Substance Abuse

8a. Pharmacy not including pharmaceuticals

8b Pharmaceuticals

9. Other Professional 

10. TOTAL OTHER CLINICAL SERVICES

(SUM LINES 5 THROUGH 9)

FINANCIAL COSTS OF ENABLING AND OTHER PROGRAM RELATED SERVICES

11. Enabling

12. Other Related Services

13. TOTAL ENABLING AND OTHER SERVICES 

(SUM LINES 11 AND 12)

OVERHEAD AND TOTALS

14. Facility

15. Administration

16. TOTAL OVERHEAD

(SUM LINES 14 AND 15)

17. TOTAL ACCRUED COSTS

(SUM LINES 4 + 10 + 13 + 16)

18. Value of Donated Facilities, Services and Supplies

19. TOTAL WITH DONATIONS

(SUM LINES 17 AND 18)
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INSTRUCTIONS FOR TABLE 8B –

ENABLING SERVICES

The content of this table has not changed since the 2002 Reporting period.

Table 8B should be completed by all of the four types of BPHC grantees covered by the UDS. 

 The table provides information on the costs of specific services that are important

components of BPHC-supported programs, but which are not broken out on Table 8A. This 

table includes only direct costs of service, and not allocation of overhead expenses. Costs are 

to be reported on an accrual basis in the same manner as costs are reported on Table 8A. 

MENTAL HEALTH/SUBSTANCE ABUSE SERVICES. (Lines 1 – 3 are no longer reported as of the 2002 

reporting period.) 

A. ENABLING SERVICES. Most of the enabling services included in this section are defined in Appendix 

A. To the extent possible, distribute direct staff and other direct costs associated with enabling 

services into the listed service categories. Enabling services staff includes those for whom FTE 

data were provided on Table 5. For Lines 4 through 12, include total direct costs for each of the 

listed service types. Include all staff costs including fringe benefits and other associated direct 

costs (e.g., equipment depreciation, supplies, related travel, professional liability insurance, etc.). 

Grantees should provide estimates where costs cannot be broken out by type of service. If a 

particular enabling service is not provided, leave the cost line blank for that service. 

TOTAL ENABLING SERVICES COSTS (Line 13) – Sum Lines 4 through 12.

NOTE: This must match Table 8A, Line 11, Column A.
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QUESTIONS AND ANSWERS FOR TABLE 8B

1. Can the cost of enabling services reported on Table 8B be higher than the cost for enabling 

services reported on Table 8A, line 11?

No. The total enabling services in 8B should equal the enabling costs reported on table 8A, 

line 11, column A (prior to the allocation of facility and administrative costs) and should be 

less then table 8A, Line 11 column C.

2. Is it permissible for donated costs to be included in Table 8B? 

 No. 

3. Are there changes to the table this year?

No. 

4. Is WIC included as an enabling service?

No. WIC is not included in the list of enabling services in Appendix B. NOTE: Services such 

as WIC, Headstart, and other non-medical services are reported on line 12 of Table 8A as 

Other Related Services).
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 8B –

ENABLING SERVICES

SERVICE COST

(a)

MENTAL HEALTH/SUBSTANCE ABUSE SERVICES

1-3 (These lines are no longer required.)

ENABLING SERVICES

4. Case Management

5. Transportation

6. Outreach

7. Patient Education

8. Translation/Interpretation 

9. Community Education

10. Environmental Health Risk Reduction

11. Other Enabling Services (specify: _________________)

12. Other Enabling Services (specify: _________________)

13. TOTAL ENABLING SERVICES COST (SUM LINES 4 - 12)
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INSTRUCTIONS FOR TABLE 9C:

MANAGED CARE

The content of this table has not changed since the 2002 Reporting period.

Table 9C should be completed by all grantees participating in Medicare, Medicaid, commercial, or 

other managed care plans; it is included only in the Universal Report. Grantees should also report 

the number of enrollees in Primary Care Case Management (PCCM) programs. If the grantee has more 

than one managed care contract of a particular type with Medicare, Medicaid, commercial, or other 

insurers, the information for each category should be added together and reported as a total. 

NOTE: There is one exception to this rule. Managed care plans covering only dental or mental 

health or pharmacy should not be reported on this table. 

This report includes revenue, expense, enrollment, and utilization information for capitated and feefor-service managed care plans. It also includes information on the number of enrollees in PCCM 

programs, though number of enrollees is the only information collected on these programs.

CAPITATED (PRE-PAID) PLANS – Are defined as plans under which the grantee receives a fixed 

payment per enrollee. Payment is made in advance, generally on a monthly basis, and covers all 

services included in the plan’s contract with the center. Under capitated arrangements, the 

grantee may also contract to be at full or partial risk for services beyond traditional primary care 

services. 

FEE-FOR-SERVICE PLANS (FFS) – Are defined as plans under which the grantee receives payment on a 

fee-for-service basis for enrollees, when the enrollees receive contractually specified services. As 

a rule, the provider receives a list of eligible enrollees just as it would for a capitated program 

and these enrollees must receive all their primary care and other stipulated services from their 

“Primary Care Provider” or PCP.

PRIMARY CARE CASE MANAGEMENT PROGRAMS - Are defined as arrangements whereby the grantee 

receives a case management fee, and is expected to serve as gatekeeper for the enrollee, 

providing referrals to more specialized services. While PCCM providers generally also provide 

the primary care services for the patient, this may not be required by the program. Table 9C only 

requests information on PCCM enrollees, reported on Line 11. Do not include any revenue or 

expenditures for PCCM enrollees on this Table.

SOURCE OF PAYMENT – Medicaid and Medicare payments should be reported according to the 

original source of payment. For example, if a center has a contract with a private HMO to 

provide services to enrolled Medicaid patients, this would be reported under Medicaid. 

Similarly, S-CHIP programs which are operated by private HMOs are classified under the “Other 

Public” payment source.

SCOPE OF PROJECT – This table requires the grantee to report on all activities included in their 

managed care contracts, within the “Scope of Project” in the grantee’s application for BPHC 

funding. The contract the project has with the managed care plan determines the types of 

services reported on this table. Ordinarily, the Scope of Project includes all (or virtually all) 

services included in a grantee’s managed care contract. A small number of grantee’s have 
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contracts that include services, which are not included in the grantee’s application for BPHC 

funding (e.g., inpatient hospital services). These services are considered “outside the scope of the 

project” and are not reported on this table. 

SERVICES WITHIN THE SCOPE OF PROJECT – Services within the scope of BPHC supported projects are 

often restricted to primary care but in some Centers may include lab, x-ray, pharmacy and/or 

specialty services. They may be covered by capitation or by fee-for-service payments. The 

defining element is whether or not they are included in the funded BPHC project (and its budget) 

and reported on in the FSR. Services within the scope of project are included in all of these 

documents. Services outside of scope have not been reported since CY-2000.

REVENUE

CAPITATION REVENUE FOR SERVICES (Line 1a) – Enter the accrued revenue from capitation for 

services. This figure is equal to the capitation earned during the calendar year, regardless of 

when it was received, though capitation is almost always received in the same year that it is 

earned. This amount generally equals the collection in Table 9D minus retroactive and

wraparound payments, unless there were late or early capitation payments received. Report 

only the capitation earned from the HMO on this line. Other payments are reported below.

FEE-FOR-SERVICE REVENUE FOR SERVICES (Line 1b) – Enter the “net accrued revenue” from fee-forservice for services. This figure is equal to the income earned during the calendar year, regardless 

of when it was or will be received. It is equal to full charges less all actual or anticipated 

disallowances or allowances except that allowances for anticipated FQHC settlements on these 

charges are not included here.

Note that a contract may pay a capitation to cover the cost of the basic visit, and pay fee-forservices for other costs such as lab, x-ray and pharmacy. In this instance the grantee will report 

income on both line 1a and 1b.

TOTAL REVENUE FOR SERVICES (Line 1) – Enter the sum of Lines 1a and 1b. 

COLLECTIONS FROM STATE MEDICAID OR FEDERAL MEDICARE RECONCILIATIONS OR WRAP AROUND 

PAYMENTS FOR THE CURRENT YEAR. (Line 3a) – Enter the (cash) amount received from Medicaid and 

Medicare reconciliation payments (payments based on the settlement of a cost report) and/or 

wrap around payments (amounts paid to bring reimbursement to cost or a negotiated fee-per-visit 

amount) for services rendered in the current (reporting) calendar year.

NOTE: In most circumstances, these cells should equal Table 9D Column C1 totals for managed 

care.

COLLECTIONS FROM STATE MEDICAID OR FEDERAL MEDICARE RECONCILIATIONS AND WRAP AROUND 

PAYMENTS FOR A PRIOR BILLING PERIOD. (Line 3b) – Enter the (cash) amount received from Medicaid 

and Medicare reconciliation payments (payments based on the settlement of a cost report) and/or 

wrap around payments (amounts paid to bring reimbursement to cost or a negotiated fee-per-visit 

amount) for services which were rendered in prior years.

NOTE: In most circumstances, these cells should equal Table 9D Column C2 totals for managed 

care.

NOTE: If reconciliations and/or wrap around payments are made for a grantee’s fiscal 
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year, and the fiscal year does not correspond to the calendar year, payments must be 

allocated between the current and prior calendar years. Grantees may use a straight 

line allocation methodology; for example, a grantee receiving reconciliations and/or 

wrap around payments covering the fiscal year April 1, 2003 - March 31, 2004 would 

allocate 25% of the payment to the current year (i.e., 2004) and 75% to the prior year

(i.e., 2003). Grantees with more sophisticated cost allocation systems may use their 

own systems but be sure to keep documentation. 

COLLECTIONS FROM PATIENT CO-PAYMENTS AND FROM MANAGED CARE PLANS FOR OTHER RETROACTIVE 

PAYMENTS (Line 3c) – Enter the (cash) amount received from patient co-payments and from other 

retroactive payments such as risk pools, incentives, and withholds. The income may have been 

earned in this or any preceding year.

NOTE: In many instances these cells will not equal Table 9D Column C3 totals for managed 

care because co-payments are recognized on this line, but are not reported in column C3 of 

Table 9D.

PENALTIES OR PAYBACKS TO MANAGED CARE PLANS (Line 3d) – Enter the (cash) amount paid during the 

reporting period as a result of penalties imposed by managed care plans, and FQHC paybacks. 

The penalties may have been “earned” in this or any preceding year.

TOTAL MANAGED CARE REVENUE (Line 4) – Enter the sum of Lines 1, 3a, 3b, 3c minus Line 3d.

EXPENSES

Expenses as used in this section means “accrued costs”. To the extent it is maintained, grantees should 

include “Incurred but not reported costs” (IBNR) for the reporting period for which they are liable. 

All amounts are reported on a modified accrual basis. 

CAPITATION EXPENSES FOR SERVICES (Line 5a) – Enter the cost of providing the capitated services 

reported, i.e., the visits reported on line 9a and other associated costs (e.g. lab, x-ray, 

pharmacy, etc.) covered by the capitation.

FEE-FOR-SERVICE EXPENSES FOR SERVICES (Line 5b) – Enter the cost of providing the fee for services 

reported, i.e., the visits reported on line 9b and other associated costs (e.g. lab, x-ray, 

pharmacy, etc) covered by the fee-for-service payments. Note that a contract may pay a 

capitation for basic visits and pay fee-for-services for other costs such as lab, x-ray and 

pharmacy. In this instance the grantee will report associated costs for the “carved out 

services” separately on line 5b.

TOTAL EXPENSES FOR MANAGED CARE SERVICES (Line 5) – Enter the sum of Lines 5a and 5b.

NOTE: Not all centers formally maintain a cost-accounting system that reports these data in this 

format. If this is the case, two methods for calculating these required numbers may be used

retrospectively:

1. AVERAGE COST PER ENCOUNTER: Virtually all health centers have a process to develop a Medicaid 

and/or Medicare approved cost per encounter. Presuming that the services offered under the 
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managed care program is the same as those in the FQHC program it is simple to take the total 

number of encounters reported on lines 9a, 9b and 9 and multiply this number times the 

average cost per encounter. The results would be placed on lines 5a, 5b and 5. 

2. RATIO OF CHARGES: If the center has a cost based fee schedule (and this is necessary to use this 

method) a more accurate method of calculating costs is possible. This system would permit 

the center’s cost analysis to be sensitive to questions of different levels of services, which are 

provided to prepaid patients as compared to others. (For example, because there is no 

incentive to multiple visits, a center may try to do more at a single visit than to call back the 

patient.) 

In this methodology, the center looks at the total charges for services to managed care patients 

and compares it to the total charges for this same set of services for all patients in the system. 

This ratio (charges for managed care divided by charges for all patients) is then multiplied 

times the total cost of providing those services. The result is a more complex but,

theoretically, more accurate statement of expenses. Note that this has to be done for each 

type of third party payor on Table 9C.

UTILIZATION DATA

MEMBER MONTHS: A member month is defined as one member being enrolled for one month. An

individual who is a member of a plan for a full year generates 12 member months; a family of five 

enrolled for six months generates (5 X 6) 30 member months. Member month information can often 

be obtained from monthly enrollment lists generally supplied by managed care companies to their 

providers.

MEMBER MONTHS FOR MANAGED CARE (CAPITATED) (Line 8a) – Enter the total capitated member 

months by source of payment. This is derived by adding the total enrollment reported by the 

plan for each month.

MEMBER MONTHS FOR MANAGED CARE (FEE-FOR-SERVICE) (Line 8b) – Enter the total fee-for-service 

member months by source of payment. A fee-for-service member month is defined as one 

patient being assigned to a service delivery location for one month during which time the 

patient may use only that center’s services, but for whom the services are paid on a fee-forservice basis. NOTE: Do not include individuals who receive “carved-out” services under a 

fee-for-service arrangement if those individuals have already been counted for the same 

month as a capitated member month. 

TOTAL MEMBER MONTHS FOR MANAGED CARE (Line 8) – Enter the sum of Lines 8a and 8b.

MANAGED CARE ENCOUNTERS (CAPITATED) (Line 9a) – Enter the total encounters for capitated

enrollees by source of payment. 

MANAGED CARE ENCOUNTERS (FEE-FOR-SERVICE) (Line 9b) – Enter the total encounters for fee-forservice enrollees by source of payment. 

TOTAL MANAGED CARE ENCOUNTERS (Line 9) – Enter the sum of Lines 9a and 9b.
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ENROLLEES IN MANAGED CARE PLANS (CAPITATED) (Line 10a) – Enter the number of capitated 

enrollees by source of payment as of (i.e., for the month of) December 31 of the reporting 

period.

ENROLLEES IN MANAGED CARE PLANS (FEE-FOR-SERVICE) (Line 10b) – Enter the number of fee-forservice enrollees by source of payment as of (i.e., individuals assigned to the grantee for the 

month of) December 31 of the reporting period.

TOTAL MANAGED CARE ENROLLEES (Line 10) – Enter the sum of Lines 10a and 10b.

ENROLLEES IN PRIMARY CARE CASE MANAGEMENT PROGRAMS (Line 11) – Enter the number of 

enrollees in PCCM programs as of December 31 of the reporting period.

NUMBER OF MANAGED CARE CONTRACTS (Line 12) – Enter the number of managed care contracts

as of December 31 of the reporting period. If a contract with an HMO covers two different 

types of patients, e.g., Medicaid and Commercial, count it once in each column. If a single 

HMO has different “options” in its contract (e.g., a high benefit vs. a moderate benefit 

commercial plan) count it only once in the appropriate column.
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QUESTIONS AND ANSWERS FOR TABLE 9C

1. What is the difference between a PCCM program and a FFS plan that also pays case management 

fees?

Under a FFS managed care plan, an entity (e.g., HMO, HIO, provider network, etc.) is

capitated and at risk. This capitated entity is usually (but not always) someone other than the 

primary care provider (PCP), and contracts with the PCP. PCCM is almost always a contract 

between the primary care provider and the state, involves neither risk nor incentives, and 

generally has no penalties if utilization is excessive. PCCM rarely involves payment of 

capitation for primary care services. 

2. We have a capitated managed care contract, but some services are “carved-out” and paid on a 

fee-for-service basis. How do we report?

Report revenue and expenses for the carve-out services on the appropriate fee-for-service 

lines. Report managed care fee-for-service encounters on Line 9b, but do NOT report

managed care member months for fee-for-service plans on Line 8b nor enrollees on 10b. 

Since these persons have already been reported under capitation, counting them under feefor-service would result in double counting individuals in the plan.

3. Do we report PCCM contracts on Line 9?

No.

4. Are there any changes to this table?

No. 
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 9C (Part I of III)–

MANAGED CARE REVENUE AND EXPENSES

PAYOR CATEGORY MEDICAID 

 (a)

MEDICARE

 (b)

OTHER PUBLIC 

INCLUDING NONMEDICAID CHIP 

(c)

PRIVATE

 (d)

TOTAL

(e)

REVENUE

1a. Capitation revenue for Services 

1b. Fee-for-Service revenue for Services 

1. TOTAL REVENUE FOR SERVICES 

(LINES 1A + 1B)

2a. Capitation revenue for Services 

Outside Scope of Project

2b. Fee-for-Service revenue for Services 

Outside Scope of Project

2. TOTAL REVENUE FOR SERVICES OUTSIDE 

SCOPE OF PROJECT (LINES 2A + 2B)

NO LONGER REPORTED

3a.

Collections from State Medicaid or 

Federal Medicare reconciliation/ wrap 

around (For current year)

3b.

Collections from State Medicaid or 

Federal Medicare reconciliation/ wrap 

around (For previous years)

3c.

Collections from patient co-payments 

and from managed care plans for other 

retroactive payments / risk pool/ 

incentive/ withhold

3d. Penalties or paybacks to managed care 

plans

4.

TOTAL MANAGED CARE REVENUE

(SUM LINE 1 + 3A + 3B + 3C) - (LINE 

3D)

NOTE: Do not include information on this table for plans that only cover dental or mental health or 

pharmacy services. 
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UDS No: ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 9C (Part II of III)–

MANAGED CARE REVENUE AND EXPENSES

PAYOR CATEGORY MEDICAID 

 (a)

MEDICARE

 (b)

OTHER PUBLIC 

INCLUDING NONMEDICAID CHIP 

(c)

PRIVATE

 (d)

TOTAL

(e)

EXPENSES

5a. Capitation expenses for Services

5b. Fee-for-Service expenses for Services

5. TOTAL EXPENSES FOR SERVICES 

(LINES 5A + 5B)

6a. Capitation expenses for Services 

Outside Scope of Project

6b. Fee-for-Service expenses for Services 

Outside Scope of Project

6.

TOTAL EXPENSES FOR SERVICES OUTSIDE

SCOPE OF PROJECT 

(LINES 6A + 6B)

NO LONGER REPORTED

7. TOTAL MANAGED CARE EXPENSES

(LINES 5)
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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 9C (Part III of III)–

MANAGED CARE REVENUE AND EXPENSES

PAYOR CATEGORY Medicaid

 (a)

Medicare 

(b)

Other Public 

including NonMedicaid CHIP 

(c)

Private

 (d)

Total

(e)

UTILIZATION DATA

8a. Member months for managed care 

(capitated)

8b. Member months for managed care

(fee-for-service)

8. TOTAL MEMBER MONTHS FOR MANAGED 

CARE (LINES 8A + 8B)

9a. Managed Care Encounters (capitated)

9b. Managed Care Encounters 

(fee-for-service)

9. TOTAL MANAGED CARE ENCOUNTERS

(LINES 9A + 9B)

10a. Enrollees in Managed Care Plans 

(capitated) (as of 12/31)

10b. Enrollees in Managed Care Plans

(fee-for-service) (as of 12/31)

10. TOTAL MANAGED CARE ENROLLEES

(LINES 10A + 10B) (AS OF 12/31)

11. Enrollees in Primary Care Case 

Management Programs (PCCM)

12. Number of Managed Care Contracts

NOTE: Enrollees in a capitated plan who also receive services under a fee-for-service arrangement (e.g. for a 

carved out service such as pregnancy or dental care) should have their enrollment reported only on the capitated 

line. Do not count the same person twice. 
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INSTRUCTIONS FOR TABLE 9D:

PATIENT-RELATED REVENUE (SCOPE OF PROJECT ONLY)

The content of this table has not changed since the 2002 Reporting period.

Table 9D must be completed by all of the four types of BPHC grantees covered by the UDS. It is 

included only in the Universal Report. This table collects information on charges, collections,

retroactive settlements, allowances, self-pay sliding fee discounts, and self-pay bad debt write-off.

ROWS: PAYOR CATEGORIES AND FORM OF PAYMENT

Five payor categories are listed: Medicaid, Medicare, Other Public, Private, and Self Pay. Except 

for Self Pay, all categories have three sub-groupings. They consist of non-managed care, capitated 

managed care, and fee-for-service managed care. Note that while similar data elements on Table 

9C exclude dental-only or mental health-only managed care plans, information reported on table 

9D includes these charges, collections and allowances in the managed care lines. 

Grantees should report as “Medicaid” all services paid for by Medicaid (Title XIX) regardless of 

whether they are paid directly or through a fiscal intermediary or an HMO. For example, in states 

with a capitated Medicaid program, where the grantee has a contract with a private plan like Blue 

Cross, the payor is Medicaid, even though the actual payment may have come from Blue Cross. 

Note that EPSDT (the childhood Early Prevention, Screening, Diagnosis and Treatment program 

which has various names in different states,) is a part of Title XIX and is included in the numbers 

reported here. Note also that S-CHIP, the State based Children’s Health Insurance Program, 

which also has many different names in different states, is sometimes paid through Medicaid. If 

this is the case, it should be included in the numbers reported here.

Grantees should report as “Medicare” all services paid for by Medicare (Title XVIII) regardless of 

whether they are paid directly or through a fiscal intermediary or an HMO. Specifically, for 

patients enrolled in a capitated Medicare program, where the grantee has a contract with a 

private plan like Blue Cross, the payor is Medicare, even though the actual payment may have 

come from Blue Cross. 

Grantees should report as “Other Public” all services paid for by State or local governments 

through specific programs other than indigent care programs. The most common of these would 

be S-CHIP, the State based Children’s Health Insurance Program, which also has many different 

names in different states, when it is paid for through commercial carriers. Other Public also 

includes family planning programs, BCCP (Breast and Cervical Cancer Control Programs with 

various state names,) and other dedicated state or local programs as well as state insurance plans, 

such as Washington’s Basic Health Plan. 

NOTE. Reporting on state or local indigent care programs that subsidize services rendered to the 

uninsured is as follows:

• Report all charges for these services and collections from patients as “self-pay” (line 13 of 

this table);
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• Report all amounts not collected from the patients as sliding discounts or bad debt writeoff, as appropriate, on line 13 of this table; and

• Report collections from the associated state and local indigent care programs on table 9E. 

State/local indigent care programs are now reported on a separate line (line 6a –

“state/local indigent care programs”) on that table.

Grantees should report as “Private” all services paid for by commercial or private insurance 

companies. Specifically, do not include any services that fall into one of the other categories. As 

noted above, charges etc. for Medicaid, Medicare and S-CHIP programs which use commercial 

programs as intermediaries are classified elsewhere.

Grantees should report as “Self Pay” all services and charges where the responsible party is the 

patient, including charges for indigent care programs as discussed above. NOTE: This includes 

the reclassified co-payments, deductibles, and charges for uncovered services for otherwise 

insured individuals which become the patient’s personal responsibility.

COLUMNS: CHARGES, PAYMENTS, AND ADJUSTMENTS RELATED TO 

SERVICES DELIVERED (Reported on a cash basis.)

FULL CHARGES THIS PERIOD (Column A) – Record in Column A the total charges for each payor 

source. This should always reflect the full charge (per the fee schedule) for services rendered to 

patients in that payor category. Charges should only be recorded for services that are billed AND

covered in whole or in part by a payor, the patient, or written off to sliding fee discounts.

Example: Optometry services and pharmacy charges should not be included in Medicare 

charges, since Medicare provides no coverage for these services. If a patient has both

Medicare and Medicaid coverage, charges for optometry and pharmacy services would be 

included in “Medicaid charges.” If a patient has only Medicare coverage, charges for

optometry and pharmacy services would be entered under “self-pay”. 

Charges that are generally not billable or covered by traditional third-party payors should not be 

included on this table. For example, a charge for parking or for job training would not normally 

be included. WIC services are not billable charges. Charges for transportation and similar 

enabling services would not generally be included in Column A, except where the payor (e.g., 

Medicaid) accepts billing and pays for these services.

Charges for pharmaceuticals donated to the clinic or directly to a patient through the clinic 

should not be included since the clinic may not legally charge for these drugs. Charges for 

standard dispensed pharmaceuticals, however, are to be included.

Charges which are not accepted by a payor and which need to be reclassified (including

deductibles and co-insurance) should be reversed as negative charges if your MIS system does not 

reclassify them automatically. Reclassifying these charges by utilizing an adjustment and rebilling 

to the proper category is an incorrect procedure since it will result in overstatement of both 

charges and adjustments. 
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NOTE: Under no circumstances should the amount paid by Medicaid or any other payor be 

used as the actual charges. Charges must come from the grantee’s CPT based fee schedule.

AMOUNT COLLECTED THIS PERIOD (Column B) – Record in Column B the amount of net receipts for 

the year on a cash basis, regardless of the period in which the paid for services were rendered. 

This includes the FQHC reconciliations, managed care pool distributions and other payments 

recorded in the columns C1, C2, C3, C4. Note: Charges and collections for deductibles and copayments which are charged to and due from patients are recorded on Line 13. 

RETROACTIVE SETTLEMENTS, RECEIPTS, OR PAYBACKS (Column C) – IN ADDITION TO INCLUDING THEM IN 

COLUMN B, details on cash receipts or payments for FQHC reconciliation, managed care pool 

distributions, payments from managed care withholds, and paybacks to FQHC or HMOs are 

reported in Column C. 

COLLECTION OF RECONCILIATION/WRAP AROUND, CURRENT YEAR (Column C1) – Enter FQHC cash 

receipts from Medicare and Medicaid that cover services provided during the current

reporting period. 

COLLECTION OF RECONCILIATION/WRAP AROUND, PREVIOUS YEARS (Column C2) – Enter FQHC cash 

receipts from Medicare and Medicaid that cover services provided during previous reporting 

periods. 

COLLECTION OF OTHER RETROACTIVE PAYMENTS INCLUDING RISK POOL/INCENTIVE/WITHHOLD

(Column C3) – Enter other cash payments including managed care risk pool redistribution, 

incentives, and withholds, from any payor. These payments are only applicable to managed 

care plans. (Note: While table 9C includes co-payments in a similar data element, this 

column does not include co-payments. They are recorded on line 13 as self pay collections.)

PENALTY/PAYBACK (Column C4) – Enter payments made to FQHC payors because of

overpayments collected earlier. Also enter payments made to managed care plans (e.g., for 

over-utilization of the inpatient or specialty pool funds).

NOTE: If a center arranges to have their “repayment” deducted from their monthly 

payment checks, the amount deducted should be shown in Column (C4) as if it had 

actually been paid.

ALLOWANCES (Column D) – Allowances are granted as part of an agreement with a third-party 

payor. Medicare and Medicaid, for example, may have a maximum amount they pay, and the 

center agrees to write off the difference between what they charge and what they receive.

Allowances must be reduced by the net amount of retroactive settlements and receipts reported in 

the columns C1, C2, C3, C4, including current and prior year FQHC reconciliations, managed 

care pool distributions and other payments.

If Medicaid, Medicare, other third-party, and other public payors reimburse less than the grantee’s 

full charge, and the grantee cannot bill the patient for the remainder, enter the remainder or 

reduction on the appropriate payor line in Column D at the time the Explanation of Benefits (EOB) 

is received and the amount is written off.
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Example: The State Title XIX Agency has paid $40 for an office visit that was billed at a full 

charge of $75. The $75 should be reported on Line 1 Column A as a full charge to Medicaid. 

 After payment was made, the $40 payment is recorded on Line 1 Column B. The $35 

reduction is reported as an adjustment on Line 1 Column D.

Under FQHC programs, where the grantee is paid based on cost, it is possible that the cash 

payment will be greater than the charge. In this case, the adjustment recorded in Column D 

would be a negative adjustment. (Financial adjustments received under FQHC are reported in 

Columns C1 and C2)

NOTE: Amounts for which another third party or a private individual can be billed (e.g., 

amounts due from patients or “Medigap” payors for copayments) are not considered

adjustments and should be recorded or reclassified as full charges due from the secondary 

source of payment. These amounts will only be classified as adjustments when all sources of 

payment have been exhausted and further collection is not anticipated and/or possible. 

Because capitated plans typically pay on a per-member per-month basis only, and make this 

payment in the current month of enrollment, these plans typically don't carry any receivables. For 

Capitated Plans (lines 2a, 5a, 8a, and 11a, ONLY!) the allowance column should be the arithmetic 

difference between the charge recorded in column A and the collection in column B unless there 

were early or late capitation payments (received in a month other than when they were earned) 

and which span the beginning or end of the calendar year.

Also note that Line 13 Column D is blanked out because up-front allowances given to selfpay patients are recorded as sliding fee discounts and valid self-pay receivables that are not 

paid should be recorded as self pay bad debt. 

SLIDING DISCOUNTS (Column E) – In this column, enter reductions to patient charges based on the 

patient’s ability to pay, as determined by the grantee’s sliding discount schedule. This would 

include discounts to required co-payments, as applicable. 

NOTE: Only self-pay patients may be granted a sliding discount based on their ability to pay. 

All other cells are blanked out. For this reason, “column E” is a “virtual column” on the 

electronic version of the UDS, appearing below line 14 on the screen. When a charge 

originally made to a third party such as Medicare or a private insurance company has a copayment or deductible written off, THE CHARGE MUST FIRST BE RECLASSIFIED TO SELFPAY. TO RECLASSIFY, first reduce the third-party charge by the amount due from the patient 

and increase the self-pay charges by this same amount. 

BAD DEBT WRITE OFF (Column F) – Any payor responsible for a bill may default on a payment due 

from it. In the UDS, only self pay bad debts are recorded. In order to keep responsible financial 

records, centers are required to write off bad debts on a routine basis. (It is recommended that this 

be done no less than annually). In some systems this is accomplished by posting an allowance for 

bad debts rather than actually writing off specific named accounts.Amounts removed from the 

center’s self-pay receivables through either mechanism are recorded here. 

Reductions of the net collectable amount for the Self-Pay category should be made on Line 13 

column F. Bad debt write off may occur due to the grantee’s inability to locate persons, a 
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patient’s refusal to pay, or a patient’s inability to pay even after the sliding fee discount is 

granted. 

Under no circumstances are bad debts to be reclassified as sliding discounts, even if the write 

off to bad debt is occasioned by a patient’s inability to pay the remaining amount due. For 

example, a patient eligible for a sliding discount is supposed to pay 50% of full charges for a 

visit. If the patient does not pay, even if he or she later qualifies for a 100% discount, the 

amount written off must still be reported as bad debt, not sliding discount. At the time of the 

visit, it was a valid collectable from the patient.

Only bad-debts from patients are recorded on this table. While some insurance companies 

do, in fact, default on legitimate debts as they go bankrupt, centers are not asked to report 

these data. For this reason, “column F” is a “virtual column” on the electronic version of the 

UDS, appearing below line 14 on the screen. 

TOTAL PATIENT RELATED INCOME (Line 14) – Enter the sum of Lines 3, 6, 9, 12, and 13. Be sure to 

include only these “subtotal” lines and not the detail for each of the subtotals. 
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QUESTIONS AND ANSWERS FOR TABLE 9D

1. Are there any important issues to keep in mind for this table?

Payments received from state or local indigent care programs subsidizing services rendered 

to the uninsured are not reported on this table. All such payments, whether made on a per 

encounter basis or as a lump sum for services rendered, shall be recorded on Table 9E. See 

Table 9E for specific instructions. Grantees receiving payments from state/local indigent care 

programs that subsidize services rendered to the uninsured should:

• Report all charges for these services and collections from patients as “self-pay” (Line 

13);

• Report all amounts not collected from the patient as sliding discounts or bad debt, as 

appropriate, on Line 13 of this table;

• Report collections from the state/local indigent care programs on Table 9E. 

State/local indigent care programs are now to be reported as a separate category (Line 

6a - state/local indigent care programs).

2. Are the data on this table cash or accrual based?

Table 9D is a ‘cash’ table in as much as all entries represent charges, collections, and 

adjustments recognized in the current year. All entries represent actual charges and

adjustments for the calendar year and actual cash receipts for the year.

3. Should the lines of the table “balance”?

No. Because the table is on a ‘cash’ basis, the columns for amount collected and for 

allowances will include payments and adjustments for services rendered in the prior year.

Conversely, some of the charges for the current year will be remaining in accounts receivable 

at the end of the year. The one exception is on the capitated lines (lines 2a, 5a, 8a, and 11a) 

where allowances are the difference between charges and collections by definition, provided 

there are no early or late capitation payments that cross the calendar year change.

4. If we have not received any reconciliation payments for the reporting period what do we show 

in Column C1 (current year reconciliations)?

If you have not received a check during this reporting period for current year services, enter 

zero (0) in Column C1. 

5. We regularly apply our sliding discount program to write off the deductible portion of the 

Medicare charge for our certified low-income patients. The sliding discount column (Column E) 

is blanked out for Medicare. How do we record this write off?

The charge needs to be removed from the Medicare line (Lines 4 - 6 as appropriate) and 

added into the self-pay line (Line 13). It can then be written off on Line 13. The same process 

would be used for any other co-payment or deductible write-off.

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UDS No. ___________________________________ Date Submitted: __________________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 9D (Part I of II) –

PATIENT RELATED REVENUE (Scope of Project Only)

RETROACTIVE SETTLEMENTS, RECEIPTS, AND PAYBACKS (c)

PAYOR CATEGORY

FULL 

CHARGES 

THIS PERIOD

(a)

AMOUNT 

COLLECTED 

THIS PERIOD

(b)

COLLECTION OF 

RECONCILIATION/

WRAP AROUND 

CURRENT YEAR

(c1)

COLLECTION OF 

RECONCILIATION/

WRAP AROUND 

PREVIOUS YEARS

(c2)

COLLECTION OF 

OTHER 

RETROACTIVE 

PAYMENTS 

INCLUDING RISK 

POOL/ INCENTIVE/ 

WITHHOLD

(c3)

PENALTY/ 

PAYBACK

(c4)

ALLOWANCES

(d)

SLIDING 

DISCOUNTS

(e)

BAD DEBT 

WRITE OFF

(f)

1. Medicaid Non-Managed 

Care 

2a. Medicaid Managed Care 

(capitated)

2b. Medicaid Managed Care 

(fee-for-service)

3. TOTAL MEDICAID 

(LINES 1+ 2A + 2B)

4. Medicare Non-Managed 

Care 

5a. Medicare Managed Care 

(capitated)

5b. Medicare Managed Care 

(fee-for-service)

6. TOTAL MEDICARE 

(LINES 4 + 5A+ 5B)

7. Other Public including 

Non-Medicaid CHIP (Non 

Managed Care)

8a. Other Public including 

Non-Medicaid CHIP 

(Managed Care Capitated)

UDS No.: ___________________________________ Date Submitted: __________________________________
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Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 9D (Part II of II) –

PATIENT RELATED REVENUE (Scope of Project Only)

RETROACTIVE SETTLEMENTS, RECEIPTS, AND PAYBACKS (c)

PAYOR CATEGORY

Full 

Charges 

This 

Period

(a)

AMOUNT 

COLLECTED 

THIS PERIOD

(b)

COLLECTION OF 

RECONCILIATION/

WRAP AROUND 

CURRENT YEAR

(c1)

COLLECTION OF 

RECONCILIATION/W

RAP AROUND 

PREVIOUS YEARS

(c2)

COLLECTION OF 

OTHER RETROACTIVE 

PAYMENTS 

INCLUDING RISK 

POOL/ INCENTIVE/ 

WITHHOLD

(c3)

PENALTY/ 

PAYBACK

(c4)

ALLOWANCES

(d)

SLIDING 

DISCOUNTS

(e)

BAD DEBT 

WRITE OFF

(f)

8b. Other Public including 

Non-Medicaid CHIP 

(Managed Care fee-forservice)

9. TOTAL OTHER PUBLIC

(LINES 7+ 8A +8B)

10. Private Non-Managed Care 

11a. Private Managed Care 

(capitated)

11b. Private Managed Care (feefor-service)

12. TOTAL PRIVATE 

(LINES 10 + 11A + 11B)

13. Self Pay

14. TOTAL 

(LINES 3 + 6 + 9 + 12 + 13)
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INSTRUCTIONS FOR TABLE 9E –

OTHER REVENUE

The content of this table is essentially unchanged since the 2002 Reporting period.

Table 9E should be completed by all BPHC grantees covered by the UDS. It is included only in the 

Universal Report. This table collects information on cash receipts for the reporting period that 

supported activities described in the scope of project(s) covered by any of the four BPHC grant 

programs. Income received during the reporting period means cash receipts received during the 

calendar year for a Federally-approved project even if the revenue was accrued during the previous 

year.

BPHC GRANTS 

LINES 1A THROUGH LINE 1F – Enter draw-downs during the reporting period for all BPHC grants 

in the primary care cluster. These include all four primary care programs included in the 

UDS. Amounts should be consistent with the PMS-272 report. 

TOTAL HEALTH CENTER CLUSTER (Line 1g) – Enter the total of Lines 1a through 1f. 

INTEGRATED SERVICES DEVELOPMENT INITIATIVE GRANTS (line 1h) – Enter the amount of the 

Integrated Services Development Initiative grant dollars drawn down.

SHARED INTEGRATED MANAGEMENT INFORMATION SYSTEMS GRANTS (line 1i) – Enter the amount of 

the Shared Integrated Management Information Systems grant dollars drawn down.

CAPITAL IMPROVEMENT PROGRAM GRANTS (line 1j) – Enter the amount of Capital Improvement 

Program grant dollars drawn down.

TOTAL BPHC GRANTS (Line 1) – Enter the total of Lines 1g (Total Health Center Cluster), 1h (Integrated 

Services Development Initiative Grants), 1i (Shared Integrated Management Information Systems

Grants), and 1j (Capital Improvement Program Grants). Be sure that all BPHC Section 330 grant 

funds drawn down during the year are included on line 1. NOTE: The amounts shown on the BPHC 

Grant Lines should reflect direct funding only and should not include passthrough or be reduced by 

money that benefited other centers.

OTHER FEDERAL GRANTS

RYAN WHITE TITLE III HIV EARLY INTERVENTION (Line 2) – Enter the amount of the Ryan White 

Title III funds drawn down in the reporting period. 

OTHER FEDERAL GRANTS (Lines 3-4) – Enter the amount and source of any other Federal grant 

revenue received during the reporting period which falls within the scope of the project(s). 

These grants include only those received directly by the center from the Federal Government. 

 Do not include federal funds which are first received by a State or Local government or other 

agency and then passed on to the grantee. These are included below on Lines 6 through 8. 
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Grantees are asked to describe the programs so the UDS editor can make sure that the 

classification of the program as a federal grant is appropriate.

TOTAL OTHER FEDERAL GRANTS (Line 5) – Enter the total of Lines 2 - 4.

NON-FEDERAL GRANTS OR CONTRACTS

STATE GOVERNMENT GRANTS AND CONTRACTS (Line 6) – Enter the amount of funds received under 

State government grants or contracts. "Contracts and Grants" are defined as amounts received 

on a line item or other basis which are not tied to the delivery of services. They do NOT 

include funds from state/local indigent care programs. When a state or local grant or 

contract other than an indigent care program pays a grantee based on the amount of health 

care services provided or on a negotiated fee for service or fee per visit, the charges,

collections and allowances are reported on Table 9D as “Other Public” services, not here on 

Table 9E

STATE/LOCAL INDIGENT CARE PROGRAMS (Line 6a) – Enter the amount of funds received from 

state/local indigent care programs that subsidize services rendered to the uninsured (examples 

include Massachusetts Free Care Pool, New Jersey Uncompensated Care Program, NY Public 

Goods Pool Funding, California Expanded Access to Primary Care Program, and Colorado 

Indigent Care Program).

NOTE: Payments received from state or local indigent care programs subsidizing 

services rendered to the uninsured should be reported on Line 6a of this table whether 

on not the actual payment to the grantee is made on a per encounter or visit basis or 

as a lump sum for services rendered. Patients covered by these programs are 

reported as uninsured on table 4 and all of their charges, sliding discounts, and bad 

debt write-offs are reported on the self-pay line (line 13) on Table 9D. Monies

collected from the patients covered by indigent programs should be reported on 9D. 

However, none of the funds reported on Line 6a of Table 9E are to be reported on 

Table 9D.

LOCAL GOVERNMENT GRANTS AND CONTRACTS (Line 7) Report the amount received from local 

governments during the reporting period that covers costs included in the scope of the 

grantee’s project(s).

FOUNDATION / PRIVATE GRANTS AND CONTRACTS (Line 8) Report the amount received during the 

reporting period that covers costs included within the scope of the project(s). Funds which 

are transferred from another grantee or another community service provider are considered 

“private grants and contracts” and included on this line.

TOTAL NON-FEDERAL GRANTS AND CONTRACTS (Line 9) – Enter the total of Lines 6, 6a, 7, and 8.

OTHER REVENUE (Line 10) – Other Revenue refers to other receipts included in the Federally 

approved scope of project that are not related to charge-based services. This may include 

fund-raising, interest income, rent from tenants, etc.

TOTAL REVENUE (Line 11) – Enter the total of Lines 1, 5, 9, and 10 for total other revenues / 

income. 
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NOTE: GRANT FUNDS SHOULD ALWAYS BE REPORTED BASED ON THE ENTITY THAT AWARDS THEM, REGARDLESS OF 

THEIR ORIGIN. FOR EXAMPLE, FUNDS AWARDED BY THE STATE FOR MATERNAL AND CHILD HEALTH SERVICES USUALLY 

INCLUDE A MIXTURE OF FEDERAL FUNDS SUCH AS TITLE V AND STATE FUNDS. THESE SHOULD BE REPORTED AS STATE 

GRANTS BECAUSE THEY ARE AWARDED BY THE STATE.
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UDS No. ___________________________________ Date Submitted: _______________________________

Reporting Period: January 1, 2004 through December 31, 2004 o Initial Submission o Revision

TABLE 9E –

OTHER REVENUES

SOURCE

AMOUNT 

(a)

BPHC GRANTS (ENTER AMOUNT DRAWN DOWN - CONSISTENT WITH PMS-272)

1a. Migrant Health Center

1b. Community Health Center

1c. Health Care for the Homeless

1e. Public Housing Primary Care 

1f. School Based Clinics

1g. TOTAL HEALTH CENTER CLUSTER (SUM LINES 1A THROUGH 1F)

1h. Integrated Services Development Initiative

1i. Shared Integrated Management Information Systems

1j. Capital Improvement Program Grants

1. TOTAL BPHC GRANTS (SUM LINES 1G + 1H + 1I + 1J)

OTHER FEDERAL GRANTS

2. Ryan White Title III HIV Early Intervention

3. Other Federal Grants (specify:________________)

4. Other Federal Grants (specify:________________)

5. TOTAL OTHER FEDERAL GRANTS (SUM LINES 2 - 4)

NON-FEDERAL GRANTS OR CONTRACTS

6. State Government Grants and Contracts

6a. State/Local Indigent Care Programs

7. Local Government Grants and Contracts

8. Foundation/Private Grants and Contracts

9. TOTAL NON-FEDERAL GRANTS AND CONTRACTS (SUM LINES 6 + 6A+7+8)

10. Other Revenue (Non-patient related revenue not reported elsewhere)

11. TOTAL REVENUE (LINES 1+5+9+10)
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APPENDIX A

LISTING OF PERSONNEL

(All Line numbers in the following table refer to Table 5)

PERSONNEL BY MAJOR SERVICE CATEGORY PROVIDER NON-PROVIDER

PHYSICIANS

• Family Practitioners (Line 1) X

• General Practitioners (Line 2) X

• Internists (Line 3) X

• Obstetrician/Gynecologists (Line 4) X

• Pediatrician (Line 5) X

•

OTHER SPECIALIST PHYSICIANS (Line 7)

• Allergists X

• Cardiologists X

• Dermatologists X

• Orthopedists X

• Surgeons X

• Urologists X

• Ophthalmologists X

• Other Specialists And Sub-Specialists X

NURSE PRACTITIONERS (Line 9a) X

PHYSICIANS ASSISTANTS (Line 9b) X

CERTIFIED NURSE MIDWIVES (Line 10) X

NURSES (Line 11)

• Clinical Nurse Specialists X

• Public Health Nurses X

• Home Health Nurses X

• Visiting Nurses X

• Registered Nurse X

• Licensed Practical Or Vocational Nurse X

OTHER MEDICAL PERSONNEL (Line 12)

• Nurse Aide/Assistant (Certified And Uncertified) X

• Clinic Aide/Medical Assistant (Certified And Uncertified 

Medical Technologists) X

LABORATORY PERSONNEL (Line 13)

• Pathologists X

• Medical Technologists X
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PERSONNEL BY MAJOR SERVICE CATEGORY PROVIDER NON-PROVIDER

• Laboratory Technicians X

• Laboratory Assistants X

• Phlebotomists X

X-RAY PERSONNEL (Line 14)

• Radiologists X

• X-Ray Technologists X

• X-Ray Technician X

DENTISTS (Line 16)

• General Practitioners X

• Oral Surgeons X

• Periodontists X

• Endodontists X

OTHER DENTAL

• Dental Hygienists (Line 17) X

• Dental Assistant (Line 18) X

• Dental Technician (Line 18) X

• Dental Aide (Line 18) X

MENTAL HEALTH (Line 20) & SUBSTANCE ABUSE (Line 21)

• Psychiatrists (Line 20a) X

• Psychologists X

• Social Workers - Clinical And Psychiatric X

• Nurses - Psychiatric And Mental Health X

• Alcohol And Drug Abuse Counselors X

• Nurse Counselor X

ALL OTHER PROFESSIONAL PERSONNEL (Line 22)

• Audiologists X

• Acupuncturists X

• Chiropractors X

• Herbalists X

• Occupational Therapists X

• Optometrists X

• Podiatrists X

• Physical Therapists X

• Respiratory Therapists X

• Speech Pathologists X

• Traditional healers X

• Nutritionists/Dietitians X

PHARMACY PERSONNEL (Line 23)
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PERSONNEL BY MAJOR SERVICE CATEGORY PROVIDER NON-PROVIDER

• Pharmacist X

• Pharmacist Assistant X

• Pharmacy clerk X

ENABLING SERVICES

CASE MANAGERS (Line 24)

• Case Managers X

• Social Workers X

• Public Health Nurses X

• Home Health Nurses X

• Visiting Nurses X

• Registered Nurses X

• Licensed Practical Nurses X

HEALTH EDUCATORS (Line 25)

• Family Planning Counselors X

• Health Educators X

• Social Workers X

• Public Health Nurses X

• Home Health Nurses X

• Visiting Nurses X

• Registered Nurses X

• Licensed Practical Nurses X

OUTREACH WORKERS (Line 26) X

PATIENT TRANSPORTATION WORKERS (Line 27)

• Patient Transportation Coordinator X

• Driver X

OTHER ENABLING SERVICES PERSONNEL (Line 28)

• Child Care Workers X

• Eligibility Assistance Workers X

• Interpreters/Translators X

OTHER RELATED SERVICES STAFF (Line 29a)

• WIC Workers X

• Head Start Workers X

• Housing assistance workers X

• Food bank / meal delivery workers X

• Employment / Educational Counselors X

ADMINISTRATION (Line 30)

• Project Director X
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PERSONNEL BY MAJOR SERVICE CATEGORY PROVIDER NON-PROVIDER

• Administrator X

• Finance Director X

• Accountant X

• Bookkeeper X

• Secretary X

• Director Of Planning And Evaluation X

• Clerk Typist X

• Billing Clerk X

• Cashier X

• Director Of Data Processing X

• Key Punch Operator X

• Personnel Director X

• Registration Clerk X

• Receptionist X

• Director Of Marketing X

• Marketing Representative X

• Enrollment/Service Representative X

FACILITY (Line 31)

• Janitor/Custodian X

• Security Guard X

• Groundskeeper X

• Equipment Maintenance Personnel X

• Housekeeping Personnel X

PATIENT SERVICES SUPPORT STAFF (Line 32)

• Medical And Dental Team Clerks X

• Medical And Dental Team Secretaries X

• Medical And Dental Appointment Clerks X

• Medical And Dental Patient Records Clerks X

• Patient Records Supervisor X

• Patient Records Technician X

• Patient Records Clerk X

• Patient Transcriptionist X

• Appointments Clerk X
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APPENDIX B

SERVICE DEFINITIONS

(All line numbers in the following table refer to Table 2)

SERVICE CATEGORY DEFINITIONS

PRIMARY MEDICAL CARE SERVICES

General Primary Medical Care

(Line 1) Provision of basic preventive and curative medical services.

Diagnostic Laboratory 

(Technical Component) 

(Line 2)

Technical component of laboratory procedures. Does not include 

services of a physician to order or to analyze/interpret results from 

these procedures. 

X-Ray Procedures 

(Technical Component) 

(Line 3)

Technical component of diagnostic X-ray procedures. Does not 

include services of a physician to order or to analyze/interpret 

results from these procedures. 

Diagnostic Tests/Screenings 

(Professional Component)

(Line 4)

Professional services to order and analyze/interpret results from 

diagnostic tests and screenings. Includes services of a physician to 

order or to analyze/interpret results from these procedures.

Emergency Medical Services 

(Line 5)

Provision of emergency services on a regular basis to meet life, 

limb or function-threatening conditions. Nearly all centers will 

provide EMS via referral arrangements. 

Urgent Medical Care 

(Line 6)

Provision of medical care of an urgent or immediate nature on a 

routine or regular basis. 

24-Hour Coverage 

(Line 7) The availability of services on a 24-hour basis.

Family Planning Services

(Contraceptive Management) 

(Line 8)

Provision of contraceptive/birth control or infertility treatment. 

Counseling and education by providers are included here; when 

provided by other staff, include under enabling services. 

HIV Testing and counseling

(Line 9)

Testing and counseling for HIV. Counseling and education by 

providers included here; when provided by other staff, include 

under enabling services.

Testing Blood Lead Levels

(Line 10)

Testing to ensure that levels of lead in blood are below critical 

levels. Tests are generally conducted for at risk children.

Immunizations 

(Line 11)

Provision of the following preventive vaccines: Diphtheria, 

Pertussis, Tetanus, Measles, Mumps, Rubella, Poliovirus, Influenza 

virus, Hepatitis B, Hemophilus influenza B.

Following Hospitalized Patients

(Line 12) Visits to health center patients during hospitalizations.

OBSTETRICAL AND GYNECOLOGICAL CARE

Gynecological Care 

(Line 13)

Gynecological services provided by a nurse, nurse practitioner, 

nurse midwife or physician, including annual pelvic exams and pap 

smears, follow-up of abnormal findings, and diagnosis and 

treatment of sexually transmitted diseases/infections. This category 

does not include family planning services.

Obstetrical Care 

(Lines 14 through 20)

Provision of listed services (i.e., prenatal care, antepartum fetal 

assessment, ultrasound, genetic counseling and testing, 

amniocentesis, labor and delivery professional care, postpartum 

care) related to pregnancy, delivery and postpartum care.
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SERVICE CATEGORY DEFINITIONS

SPECIALTY MEDICAL CARE

Directly observed TB therapy 

(Line 21)

Delivery of therapeutic TB medication under direct observation of 

center staff.

Respite Care

(Line 22)

Recuperative or convalescent services used by homeless people 

with medical problems who are too ill to recover on the streets or 

in a shelter. It includes the provision of shelter and medical care 

with linkages to other health care services such as mental health, 

oral health, substance abuse treatment and social services.

Other specialty care 

(Line 23)

Services provided by medical professionals trained in any of the 

following specialty areas: Allergy; Dermatology; Gastroenterology; 

General Surgery; Neurology; Optometry/Ophthalmology; 

Otolaryngology; Pediatric Specialties; Anesthesiology.

DENTAL CARE 

Dental Care 

(Lines 24 through 27)

Provision by a dentist or dental hygienist of the listed services: 

preventive, restorative, emergency, and restorative.

MENTAL HEALTH/SUBSTANCE ABUSE SERVICES

Mental Health Treatment/ Counseling 

(Lines 28 & 31)

Developmental Screening

(Line 29)

24-Hour Crisis Intervention/

Counseling 

(Line 30)

Mental health therapy, counseling, or other treatment provided by a 

mental health professional.

Substance Abuse Treatment/

Counseling 

(Lines 32 & 33)

Counseling and other medical and/or psychosocial treatment 

services provided to individuals with substance abuse (i.e., alcohol 

and/or other drug) problems. May include screening and diagnosis, 

detoxification, individual and group counseling, self-help support 

groups, alcohol and drug education, rehabilitation, remedial 

education and vocational training services, and aftercare.

Comprehensive mental health / 

substance abuse screening. 

(Line 33a)

Comprehensive mental health / substance abuse screening is a tool 

used to identify individuals / clients / users / patients with 

emotional problems, mental illness, and /or addictive disorders 

who may desire or benefit from behavioral health and recovery 

services designed to promote mental health and wellness. The 

screening is conducted by or under the direction of the following 

licensed behavioral health providers: clinical or counseling 

psychologist, psychiatrist, clinical social worker, marriage/family 

therapist, psychiatric nurse specialist or professional counselor.

OTHER PROFESSIONAL SERVICES

Hearing Screening 

(Line 34) Diagnostic services to identify potential hearing problems.

Nutrition Services Other Than WIC 

(Line 35)

Advice and consultation appropriate to individual nutrition needs.

Occupational Or Vocational Therapy 

(Line 36)

Therapy designed to improve or maintain an individual's 

employment/career skills and involvement.

Physical Therapy 

(Line 37)

Assistance designed to improve or maintain an individual's 

physical capabilities. 

Pharmacy Dispensing of prescription drugs and other pharmaceutical 
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SERVICE CATEGORY DEFINITIONS

(Line 38) products.

Pharmacy – Physician Dispensing

(Line 39)

Operation of a dispensary at a clinic service delivery location

where the clinicians are responsible for doing the actual dispensing 

of the drugs.

Vision Screening 

(Line 40) Diagnostic services to identify potential vision problems. 

Podiatry

(Line 41)

Services provided by a medical professional licensed to diagnose 

and treat conditions affecting the human foot, ankle, and their 

governing and related structures, including the local manifestations 

of systemic conditions.

Optometry

(Line 42)

Services provided by a medical professional licensed or certified to 

diagnose, treat and manage diseases and disorders of the visual 

system, the eye and associated structures as well as diagnosis of 

related systemic conditions.

ENABLING SERVICES

Case Management 

(Line 43)

Client-centered service that links clients with health care and 

psychosocial services to insure timely, coordinated access to 

medically appropriate levels of health and support services and 

continuity of care. Key activities include: 1)assessment of the 

client's needs and personal support systems; 2) development of a 

comprehensive, individualized service plan; 3)coordination of 

services required to implement the plan; client monitoring to assess 

the efficacy of the plan; and 4) periodic re-evaluation and 

adaptation of the plan as necessary.

Child Care 

(Line 44)

Assistance in caring for a user's young children during medical and 

other health care visits.

Discharge Planning 

(Line 45)

Services related to arranging an individual's discharge from the 

hospital (e.g., home health care).

Eligibility Assistance 

(Line 46)

Assistance in securing access to available health, social service and 

other assistance programs, including Medicaid, WIC, SSI, food 

stamps, TANF, and related assistance programs. Does not include 

eligibility assistance provided by grantee or government staff under 

arrangements for Out-stationed Eligibility Workers, as mandated by 

law; report the latter on line 51.

Environmental Health Risk Reduction 

(Line 47)

Includes the detection and alleviation of unhealthful conditions 

associated with water supplies, sewage treatment, solid waste 

disposal, rodent and parasitic infestation, field sanitation, housing, 

and other environmental factors related to health (e.g., lead paint 

abatement and pesticide management).

Health Education 

(Line 48)

Personal assistance provided to promote knowledge regarding 

health and healthy behaviors, including knowledge concerning 

sexually transmitted diseases, family planning, prevention of fetal 

alcohol syndrome, smoking cessation, reduction in misuse of 

alcohol and drugs, improvement in physical fitness, control of 

stress, nutrition, and other topics. Included are services provided to 

the client's family and/or friends by non-licensed mental health 

staff which may include psychosocial, caregiver support, 

bereavement counseling, drop-in counseling, and other support 

groups activities.

Interpretation/Translation Services 

(Line 49)

Services to assist individuals with language/communication barriers 

in obtaining and understanding needed services.

Nursing Home And Assisted-Living 

Placement (Line 50)

Assistance in locating and obtaining nursing home and assistedliving placements.
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SERVICE CATEGORY DEFINITIONS

Outreach 

(Line 51)

Case finding, education or other services to identify potential 

clients and/or facilitate access/referral of clients to available 

services.

Transportation 

(Line 52)

Transportation, including tokens and vouchers, provided by the 

grantee for users.

Out-Stationed Eligibility Workers 

(Line 53)

Provision of assistance to individuals to enable them to qualify for 

Medicaid, under provisions of Federal law requiring Out-Stationed 

Eligibility Workers.

Home Visiting 

(Line 54)

Provision of services in the client’s home. Not inclusive of services 

such as medical, home nursing, case management etc. which have 

their own categories.

Parenting Education

(Line 55)

Individual or group sessions designed to enhance the child-rearing 

skills of parents/caregivers.

Special Education Program

(Line 56) Educational programs designed for children with a disability.

Other 

(Line 57)

This line provides the opportunity to identify an enabling service 

you are providing that is otherwise not listed. Please specify the 

service provided.

PREVENTIVE SERVICES RELATED TO TARGET CLINICAL AREAS

Pap Smear

(Line 58)

Microscopic examination of cells collected from the cervix to 

detect cancer, changes in cervix, or non-cancerous conditions such 

as infection or inflammation.

Fecal occult blood test

(Line 59 Test to check for small amounts of hidden blood in stool.

Sigmoidoscopy

(Line 60)

An examination of the rectum and lower part of the colon through 

a tube which contains a light source and a camera lens. 

Colonoscopy

(Line 61)

An examination of the rectum and entire colon using a 

colonoscope. Procedure can be used to remove polyps or other 

abnormal tissue.

Mammograms

(Line 62) An x-ray of the breast.

Smoking cessation program

(Line 63)

A clinical and public-health intervention program for smoking 

cessation which may involve identification of smokers, diagnosis of 

nicotine dependence, and self-help products and counseling.

Glycosylated hemoglobin 

measurement for people with diabetes 

(Line 64)

A test that assesses the average blood glucose level during several 

months.

Urinary microalbumin measurement 

for people with diabetes

(Line 65)

A laboratory procedure to detect very small quantities of protein in 

the urine indicating kidney damage.

Foot exam for people with diabetes

(Line 66)

A foot examination using monofilaments to test for sensation from 

pressure that identifies those patients who have lost protective 

sensation in their feet.

Dilated eye exam for people with 

diabetes (Line 67) 

An examination in which the pupils are dilated in order to check 

for diabetic eye disease.

Blood pressure monitoring

(Line 68)

Tracking blood pressure through regular measurement of blood 

pressure.

Weight reduction program

(Line 69)

A program in which patients are taught to eat healthy foods, engage 

in exercise, and monitor caloric intake in order to lose weight and 

improve their health.

Blood cholesterol screening

(Line 70)

A blood test that will detect the levels of cholesterol and 

triglycerides in the body in order to discover if there are abnormal 

or unhealthy levels of cholesterol in the blood.
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SERVICE CATEGORY DEFINITIONS

Follow-up testing and related health 

care services for abnormal newborn 

bloodspot screening (Line 71)

Conducting additional newborn screening (using the bloodspot 

screening or other methods) to assess for common and/or serious 

health conditions of newborn infants. 

OTHER SERVICES

WIC Services 

(Line 72)

Nutrition and health counseling services provided through the 

Special Supplemental Food Program for Women, Infants and 

Children

Head Start

(Line 73)

Comprehensive developmental services for low-income, preschool 

children less than 5 years of age

Food Banks / Delivered Meals

(Line 74)

Provision of food or meals, not the finances to purchase food or 

meals.

Employment/ Educational Counseling

(Line 75)

Counseling services to assist an individual in defining 

career/employment/educational interests, and in identifying 

employment opportunities and/or education options

Assistance in Obtaining Housing

(Line 76)

Assistance in locating and obtaining suitable shelter, either 

temporary or permanent. May include locating costs, moving 

costs, and/or rent subsidies.