U.S. Department of Health and Human Services
Health Resources and Services Administration
Bureau of Primary Health Care

You will need this guidance whether you plan to apply on-line or on paper. Read the entire document carefully before preparing your application. Please download and save to your computer either the Word or Acrobat file. The Word file is recommended for all applicants, whether submitting on-line or on paper.

This application guidance details the Service Area Competition (SAC) eligibility requirements, review criteria and awarding factors for organizations seeking a grant for operational support under the Consolidated Health Center Program including: Community Health Centers (CHC), Migrant Health Centers (MHC), Health Care for the Homeless (HCH), Public Housing Primary Care (PHPC) and School Based Health Centers (SBHC) authorized under section 330 of the Public Health Service (PHS) Act as amended.

This application guidance supercedes Program Information Notice (PIN) 2004-01 used to detail the requirements, review criteria and awarding factors for organizations seeking operational support through a SAC in Fiscal Year (FY) 2004. For FY 2005, the following differences should be noted:

Applicants are limited to currently funded health centers whose project period expires on or after October 31, 2004, and new organizations proposing to serve the same areas and/or populations currently being served by these existing health centers. Organizations are also eligible to apply for areas designated in the HRSA Preview and/or Federal Register as currently being served by interim grantees. All applicants requesting SAC funds must use this guidance. It should be reviewed thoroughly prior to making a decision to apply.

It is the responsibility of the applicant to ensure that the complete application is submitted electronically or received by the published due date. Applications submitted electronically or received after the due date will not be accepted for processing and will be returned without consideration. Please indicate that you are responding to HRSA 05-086: SAC.

Please note that applications for SAC may not be submitted via the BPHC Web-Based Single Grant Application process.

For your convenience, application deadlines for projects ending in FY 2005 are provided below. Please review the HRSA Preview or Federal Register for more current information.

If you have questions regarding the FY 2005 service area competition application and/or the review process described in this application guidance please call Preeti Kanodia in the Bureau of Primary Health Care’s Division of Health Center Development at 301-594-4300 or pkanodia@hrsa.gov.

PURPOSE
The Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC) administers the Consolidated Health Center Program, as authorized by section 330 of the Public Health Service (PHS) Act, 42 U.S.C. 254b, as amended. The Consolidated Health Center Program promotes the development and operation of community-based primary health care service systems in medically underserved areas and improves the health status of medically underserved populations. This application guidance details the Service Area Competition (SAC) eligibility requirements, review criteria and awarding factors for organizations seeking a grant for operational support under the Consolidated Health Center Program including: Community Health Centers (CHC), Migrant Health Centers (MHC), Health Care for the Homeless (HCH), Public Housing Primary Care (PHPC) and School Based Health Centers (SBHC) authorized under section 330 of the PHS Act as amended.

For the purposes of this guidance an EXISTING GRANTEE is an organization funded under section 330 who is submitting a SAC (competing continuation or project period renewal) application at the end of their project period for support to continue providing services to their defined service area and population. Existing grantees may include any ‘new starts’ (new grantee awarded through the New Access Point funding opportunity) whose project period is ending on or after October 31, 2004.

For the purposes of this guidance a NEW ORGANIZATION is an existing and operational provider that is submitting a SAC application for support to serve the defined service area and population in place of the existing grantee at the end of its project period. Please review the Eligibility section for more information.

The SAC application is a request for financial assistance to provide comprehensive primary care services to an underserved area or population that has been competitively announced in the HRSA Preview and/or Federal Register. Existing Consolidated Health Center Program grantees that are seeking support to renew a project period that would otherwise expire on or after October 31, 2004, must submit a SAC application for continued grant support.

An announced SAC includes the entire approved scope of project of an existing grantee in the defined service area. Existing grantees may NOT request a change in their scope of project through the SAC. New organizations are expected to demonstrate that services are available to the same area and/or population currently served by the existing grantee’s scope of project.

Organizations eligible to compete include public or nonprofit private entities, including tribal, faith-based and community-based organizations. All applicants are expected to demonstrate compliance with the requirements of section 330 of the PHS Act as amended and applicable regulations and guidances. Interested organizations should refer to the HRSA Preview and/or Federal Register for further information regarding specific areas and deadlines.

BACKGROUND
The mission of the BPHC is “to increase access to comprehensive primary and preventive health care and to improve the health status of underserved and vulnerable populations.” All of the programs administered by the BPHC are focused toward ensuring the availability and accessibility of essential primary and preventive health services to the people who have the most limited access to services and face the greatest barriers to care. The BPHC is committed to the goal of improving and expanding access to health care for all Americans nationwide, and most importantly for the estimated 43 million uninsured people in the United States who do not have adequate access to affordable, appropriate primary and preventive health care. More than 50 million people live in Federally designated underserved areas and lack access to a private primary care provider.

Individually, each health center plays an important role in this plan and combined they have had a critical impact on the health care status of underserved and vulnerable populations throughout the United States. At the end of the calendar year 2003, there were nearly 900 federally-funded health centers with almost 3,600 primary care delivery sites located in urban and rural underserved areas throughout the U.S. and its territories. Approximately 12.5 million medically underserved and uninsured patients receive high quality, cost-effective, culturally appropriate, accessible and affordable preventive and primary health care services through the federally-funded health centers.

It is the intent of the BPHC to continue to support health services in these underserved areas, given the unmet need inherent in the provision of services to medically underserved populations. It is expected that each SAC application submitted to serve one of these areas and/or populations will present a clear focus on maintaining access to care and reducing health disparities identified in the same target population(s) that is currently being served by the existing grantee.

Specific Requirements/Expectations
All applicants are expected to demonstrate compliance with the applicable requirements of section 330 of the PHS Act and BPHC guidelines, including the Health Center Program Expectations (Program Information Notice 98-23). Community Health Centers, Migrant Health Centers and/or School-Based Health Centers are also expected to demonstrate compliance with the implementing regulations (42 CFR Part 51c). In addition to these general requirements, there are specific requirements and expectations for applicants requesting funding under each type of health center authorized under section 330. Applicants requesting funding to support one or more health center types are expected to demonstrate compliance in the application with the specific guidelines, expectations and requirements, as applicable. Failure to document and demonstrate compliance in the application will significantly reduce the likelihood of approval and funding.

COMMUNITY HEALTH CENTER (CHC) APPLICANTS (section 330(e)):
CHC applicants must demonstrate in their proposal how they will maintain access to comprehensive primary and preventive health care and improve the health status of underserved and vulnerable populations in the area to be served. Applicants are also expected to demonstrate that the proposal will address the major health care needs of the target population and will ensure the availability and accessibility of essential primary and preventive health services, including oral health and mental health and substance abuse services, to all individuals in the service area. Applicants are expected to demonstrate compliance with section 330(e) and all applicable regulations and BPHC guidelines.

MIGRANT HEALTH CENTER (MHC) APPLICANTS (section 330(g)):
MHC applicants must demonstrate in their proposal how they will maintain access to comprehensive primary and preventive health care and improve the health status of underserved and vulnerable populations in the area to be served. Applicants are also expected to address how the special needs of migratory and seasonal farmworkers (MSFW) and their families are being or will be met. MHC applicants are expected to demonstrate that the proposal will ensure the availability and accessibility of essential primary and preventive health services, including oral health and mental health and substance abuse services, to all individuals in the service area. Mechanisms may include outreach that is integrated into the primary health care delivery system; use of mobile vans or health teams that travel to migrant camps; transportation; extended clinic hours; etc. In addition, applicants must describe how they will address the special environmental health concerns that are associated with MSFW activities. Applicants are expected to demonstrate compliance with section 330(e) and 330(g), and all applicable regulations and BPHC guidelines.

MHC applicants must include information about how the health center governance requirements will be addressed. Organizations that are only requesting support for a MHC and are requesting a waiver for some portion of the governance requirements, must complete and submit Form 6-B and submit a waiver request that is in compliance with guidelines described in PIN 98-12 with the application. The waiver request should include the description of the reasons for the waiver and a detailed plan regarding how the health center will comply with the intent of the statute, i.e. consumer input. Requests for waivers will not be granted to applicants that are also approved for CHC or SBHC funding.

HEALTH CARE FOR THE HOMELESS (HCH) APPLICANTS (section 330(h)):
HCH applicants must demonstrate in the proposal how they will maintain access to comprehensive primary and preventive health care and improve the health status of underserved homeless people in the area to be served. The application must address the major health care needs of the target population and ensure the availability and accessibility of essential primary and preventive health services, including oral health, mental health and substance abuse services. Applicants are expected to demonstrate compliance with section 330(e) and 330(h), and all applicable regulations and BPHC guidelines.

HCH applicants must indicate the mechanism for delivering comprehensive substance abuse services to homeless patients. HCH applicants must thoroughly explain the manner in which comprehensive outreach is to be conducted, and how transportation and other enabling services will be provided. HCH applicants must also describe the manner in which case management, eligibility assistance, and access to housing services will be made available to homeless patients.

HCH applicants must include information about how the health center governance requirements will be addressed. Organizations that are only requesting support for HCH grants and are requesting a waiver for some portion of the governance requirements, must complete and submit Form 6-B and submit a waiver request that is in compliance with guidelines described in PIN 98-12 with the application. The waiver request should include the description of the reasons for the waiver and a detailed plan regarding how the health center will comply with the intent of the statute, i.e. consumer input. Requests for waivers will not be granted to applicants that are also approved for CHC or SBHC funding.

PUBLIC HOUSING PRIMARY CARE (PHPC) APPLICANTS (section 330(i)):
PHPC applicants must demonstrate in their proposal how they will maintain access to comprehensive primary and preventive health care and improve the health status of underserved public housing residents in the area to be served. The application must address the major health care needs of the target population and ensure the availability and accessibility of essential primary and preventive health services, including oral health, mental health, and substance abuse services. Applicants are expected to demonstrate compliance with section 330(e) and 330(i), and all applicable BPHC guidelines.

PHPC applicants must describe the mechanism for involving residents in the preparation of the application and in the on-going planning and administration of the program. PHPC applicants must also include information about how the health center governance requirements will be addressed. Organizations that are only requesting support for PHPC and are requesting a waiver for some portion of the governance requirements, must complete and submit Form 6-B and submit a waiver request that is in compliance with guidelines described in PIN 98-12 with the application. The waiver request should include the description of the reasons for the waiver and a detailed plan regarding how the health center will comply with the intent of the statute, i.e. consumer input. Requests for waivers will not be granted to applicants that are also approved for CHC or SBHC funding.

SCHOOL-BASED HEALTH CENTERS (SBHC) APPLICANTS:
SBHC applicants must demonstrate in their proposal how they will maintain access to comprehensive primary and preventive health care, which includes referrals, tracking and follow-up for students and other community members. The application must address the major health care needs of the target population and ensure the availability and accessibility of essential primary and preventive health services, including oral health, mental health, and substance abuse services. Applicants are expected to demonstrate compliance with section 330(e) and all applicable regulations and BPHC guidelines.

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

Requests for waivers of the governance requirements will not be granted to SBHC applicants.

TYPE OF AWARD
SAC grant awards are to support the continued provision of comprehensive primary and preventive health care services to underserved communities and populations currently served through existing section 330 funding.

SUMMARY OF FUNDING
It is expected that the request for Federal support will not exceed in any year of the proposed project period, the annual level of Federal section 330 funding that is currently provided to the area and/or population. It is also expected that the budgets presented in the application will be reasonable and appropriate based on the scope of the services [to be] provided and the number and type (i.e., uninsured, homeless, migrant, public housing residents, low income children and adolescents, etc.) of individuals to be served. Applicants should propose a multi-year project period: 5-years for existing grantees and 3-years for new organizations. The budgets should be consistent with the health care and business plans presented in the application, as well as the proposed project period (i.e., 3 or 5 years).

The SAC program will provide funding during Federal FY 2005. Approximately $355,000,000 is expected to be available to fund an estimated 277 awards. Funding beyond the first year is dependent on the availability of appropriated funds and grantee satisfactory performance.

Federal funding levels awarded and the length of project period may be adjusted based on an analysis of the organization’s performance and experience related to operating costs, utilization, provider staffing and revenue generation. Approved applicants will not be funded at levels greater than the currently approved base level of funding for the existing grantee serving an announced underserved area or population. See Section IV of this application guidance for further information and instruction on the development of the application budget. Federal funding levels for newly funded applicants may also be adjusted based on analysis of the budget and cost factors.

For additional information regarding the current level of targeted support for a specified community or population, please contact Preeti Kanodia with Division of Health Center Development, Bureau of Primary Health Care at (301) 594-4300.

1. ELIGIBLE APPLICANTS
An application will be considered eligible if it meets all of the specific eligibility requirements. Applications that do not meet the eligibility requirements will not be accepted for processing and will be returned.

Organizations eligible to compete include public or nonprofit private entities, including tribal, faith-based and community-based organizations. All applicants are expected to demonstrate compliance with the requirements of section 330 of the PHS Act as amended. Interested organizations should refer to the HRSA Preview and/or Federal Register for further information regarding specific areas and deadlines.

Existing grantees whose project periods expire on or after October 31, 2004 should apply for grant funding under this guidance. New organizations proposing to serve the same area(s) and/or population(s) currently being served by these existing centers may also apply for a grant for operational support under section 330 of the PHS Act as amended under this guidance. Organizations are also eligible to apply for areas designated in the HRSA Preview and/or Federal Register as currently being served by interim grantees under this guidance.

Responsiveness
Eligible applicants are expected to provide services to the entire announced service area (all counties, census tracks, etc.) and to all populations (CHC, HCH, MHC, etc) currently being served by the existing grantee. Applicants proposing to serve only a segment of the population and/or area will be deemed unresponsive and will be returned.

Organizations are expected to be existing operational providers of primary health care services to underserved populations in the area, with facilities available in the existing service area. Applicants that do not adequately demonstrate that the organization is an active primary care provider in the community with appropriate staffing and service locations will be considered unresponsive and will be returned.

2. COST SHARING/MATCHING
Cost sharing or matching is not a requirement for this funding opportunity. Applicants are expected to maximize all sources of revenue. It should be noted that the appropriateness and reasonableness of the total budget and the extent to which other appropriate resources are obtained and leveraged within the budget is a key evaluation element in the review of the proposed project. Please see the budget and budget justification section of this document (pg. 16) for clarification and guidelines pertaining to the presentation of the budget.

Change of Scope
Existing grantees should ensure that their application only reflects their currently approved scope of project. Any proposed changes must be submitted to the HRSA’s Division of Grants Management Operations for prior approval under separate cover. Please refer to the most recent BPHC guidance on this subject contained in PIN 2002-07 (available onsite at www.bphc.hrsa.gov), or contact BPHCscope@hrsa.gov for more information.

IV. Application and Submission Information

Application Materials
The entire application guidance should be reviewed thoroughly prior to making a decision to apply for operational support for an announced area and population. Applicants must submit proposals using this guidance in conjunction with Public Health Service (PHS) Application Form 5161-1. The PHS 5161-1 forms contain additional general information and instructions for grant applications, proposal narratives, and budgets as prescribed by the Office of Management and Budget, therefore, that information is not repeated in this document.

Instructions for preparing portions of the application that must accompany PHS Form 5161-1 appear below.

It is recommended that applicants also thoroughly review the following reference documents.
• Health Care Safety Net Amendments of 2002, Public Law 107-251 (section 330 of the PHS Act as amended)
• PIN 98-12, “Implementation of the Section 330 Governance Requirements” (signed April 28, 1998)
• PIN 98-23, “Health Center Program Expectations” (signed August 17, 1998)
• PIN 97-27, “Affiliation Agreements of Community and Migrant Health Centers” (signed July 22, 1997)
• PIN 98-24, “Amendment to PIN 97-27 Regarding Affiliation Agreements of Community and Migrant Health Centers” (signed August 17, 1998)
• PIN 2001-13, “Clarification of Program Requirements and Benefits for Bureau of Primary Health Care Supported School-Based Health Center Programs” (signed June 6, 2001)
• PIN 2002-07, “Scope of Project Policy” (signed December 31, 2001)
• PAL 2002-09, “President’s Initiative to Expand Health Centers” (signed May 16, 2002)

These documents and any others referenced in this grant application kit are available on the BPHC web page: http://www.bphc.hrsa.gov/pinspals/. The PHS 5161-1 is available from http://www.hrsa.gov/grants/forms.htm.

To request a hard copy of an application kit for this program, please contact the HRSA Grants Application Center at the following address. When contacting the Grants Application Center, please refer to Program Announcement Number HRSA 05-086: Service Area Competition.

The Legin Group, Inc.
HRSA Grant Application Center
Program Announcement Number: HRSA 05-086
901 Russell Avenue, Suite 450
Gaithersburg, MD 20879
Telephone: 877-477-2123
HRSAGAC@hrsa.gov.

Application Preparation
The purpose of this application guidance is to provide comprehensive, supplemental grant application instructions and formats for applicants seeking support to serve an area and/or population announced in the HRSA Preview and/or Federal Register. This application should be used in conjunction with Application Form PHS 5161 1.

Applicants are encouraged to thoroughly review documents referenced above prior to finalizing a decision to apply and/or preparing an application for submission. Applications should provide all required information in the sequence and format described in the instructions. Information and data should be accurate and consistent, and written instructions should be followed carefully and completely. Applications not meeting application requirements may be returned without processing or may result in a low rating by the Independent Review Committee (IRC).

Application Format Requirements
If applying on paper, the entire application may not exceed 150 pages in length, including the abstract, project and budget narratives, face page, attachments, any appendices and letters of commitment and support. Pages must be numbered consecutively.

If applying on-line, the total size of all uploaded files may not exceed 20 MB and may not exceed 150 pages when printed.

Applications, whether submitted on paper or electronically, that exceed the specified limits of 150 pages will be deemed non-compliant and will be returned to the applicant without further consideration.

a. Number of Copies (Paper Applications only)
Applicants should submit one (1) original and two (2) unbound copies of the application. Applications must be single sided. Please do not bind or staple the application. Sets of applications should be secured with rubber bands or binder clips.

Applicants are cautioned against using color prints or graphics. Additional copies of an application must be duplicated for review purposes; any color print or graphics may not copy successfully. Computer-generated facsimiles may be substituted for any of the forms provided in this packet. Such substitute forms should be printed in black ink, but must maintain the exact wording and format of the government-printed forms contained in the PHS 5161-1, including all captions and spacing. Deviations may be grounds for HRSA to reject the entire application.

b. Font and Section Headings
Please use an easily readable typeface, such as Times Roman, Courier, CG Times, or Arial. The text and table portions of the application should be submitted in 12 point and 1.0 line spacing. Please put all section headings flush left in bold type. Section headings should be consistent with the guidance.

Figures, charts, tables, figure legends, and footnotes may be smaller in size but must be clear and readily legible.

c. Paper Size and Margins
For scanning purposes, please submit the application on 8 ½” x 11” white paper that can be photocopied, with conventional border margins. Please left-align text. Do not use photo reduction, and do not send photos or over-sized documents, posters, videotapes, cassette tapes, or other material that cannot be photocopied.

d. Numbering and Names
Please number the pages of the application sequentially starting with the SF 424 Face sheet to the end of the application, including all charts, figures, tables, and appendices. Please include the name of the applicant on each page.

Applicants are reminded that applications MUST NOT exceed 150 pages IN TOTAL including all required and optional attachments whether submitted on paper or electronically.

Application Sequence
Application components should be assembled as follows:
• PHS 5161-1: Face Sheet (SF 424)
• Table of Contents
• General Information Worksheet (FORM 1-A)
• PHS 5161-1: Application Checklist (Pages 25-26)
• Budget Presentation, including:
- BPHC Funding Request Summary (FORM 1-B)
- PHS 5161-1: Form SF 424A, Sections A, B, E, and if applicable F
- Detailed Budget Justification - for each Year of funding requested
- Proposed Staff Profile – for the first Year of the proposed project (FORM 2)
- Income Analysis – for the first Year of the proposed project (FORM 3)
• Staffing Plan and Personnel Requirements
• PHS 5161-1: Non-Construction Assurances (SF 424B)
• PHS 5161-1: Certifications (Pages 17-19)
• Project Abstract
• Program Narrative
• Health Care Plan
• Business Plan
• Remaining Program Specific Forms (FORMS 4-7) as appropriate. Applicants must submit Forms 4-7. Only applicants requesting a waiver for governance requirements must submit Form 6-B.
• Appendices:
- All Required Attachments - See Application Completion Checklist (p. 54) for additional information
- Other Attachments, as applicable

Failure to include all of the above documents as part of the application may result in an application being returned to the applicant as “incomplete.” Applications are limited to no more than 150 pages in total including all required and optional documents, whether submitted on paper or electronically.

Application Format
Applications for funding must consist of the following documents in the following order:

i. Application Face Page
PHS Application Form 5161-1 provided with the application package. Prepare this page according to instructions provided in the form itself. The Catalog of Federal Domestic Assistance Number is 93.224.

DUNS and CCR Numbers
All applicant organizations are required to have a Data Universal Numbering System (DUNS) number in order to apply for a grant from the Federal Government. The DUNS number is a unique nine-character identification number provided by the commercial company, Dun and Bradstreet. There is no charge to obtain a DUNS number. Information about obtaining a DUNS can be found at http://www.hrsa.gov/grants/duns.htm or call 1-866-705-5711. Please include the DUNS number next to OMB Approval Number on the application face page. Application will not be reviewed without a DUNS number.

Additionally, all applicants are required to register with the Federal Government’s Central Contractor Registry (CCR) in order to do electronic business with the Federal Government. Information about registering with the CCR can be found at http://www.hrsa.gov/grants/ccr.htm. Funding awards cannot be issued with a CCR number.

ii. Table of Contents
To facilitate review, provide a table of contents or index reflecting the major headings (including appendices), with sub-headings and applicable page numbers.
(a) General Information Worksheet – Form 1 - A (See Attachment A of this document.)

iii. Application Checklist
This form and detailed instructions are available in the Application From PHS 5161-1 (p. 25-26) provided with the application kit.

iv. Budget for Multi-Year Grant Awards
This announcement is inviting applications for project periods up to 5 years for existing organizations, and up to 3 years for new organizations. Awards, on a competitive basis, will be for an one year budget period, although project periods may be for 5 years. Applications for continuation grants funded under these awards beyond the initial one-year budget period but within the approved project period will be entertained in subsequent years on a noncompetitive basis, subject to availability of funds, satisfactory progress of the grantee and a determination that continued funding would be in the best interest of the Government.

Please complete Sections A, B, E, and F (if applicable) of PHS 5161-1: Standard Form 424A for the first year of the proposed project. A complete budget presentation should include:
• BPHC Funding Request Summary (FORM 1-B)
• PHS 5161-1: Form SF 424A, Sections A, B, E, and, if applicable, F.
• Detailed Budget Justification for each 12-month period requested for Federal funding.
• Proposed Staff Profile - for the first year of the project, including any anticipated changes within the proposed project period (FORM 2)
• Income Analysis – for the first year of the proposed project (FORM 3)
See instructions in Section IX of this document for further guidance on completing the budget presentation.

v. Budget Justification
A sample format and further guidelines are provided in Section IX of this document.

Applicants must provide a narrative that explains the amounts requested for each line in the PHS 5161-1: Form SF 424A. Applicants must submit 12-month budgets for each of the one-year budget periods within the proposed project period (5 years for existing organizations, 3 years for new organizations). The budget justification must clearly describe each cost element and explain how each cost contributes to meeting the project’s objectives/goals. Be very careful about showing how each item in the “other” category is justified. The budget justification MUST be concise. Do NOT use the justification to expand the project narrative.

Expense information must include further detail by object class. The budget justifications for the individual health center type must be provided in sufficient detail to support one-step below the object class category level, as described below. In addition, if there are budget items for which costs are shared with other programs (e.g., HRSA programs or an independent home health program administered by the applicant organization), the basis for the allocation of costs between federally supported programs and other independent programs must be explained. A sample budget justification is available in Section IX as a broad outline.

Be sure to include the following in the Budget Justification. Additional information and detail may be provided in narrative form, as needed.

Personnel Costs: Please reference ‘Form 2: Proposed Staff Profile’ as justification for dollar figures. In general, personnel costs should be explained by listing each staff member who will be supported from requested grant funds, name (if possible), position title, percent full time equivalency, annual salary, and the exact amount requested for each budget year.

Fringe Benefits: Itemize the components that comprise the fringe benefit rate, for example health insurance, FICA, life insurance, retirement plan, tuition reimbursement, etc. For any increase greater than 5 percent over the prior year rate, provide an explanation. In general, the fringe benefits should be directly proportional to that portion of personnel costs that are allocated for the project.

Equipment: List equipment costs and provide justification for the need of the equipment to carry out the program’s goals. Extensive justification and a detailed status of current equipment must be provided when requesting funds for the purchase of computers and furniture items. Only major (costing over $5,000 per unit) equipment items need to be itemized, with equipment costs and justifications. Items costing less than $5,000 should be identified under ‘Supplies’ with a brief explanation.

Supplies: List the items that the project will use. Categorize supplies according to type – medical, lab, pharmacy, office, etc. Office supplies could include paper, pencils, and the like; medical supplies are syringes, blood tubes, plastic gloves, etc., and educational supplies may be pamphlets and educational videotapes. Explain how the amounts were developed (e.g., medical supplies were based on 20,000 encounters at $2 per encounter to arrive at the $40,000 appearing in the budget).

Travel: List travel costs according to local and long distance travel. For local travel, the mileage rate, number of miles, reason for travel and staff member/consumers completing the travel should be outlined. The budget should also reflect the travel expenses associated with participating in meetings and other proposed trainings or workshops.

Contractual (sub-contracts): Categorize substantive programmatic or administrative contracts costs according to type (e.g., medical referral, lab referral, management consultant) under 2 headings – patient care and non-patient care by costs. To the extent possible, all subcontract budgets and justifications should be standardized, and contract budgets should be presented by using the same object class categories contained in the Standard Form 424A. Provide a clear explanation as to the purpose of each contract, how the costs were estimated, and the specific contract deliverables.

Other: Put all costs that do not fit into any other category into this category and provide and explanation of each cost in this category. Itemize all costs in this category and explain in sufficient detail. In most cases, consultant costs for technical assistance, legal fees, rent, utilities, insurance, dues, subscriptions, and audit related costs would fall under this category.

Indirect Costs: Only those organizations with a pre-approved federally negotiated indirect cost rate should include an indirect cost rate in the budget presentation. Indirect costs are those costs incurred for common or joint objectives which cannot be readily identified but are necessary to the operations of the organization, e.g., the cost of operating and maintaining facilities, depreciation, and administrative salaries. For institutions subject to OMB Circular A-21, the term “facilities and administration” is used to denote indirect costs. If the applicant does not have a federally negotiated indirect cost rate, you may obtain one by visiting the Division of Cost Allocation website: http://rates.psc.gov/. Please refer to PHS 5161-1, page 31 for further information. Organizations that pay an overhead rate to a parent organization need to provide an object class breakdown for those costs.

vi. Staffing Plan and Personnel Requirements
Applicants must present a staffing plan and provide a justification for the plan that includes education and experience qualifications and rationale for the amount of time being requested for each staff position. Position descriptions that include the roles, responsibilities, and qualifications of proposed project staff may be included in Appendix C. Copies of biographical sketches for any key employed personnel that will be assigned to work on the proposed project must be included in Appendix D.

vii. Assurances
This form and detailed instructions are available in the Application From PHS 5161-1 provided with the application kit.

viii. Certifications
This form and detailed instructions are available in the Application From PHS 5161-1 (p. 17-19) provided with the application kit.

ix. Project Abstract
Provide a summary of the application. This document may be distributed to Congress and the Department of Health and Human Services (HHS), or used in press releases to provide a short description of the services provided by this grant. The project abstract must be single-spaced and limited to one page in length.

Please place the following at the top of the abstract:
 Project Title
 Applicant Name
 Address
 Contact Phone Numbers (Voice, Fax)
 E-Mail Address
 Web Site Address, if applicable
 Congressional districts within your service area
 Types of HRSA/BPHC funding requested in this application
 Existing federal funding received.

Please prepare the abstract so that it is clear, accurate, concise, and without reference to other parts of the application. The abstract must include a brief description of the proposed grant project including the needs to be addressed, the proposed services, and the population group(s) to be served. Specifically, this includes:
• A brief history of the organization, the community served and target population(s).
• Numbers of providers, FTEs, delivery locations, services, users, and total encounters using data included in your application for the last 12 months of operation (or last calendar year).
• State initiatives/managed care, CHIP, Medicaid, 1115 Waivers, etc. that impact the health center
• Other relevant information about the current/proposed scope of project including type(s) of health centers (i.e. CHC, MHC, HCH, PHPC, or SBHC) in the current scope.
• Brief description of the proposed project.

x. Program Narrative
The project narrative should be a detailed picture of the community/target population(s) to be served, the applicant organization, and the organization’s plan for addressing the identified health care needs/issues of the community/target population(s). [See Section VIII, for a definition of target population and service area.] In general, this section includes a description of the health care needs of the community/target population(s), the factors responsible for these needs, community resources available to meet community health needs, the planning process and community needs assessment that precipitated the grant application, how the organization has/will integrate services with other efforts in the community, the extent to which the applicant’s project plan addresses the specific program requirements (i.e., compliance), the organization’s capacity to address the health needs and experience in providing services, and the readiness of the applicant organization to initiate the proposed project. The program narrative should be consistent with the Health Care and Business Plan sections.

All applicants should ensure that each category is completely addressed based on the specific elements in the Review Criteria (p. 29), including any the appropriate health center specific elements. Throughout the program narrative, reference may be made to exhibits and charts, as needed, in order to reflect information about multiple sites and/or geographic or demographic data. These exhibits and charts should be included as part of the required/optional attachments. The attachments should not contain any required narrative.

The following provides a framework for the program narrative. It should be succinct, self-explanatory and well organized so that reviewers can fully understand the proposed project. The Program Narrative should be organized using the following section headers:

 INTRODUCTION
The introduction is intended to be a brief synopsis of the community/target population(s), the applicant organization, and the scope of the proposed project. The applicant should summarize the need for health services in the community and the organization’s proposed response to that need.

 NEED
See Criterion 1: NEED in the Review Criteria (p.29) for the specific elements that should be addressed.

 RESPONSE
See Criterion 2: RESPONSE in the Review Criteria (p.31) for the specific elements that should be addressed.

 EVALUATIVE MEASURES
See Criterion 3: EVALUATIVE MEASURES in the Review Criteria (p.33) for the specific elements that should be addressed.

 IMPACT
See Criterion 4: IMPACT in the Review Criteria (p.33) for the specific elements that should be addressed.

 RESOURCES/CAPABILITIES
See Criterion 5: RESOUCES/CAPABILITIES in the Review Criteria (p.34) for the specific elements that should be addressed.

 SUPPORT REQUESTED
See Criterion 6: SUPPORT REQUESTED in the Review Criteria (p.35) for the specific elements that should be addressed.

 GOVERNANCE
See Criterion 7: GOVERNANCE in the Review Criteria (p.36) for the specific elements that should be addressed by all applicants.
See PIN 98-12 for additional information on section 330 governance requirements.
Please provide a copy of the signed bylaws demonstrating compliance with and reflecting all functions and responsibilities cited in section 330, as appropriate.

(a) Health Care Plan a sample format and guidelines are provided in Section IX of this document.
In general, the health care plan should be used to outline goals and objectives related to identified community health needs/issues as well as quality improvement activities within the practice that are specific to the area or population for which Federal funding is being requested. The health care plan can and should be used as an ongoing monitoring and evaluation tool by both the grantee and BPHC. Fiscal, administrative, Management Information Systems (MIS), and leadership activities are, in general, described in the business plan. However, clinically related MIS, administrative, or management issues may also be described in the health care plan.

In addition to major community health related issues, applicants are expected to address the following in their health care plan, as applicable:
• Major health-related goals and objectives for each of the life cycles and populations to be served by the proposal.
• Improving performance, quality, and outcomes, e.g. quality improvement plan activities, Clinical Outcome Measures, Healthy People 2010 Objectives, Health Disparities Collaboratives, Health Plan Employer Data and Information Set (HEDIS) measures, accreditation standards, Relative Value Units.
• Eliminating health disparities as appropriate for the target community, e.g., infant mortality, adult and pediatric immunizations, diabetes mellitus, cardiovascular disease, HIV infection, cancer prevention, asthma, hypertension, obesity.
• Retention and recruitment of qualified staff.
• Participation in the Health Disparities Collaborative or implementation of any type of quality improvement, and description of sustaining and spreading the model of care, including the continuation and spread of the disease management and quality improvement activities.
• Unresolved clinical issues identified in a previous Notice of Grant Award (NGA), Primary Care Effectiveness Review (PCER), Office of Performance Review (OPR) and/or pre-application guidance letter, as applicable.
• If special populations (e.g., migrant/seasonal agricultural workers, residents of public housing, homeless persons, low-income school children, etc.) are included in the target population, the health care plan must describe how the special access problems and the unique health care needs of these populations are being met.

The health care plan must also address in narrative form those issues that cannot be captured in the table format, such as the following items:
• Managed care arrangements and their impact on the organization.
• Factors that may have affected, or are expected to affect, progress in either a positive or negative way.
• Current grantees should also address outstanding business/management issues identified in a previous NGA, pre-application guidance letter, Primary Care Effectiveness Report (PCER), and/or Office of Performance Review (OPR).

(b) Business Plan a sample format and guidelines are provided in Section IX of this document.
The business plan should be used to outline goals and objectives for improving operations of the project and indicating how these are tied into the overall operational business goals of the organization.

The business plan should be formatted in the categories of administrative, governance, fiscal, and MIS. Applicants are also expected to address the following issues, as applicable, in the business plan.
• Network development in a managed care environment.
• Cost-savings activities such as joint purchasing or network development
• Continuous quality improvement relative to administrative/fiscal activities. Current grantees should address the status of issues identified in a previous Notice of Grant Awards (NGA) and/or pre-application guidance letter.
• Plans for attaining and maintaining long-term viability (i.e., future requirements for space, personnel, capital, etc.)

The business plan must also address in narrative form those issues that cannot be captured in the table format, such as the following items:
• Audit conditions or exceptions as identified in the most recent report.
• Managed care arrangements and their impact on the organization.
• Factors that may have affected, or are expected to affect, progress in either a positive or negative way.
• Current grantees should also address outstanding business/management issues identified in a previous NGA, pre-application guidance letter, and/or PCER.

xi. Program Specific Forms
Forms 1-3 should be included in the appropriate section of the application, as detailed in the Application Sequence. Please refer to Attachment A of this guidance for copies of all forms.

All applicants for SAC funding must submit the required program specific forms (see Application Completion Checklist (p. 54) for a list of required forms and attachments). Forms 1 through 5, 6-A, and 7 are required for all applicants. Only applicants requesting a waiver for governance requirements must submit Form 6-B (p. 65). See PIN 98-12 for additional information on section 330 governance requirements. Applicants should complete all forms based on the entire scope of the project (i.e., total for all sites).

The forms supply information in a concise and consistent fashion. Shaded areas of Forms (rows and/or columns) should not be completed. Computer-generated facsimiles may be substituted for any of the forms provided in this packet. Such substitute forms should be printed in black ink, but they must maintain the exact wording and format of the government-printed forms, including all captions and spacing.

FORM 1, Part A – General Information Worksheet: Provides summary information. This form should present information that is consistent with the budget, user and encounter projections presented in the project description, Health Care and Business Plans and any other Forms.

FORM 1, Part B – BPHC-Funding Request Summary: To facilitate identification of the amount of Federal funding being requested, each applicant must complete the BPHC Funding Request Summary. Existing grantees should submit information for a five-year project period, and indicate current funding from each health center type, as applicable. New organizations should submit information for a three- year project period and indicate/request for funding for the applicable health center type(s). All funding requests should be level over the length of the project period (i.e., no increase or decrease between budget periods) and in accordance with the current level of targeted support.

FORM 2 – Proposed Staff Profile: Identifies the total personnel and number of FTEs to staff the health center and number to be supported with federal funds for the first year of the proposed project. Applicants should include staff for the entire scope of the project (i.e., total for all sites). Anticipated staff changes within the proposed project period should be addressed within the budget presentation.

FORM 3 – Income Analysis Format: Presents revenue information for the first year of the proposed project period, showing how projections for patient service revenue were made by breaking out revenue by payment source. Anticipated changes within the proposed project period should be addressed within the budget presentation

FORM 4 – Community and User Characteristics: Reports community-wide and target population data for the entire scope of the project (i.e., all sites) for the most recent period for which data are available. Estimates are acceptable.

FORM 5, Part A – Services Provided: Applicants should identify what services will be available at the health center site(s) for the entire organization and how these services will be provided.

FORM 5, Part B – Service Sites: [See Section VIII (pg. 44), for a definition of service site.]
Applicants should include addresses for only those service sites to be included under the Scope of Project. Currently funded health centers should include all current service sites listed on the most recent Exhibit B “Service Sites” (from the most recently submitted Change of Scope, or non-competing continuation application). Current grantees may NOT request support for new service sites in this application, see PIN 2002-07 for additional information. New organization should list all existing and operational service sites.

1. Report name and address of each service site, including the 9-digit zip code.
NOTE: Please do not provide mailing address but the physical location address.

2. For each service site location, also:
a. Indicate whether the service site operates year-round or on a seasonal basis.
b. Indicate whether the service site operates full-time or part-time.
Full–time is defined as service sites that are operational 40 hour per week. Part-time is operational less than 40 hours per week. If the service site is part-time, indicate how many hours of operation per week.
c. Define service area by listing the census tracts, 5 digit zip codes of the areas served, whole or partial counties, or Minor Civil Divisions included in it.

FORM 5, Part C – Other Activities/Locations: SAMPLE FORM.
Please see definition of service site in Section VIII (pg. 44) to determine those activities or locations that should be listed on the Form. Service sites should be listed on Form 5, Part B.

BPHC recognizes that some delivery “activities/locations” have been approved as part of the scope of project and have therefore appeared on previously submitted Exhibit B Service Site Forms. Although not considered sites as defined in Section VIII, these “activities/locations” will continue to be documented in continuation applications and to be considered part of the approved scope of project. Any new additions or deletions must be requested through the Change in Scope process, consistent with guidance provided in PIN 2002-07.

Current grantees may NOT request support of a new site under this application, see PIN 2002-07 for additional information. New organization should list all existing and operational service sites.

FORM 6, Part A – Board Member Characteristics: Applicants should list all current board members and provide relevant characteristics, as requested.

FORM 6, Part B – Request for Waiver of Governance Requirements (if applicable):
Health centers are eligible for a governance waiver ONLY IF they are requesting HCH, PHPC, and/or MHC funding only. Requests for waivers will not be granted to applicants that are also approved for CHC or SBHC funding. If a waiver is requested, applicants should clearly identify which requirements are to be waived, and present alternative arrangements in lieu of the required elements. (See PIN 98-12 for additional information.)

FORM 7 – Compliance Checklist: This form provides a checklist for assuring compliance with all section 330 requirements.

xii. Appendices
Applicants are required to submit all documents as listed on the Application Completion Checklist (p. 54) to complete the content of the application. Applicants may include other attachments and documents with the application as applicable to support the proposed project plan. Please note that these are supplementary in nature, and are not intended to be a continuation of the project narrative. Be sure each appendix is clearly labeled. All forms and attachments are expected to reflect the scope of the application submitted, as appropriate.

1) Appendix A: Project Organizational Chart and Service Area Map
Applicant should provide a one-page figure that depicts the organizational structure of the project, including subcontractors and other significant collaborators. Applicants should also include a map of the service area indicating MUAs/MUPs, other health care providers, and the organization’s point(s) of service (i.e., service sites listed in Form 5, Part B) within the area.

2) Appendix B: Corporate Bylaws
Bylaws should be signed as approved by the Board of Directors by the appropriate individuals.

3) Appendix C: Job or Position Descriptions for Key Personnel, optional
Keep each to one page in length as much as is possible. Item 6 in the Program Narrative section of the PHS 5161-1 Form provides some guidance on items to include in a job description. If these documents are not included in the application, the organization MUST assure that these documents will be available within 3-5 business days upon request.

4) Appendix D: Biographical Sketches of Key Personnel
Include biographical sketches for persons occupying the key positions described in Appendix C, not to exceed two pages in length each. Applicants should also indicate any current vacancies in key personnel. In the event that a biographical sketch is included for an identified individual who is not yet hired, please include a letter of commitment from that person with the biographical sketch.

6) Appendix F: Other contracts, agreements, etc., as applicable or required.
Provide any documents that describe substantive working relationships between the applicant agency and other agencies and programs cited in the proposal (e.g., contracted provider and/or staff, management services, etc). Documents that confirm actual or pending contractual agreements should clearly describe the roles of the subcontractors and any deliverable. Letters of agreements must be dated.

Short summaries should be provided to describe all other working relationships/contracts between the applicant agency and other agencies and programs. Each summary should include:
• Name and contact information for affiliated agency(ies);
• Type of agreement (i.e., contract, letter of agreement, etc.)
• Brief description of the relationship/contract (i.e., type of services, referrals, etc. and how/where these are provided.)
• Timeframe for the contract/relationship.
Please note: Summaries are acceptable ONLY IF the applicant can demonstrate that the contract/agreement(s) can be provided within 3-5 business days upon request.

7) Appendix G: Most recent independent financial audit
Audit information will be considered complete if it includes all balance sheets and management letters. Please provide a detailed explanation if audit information is not available for the applicant organization.

8) Appendix H: Articles of Incorporation
The official signatory page of the Articles of Incorporation (seal page) is sufficient in lieu of the entire document.

9) Appendix I: Internal Revenue Service (IRS) Tax Exempt Certification for the Applicant, new organizations only
All new organizations must submit a copy of the IRS Tax Exempt Certificate or a copy of the application for such certificate. If the new applicant organization is a public entity, the IRS Tax Exempt Certification for the Co-Applicant Board should be provided, if applicable.

10) Appendix J: Letters of Support
The applicant should include any letters of support as appropriate to demonstrate support and commitment to the project. The applicant should also include a one-page list of all additional support letters not included in the application, but available onsite.

11) Appendix K: Other Relevant Documents, optional
Applicants may include other attachments and documents to the application, as applicable, to support the proposed project plan. Other documents may include floor plans of the facility(ies), charts, organizational brochures, etc.

Applicants are reminded that applications are limited to no more than 150 pages IN TOTAL for all required and optional attachments.

3. SUBMISSION DATES AND TIMES
It is the responsibility of the applicant to ensure that the complete application is submitted electronically or postmarked by the published due date. Applications are due on the appropriate dates associated with the service area as specified in the HRSA Preview and/or Federal Register. Applications will be considered on time if received or mailed by the due date, as shown only by the electronic submission record or a legible U.S. Postal Service dated postmark or a legible date receipt from a commercial carrier. Applications submitted electronically or postmarked after the due date will not be accepted for processing and will be returned without consideration. Please indicate that you are responding to HRSA 05-086: SAC.

Applications will be considered as meeting the deadline if they either:
(1) Are received on or before the due date; or
(2) Postmarked or E marked on or before the due date, and received in time for the Independent Review Committee review.

Application Due Date
The due dates for applications under this grant announcement are as follows for projects ending in fiscal year (FY) 2005:

The Chief Grants Management Officer (CGMO) or a higher level designee may authorize an extension of published deadlines when justified by circumstances such as natural disasters (e.g. floods or hurricanes), widespread disruptions of mail service, or other disruptions of services, such as a prolonged blackout. The authorizing official will determine the affected geographical area(s).

Receipt Acknowledgement:
Applications submitted electronically will be time/date stamped electronically, which will serve as receipt of submission.

Upon receipt of a paper application, the Grants Application Center will mail an acknowledgement of receipt to the applicant organization’s Program Director.

In the event that questions arise about meeting the application due date, applicants must have a legibly dated receipt from a commercial carrier or the U.S. Postal Service. Private metered postmarks will not be accepted as proof of timely mailing.

Late applications:
Applications that do not meet the criteria above are considered late applications. Health Resources and Services Administration (HRSA) shall notify each late applicant that its application will not be considered in the current competition.

The Consolidated Health Center program is subject to the provisions of Executive Order 12372, as implemented by 45 CFR Part 100. Executive Order 12372 allows States the option of setting up a system for reviewing applications from within their States for assistance under certain Federal programs. Application kits made available under this guidance will contain a listing of States that have chosen to set up such a review system, and will provide a State Single Point of Contact (SPOC) for the review. Information on states affected by this program and State Points of Contact may also be obtained from the Grants Management Officer listed in the AGENCY Contact(s) section, as well as from the following Web site: http://www.whitehouse.gov/omb/grants/spoc.html.

All applicants other than federally recognized Native American Tribal Groups should contact their SPOC as early as possible to alert them to the prospective applications and receive any necessary instructions on the State process used under this Executive Order.

For proposed projects serving more than one State, the applicant is advised to contact the SPOC of each affected State. The due date for State process recommendations is 60 days after the applicable Federal application receipt due date. The BPHC does not guarantee that it will accommodate or explain its responses to State process recommendations received after the due date. (See “Intergovernmental Review of Federal Programs,” Executive Order 12372, and 45 CFR Part 100, for description of the review process and requirements.)

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

a) A copy of the face page of the application (SF 424).
b) A summary of the project, not to exceed one page, which provides:
• A description of the population to be served, whose needs would be met under the proposal.
• A summary of the services to be provided, and
• A description of the coordination planned with the appropriate State or local health agencies.

Applicants responding to this announcement may request funding for a project period of up to five (5) years for existing grantees, and up to three (3) years for new organization. Funding requests should be consistent with the current level of Federal section 330 funding in the announced service area. Awards to support projects beyond the first budget year will be contingent upon Congressional appropriation, satisfactory progress in meeting the project’s objectives, and a determination that continued funding would be in the best interest of the government.

Federal funding levels and the length of project period may be adjusted based on an analysis of performance and actual experience, and/or the budget operating costs, utilization, provider staffing and revenue generation for the specific service area. See Section IV of this application guidance for further information and instruction on the development of the application budget.

Change of Scope: Existing grantees should ensure that their application only reflects their currently approved scope of project. Any proposed changes must be submitted to the HRSA’s Division of Grants Management Operations for prior approval under separate cover. Please refer to the most recent BPHC guidance on this subject contained in PIN 2002-07, or contact BPHCscope@hrsa.gov for more information.

Paper Submission
If you choose to submit paper copy, please send the original and two (2) copies of the application, including all attachments, to:

The HRSA Grants Application Center
The Legin Group, Inc.
Attn: Service Area Competition
Program Announcement No. HRSA 05-086
CFDA No. 93.224
901 Russell Avenue, Suite 450
Gaithersburg, MD 20879
Telephone: 877-477-2123

In the event that questions arise about meeting the application due date, applicants must have a legibly dated receipt from a commercial carrier or the U.S. Postal Service. Private metered postmarks will not be accepted as proof of timely mailing.

Electronic Submission
To register and/or log-in to prepare your application, go to https://grants.hrsa.gov/webexternal/login.asp. For assistance in using the on-line application system, call 877-GO4-HRSA (877-464-4772) between 8:30 am to 5:30 pm ET or e-mail callcenter@hrsa.gov.

Application narratives, spreadsheets and attachments, including programmatic forms, will need to be created separately and submitted as attachments to the application. You will be prompted to “upload” your attachments at strategic points within the application interface. The following document types will be accepted as attachments: WordPerfect (.wpd), Microsoft Word (.doc), Microsoft Excel (.xls), Rich Text Format (.rtf), Portable Document Format (.pdf). If there are tables that are not supported as data entry forms from within the application, they should be downloaded to your hard drive, filled in, and then uploaded as attachments with your application.

Applications submitted electronically will be time/date stamped electronically, which will serve as receipt of submission.

To look for funding opportunities, go to http://www.hrsa.gov/grants and follow the links. Information on grant opportunities both within HRSA and in other Federal agencies is also available through http://www.grants.gov, the official E-Grants website where applicants can find and apply for federal funding opportunities.

Please note that while HRSA is accepting service area competition applications on-line, these may NOT be submitted via the Web-based Single Grant Application.

All applicants should ensure the following seven (7) Review Criteria are fully addressed within the Program Narrative and supported by other supplementary information in the other sections of the application, as appropriate. In addition, the Program Narrative must address the appropriate health center specific elements, which follow at the end of each section, as appropriate. The following Review Criteria will be used by the Independent Review Committee (IRC) to evaluate the merits of the proposed plan presented in each SAC application.

The seven (7) Review Criteria for the SAC funding opportunity and maximum points awarded are as follows:

1. Applicant describes the service area(s)/community(ies) being served, including:
(a) The service area population, i.e. urban, rural, sparsely populated [7 people or less per square mile].
(b) The counties, census tracts, minor civil divisions, schools/school districts, etc., (as appropriate) in the service area.
(c) Any Medically Underserved Areas (MUAs), Medically Underserved Populations (MUPs), High Impact Areas, and Health Professional Shortage Areas (HPSAs), as applicable.

2. Applicant describes the target population(s) (e.g., general community members, migrant/seasonal agricultural workers, residents of public housing, homeless persons, low-income school children, etc.) within the service area/community, including:
(a) The unserved and underserved populations in the community, including any other populations that are in need of access to primary health care (e.g., elderly population, immigrant population, migrant/seasonal farmworkers, homeless populations, residents of public housing, low-income school children/adolescents and their families, etc.).
(b) The unique demographic characteristics of the target population (e.g., age, gender, insurance status, unemployment, poverty level, ethnicity/culture, education, etc.).
(c) The relevant access to care and health status indicators of the target population/community.

3. Applicant identifies how many people are currently being served by the organization. Applicant also discusses how many will be served and the number of projected encounters that will be generated through the proposed project. This information should be consistent with the information presented on Form 1-A: General Information Worksheet (p. 56).

4. Applicant identifies and describes the most significant barriers to care, gaps in services, significant health disparities and the major health care problems in the community. This should include a description of:
(a) Any culturally specific characteristics that impact access to and the delivery of health care services.
(b) Any relevant geographic barriers to care and other factors impacting access to care.
(c) Any major and/or unique health care needs of the target population(s).
(The Health Care and Business Plans should present goals and measurable, time-framed objectives to address the identified needs.)

5. Applicant demonstrates an understanding of the most common causes of mortality, and the incidence and prevalence of chronic and infectious diseases in the target population.

6. Applicant describes any significant changes over the past year in the service area or population being served (i.e., influx of refugee population, or closing of local factory, etc.) impacting on the need for services. This should include a description of any significant changes for each target population type served (i.e., CHC, MHC, HCH, PHPC, and/or SBHC).

7. Applicant identifies any health care providers of care (including all other FQHCs and section 330 grantees), resources and/or services of other public and private organizations within the proposed service area that are providing care to the target population(s). The applicant should also evaluate the effectiveness of available resources and/or services in providing care to the target community/population.

8. Applicant demonstrates a thorough understanding of the health care environment including:
(a) The impact in the State of the implementation of SCHIP, 1115 and 1915(b) waivers, State Medicaid prospective payment system; Medicaid managed care, State laws, current and proposed welfare reform initiatives, etc.;
(b) The impact that these changes have had on the access to services or demand for services among the target population(s), on the ability to respond to patient demand, and/or on the fiscal stability of the organization;

In addition to the above, applicants requesting funding for one or more types of health centers authorized under the section 330 program, should also address the following:

FOR MHC APPLICANTS:
(a) Applicant describes the major agricultural environment, the crops and growing seasons, including a discussion of any impact on the demand for services among migrant and seasonal farmworkers (e.g., the need for hand labor or the number of temporary workers, etc.).

FOR HCH APPLICANTS:
(a) Applicant describes the availability of housing in the community and the impact of this and other factors on the demand for services among homeless individuals and families.

FOR PHPC APPLICANTS:
(a) Applicant describes any recent changes in the availability of public housing to serve area residents and the impact on the demand for services among residents in the targeted public house communities served.

FOR SBHC APPLICANTS:
(a) Applicant describes any changes to the number or type of students enrolled in the targeted schools and the impact on the demand for services in these locations.

1. Applicant describes the proposed service delivery model (e.g., freestanding, single or multi-site, migrant voucher, mobile site, school-based location, or combination), and locations/settings where services are provided. Applicant should include a discussion of how services will be provided at each proposed service site (e.g. via contract, referral system, etc.) and access problems the model would address and resolve.

2. Applicant demonstrates that the proposed model is most appropriate and responsive to the identified community health care needs (i.e., the service delivery plan addresses the priority health and social problems of the target population(s) for all the major life cycles).

3. Applicant demonstrates that the required primary, preventive and supplemental health services (e.g., enabling services, eligibility assistance, outreach, and transportation) will be available and accessible to all lifecycles of the target population either directly on-site or through established arrangements without regard to ability to pay.

4. Applicant demonstrates a clear and defined plan for providing oral health care that assures availability and accessibility to the target population either directly on-site or through established arrangements (e.g., contract, referral, etc.) without regard to ability to pay.

5. Applicant demonstrates a clear and defined plan for providing mental health care and substance abuse services that assures availability and accessibility to the target population either directly on-site or through established arrangements (e.g., contract, referral, etc.) without regard to ability to pay.

6. Applicant addresses the chronic disease incidences within the target population, and participation in a formal disease/care management and system improvement program, such as the BPHC-supported or sponsored Health Disparities Collaborative.

7. Applicant describes and demonstrates that the services will be culturally and linguistically appropriate.

8. Applicant demonstrates comprehensiveness and continuity of care, including a discussion of the following:
(a) Hours of operation that assure services are available and accessible at times meeting the needs of the population including evenings and weekends as appropriate;
(b) Mechanism to assure professional coverage during the hours when the health center is closed;
(c) Performance improvement system that includes eliminating disparities in health outcomes, reducing patient risk, improving patient satisfaction, credentialing and privileging, incident reporting, etc., that integrates planning, management, leadership and governance into the evaluation processes of program effectiveness; and
(d) Case management system that demonstrates care coordination at all levels of health care, including arrangements for referrals, hospital admissions discharge planning and patient tracking.

9. Applicant demonstrates collaboration and coordination of services with other providers including other existing FQHCs and section 330 grantees in the area (e.g. contracts, MOUs, letters of support, etc.)

10. Applicant discusses the extent to which project activities are coordinated and integrated with the activities of other federally-funded, State and local health services delivery projects and programs serving the same population(s). This should include a description of both formal and informal collaborative and partner arrangements, which assure a seamless continuum of care and access to appropriate specialty care for the target population(s). Applicant should have provided copies of relevant contracts, MOUs, letters of commitment or investment (e.g., from the school board, local hospital, public health department, etc.), as part of the application attachments.

11. Applicant demonstrates that the proposed clinical staffing pattern (e.g., number and mix of primary care physicians and other providers and clinical support staff, language and cultural appropriateness, etc.) is appropriate for the level and mix of services to be provided.

12. Applicant describes a detailed plan for recruiting and retaining appropriate health care providers as appropriate for achieving the proposed staffing pattern.

In addition to the above, applicants requesting funding for one or more types of health centers authorized under the section 330 program, should also address the following:

FOR MHC APPLICANTS:
(a) Applicant describes the response to health care needs associated with the environmental and/or occupational hazards to which farmworkers and their families are exposed, and how these needs will be met.
(b) Applicant describes the setting(s) in which health and enabling services will be provided, i.e., special arrangements to provide services at camps and/or farms; use of mobile teams and or vans; extended hours/weekend services; etc.
(c) Applicant describes an outreach program that will increase access to primary and preventive health care services and how the outreach program is integrated into the primary care delivery system.

FOR HCH APPLICANTS:
(a) Applicant describes the arrangements for providing required substance abuse services.
(b) Applicant demonstrates the mechanism for informing homeless people of the availability of services and the features of its outreach program.
(c) Applicant describes the coordination of services with providers of housing, job training, and other essential supports for persons who are homeless. The applicant must also describe its relationship with homeless coalitions, advocacy groups, and the existing continuum of care organizations in their community.
(d) Applicant describes the nature and scope of its expanded case management services.

FOR PHPC APPLICANTS:
(a) Applicant provides documentation that the location of the service site(s) is (are) in or directly adjacent to the public housing community(ies) being targeted.
(b) Applicant provides a formal agreement with the local public housing authority that demonstrates access to on-site space, where applicable.
(c) Applicant describes how residents will be involved in the administration of the program.

FOR SBHC APPLICANTS:
(a) Applicant provides evidence of on-site care through established arrangements with the school staff and providers (e.g., school nurse, school psychologist, etc.) when applicable.
(b) Applicant provides documentation of access to health care during the summer and other times when the school is closed (e.g. vacations, weekends).
(c) Applicant provides written documentation of an agreement with the school system to permit access to the school facility for the SBHC should be included.

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

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

3. Applicant describes the mechanism(s) by which the organization identifies and responds to the community and its needs (e.g., patient surveys, needs assessments).

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

5. Applicant demonstrates through the health care plan that both goals and time-framed, measurable objectives are in place that address the identified needs and disparities of the target population.

6. Applicant demonstrates through the Business Plan that operational issues will be addressed and that the administrative, financial and clinical systems are appropriate for the proposed project.

7. Applicant discusses any issues identified in the Notice of Grant Award (NGA), Primary Care Effectiveness Review (PCER), Office of Performance Review (OPR) or Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reviews, pre-application guidance letter (PAGL) or other findings, as applicable. This should include a discussion of the organization’s response to the listed findings.

1. Applicant describes the organization’s role and relationships within the community including:
(a) How the organization fits into the community and its service delivery network;
(b) The role of clients, community, staff and Board of Directors in establishing and evaluating the organization’s objectives and priorities; and
(c) Partnerships and collaborations with other providers in the community.

2. Applicant demonstrates and provides evidence of the community’s support for the organization. Letters of support and MOUs and/or a list of additional letters of commitment, MOUs, etc. on file at the health center, as appropriate should be included in the Appendices.

3. Applicant discusses the extent to which the proposed health center will address the priority health care needs, improve access to primary health care services and reduce health disparities for the medically underserved in the community/target population(s).

4. Applicant describes how the proposed project correlates to the goals and objectives of the Healthy People 2010 initiative, specifically to (1) increase the quality and years of a healthy life; and (2) eliminate our country’s health disparities.

5. Applicant describes the goals and objectives of the existing project (i.e. existing approved “Scope of Project for existing grantees). This should include a discussion of outcomes, both positive and negative, or unanticipated issues that may be important, and the organization’s response.

6. Applicant discusses the short- and long-term strategic planning process including any proposed plans for future activities such as plans to expand into new areas, and how such activities will be integrated into the current service delivery system.

In addition to the above, applicants requesting funding for one or more types of health centers authorized under the section 330 program, should also address the following:

FOR MHC APPLICANTS:
(a) Applicant discusses any network of care for migrant health. This should include a discussion of linkages (e.g., MOAs, MOUs, contracts, etc.) with other migrant health organizations such as Migrant Education, Migrant Head Start, and Migrant WIC programs. Copies of appropriate signed agreements, contracts, etc should have been submitted in the Appendix.

FOR HCH APPLICANTS:
(a) Applicant documents the relationship with housing providers and other local organizations that provide services and support to homeless persons.
(b) Applicant documents the degree of participation in community-wide planning on behalf of homeless persons through participation with the local continuum of care or other entities.

FOR PHPC APPLICANTS:
(a) Applicant documents the relationship with the local public housing authority and with public housing resident groups within the community.

1. Applicant discusses why it is the appropriate entity to receive funding (e.g. staff skills, capacity, clinical outcomes, cultural and linguistic competence, evaluation capabilities, etc.).

2. Applicant discusses the history and status as a designated Federally Qualified Health Center, where applicable, including eligibility for malpractice coverage under the Federal Tort Claims Act, and years of uninterrupted services to the target area and populations.

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

4. Applicant demonstrates that the organizational structure (including any sponsorship, parent organization, corporate affiliation, etc.) is compliance with section 330 requirements, and appropriate for the proposed project.

5. Applicant demonstrates that the proposed staffing plan is appropriate and adequate given the scope of the proposed project.

6. Applicant demonstrates that the key management staff (e.g. CEO, CFO, CMO) of the health center are appropriate and that the process for hiring key management staff is in accordance with Health Center Program Expectations. This should include a description of any specific leadership for each health center type (i.e. CHC, MHC, HCH, PHPC, or SBHC), as applicable.

7. Applicant describes any key management staff changes during the last year, and/or any long-term vacancy, as applicable.

8. Applicant describes the current facility(ies), and demonstrates that they are appropriate for the proposed service delivery plan.

9. Applicant identifies unique characteristics and significant accomplishments of the organization.

10. Applicant describes prior experiences and expertise in:
(a) Working with the target population(s);
(b) Addressing the identified health care needs; and
(c) Developing and implementing appropriate systems and services to meet the needs of the community.

11. Applicant identifies any section 330 funding received over the last five years, including participation in any special initiatives (e.g., integrated service network, dental pilot, etc.) and urgent supplemental funds and/or funds received from other related Federal programs such as Healthy Start, Housing and Urban Development Homeless resources, etc.

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

1. Applicant demonstrates that the budget presentation (an annualized budget for each 12 month period for which funding is requested of the new project period) is appropriate and reasonable in terms of:
(a) The level of requested Federal grant funds versus total budget for each year;
(b) The total resources required to achieve the goals and objectives of the applicant’s proposed service delivery plan (i.e., total project budget);
(c) The maximization of non-grant revenue relative to the proposed plan and other Federal/State/local/in-kind resources applied to the project;
(d) The projected patient income is reasonable based on the patient mix and number of projected users and encounters;
(e) The number of proposed users and encounters;
(f) The total cost per user and encounter;
(g) The total federal section 330 grant dollars per user.

2. Applicant demonstrates that the Federal grant funds requested are being used to leverage other sources of funding.

3. Applicant demonstrates that the business plan goals and objectives are targeted and demonstrate appropriate financial planning in the development of the proposal and for the long-term success of the project.

4. Applicant describes how the proposed health center is a cost-effective approach to meeting the primary care needs of the target population given the health care needs of the target population and the level of health care resources currently available in the community.

Criterion 7: GOVERNANCE (10 points)
Applicants must provide a copy of the signed bylaws demonstrating compliance with and reflecting all functions and responsibilities cited in section 330, as appropriate.

1. Applicant describes the structure of the Board in terms of size, expertise, and representativeness of the communities/populations served (e.g. appropriate racial/ethnic, economic status, and gender representation, 51% consumer majority, etc.).

2. Applicant discusses measures for assuring that the Board is complaint with appropriate and applicable regulations and BPHC guidance. .

3. Applicant discusses the mechanism of continued Board training, including training new governing board members in appropriate responsibilities and requirements of the Federal grant.

4. Applicant describes the provision for ensuring monthly meetings of the Board or an alternate mechanism if a waiver is requested.

5. Applicant describes the mechanism for quality assurance, including a mechanism to evaluate Board effectiveness.

6. Applicant demonstrates that the Board has appropriate oversight responsibilities, specifically the responsibility to:
(a) Directly employ, select/dismiss and evaluate the CEO/Executive Director;
(b) Adopt policies and procedures for personnel and financial management;
(c) Establish center priorities and activities;
(d) Approve annual budget; and
(e) Schedule hours of operation.

In addition to the above, applicants requesting funding for one or more types of health centers authorized under the section 330 program, should also address the following:

HCH, PHPC, and MHC APPLICANTS:
(a) All HCH, PHPC and/or MHC applicants that are also requesting CHC and/or SBHC funding must demonstrate that at least one member of its Board is representative of the special population.
(b) Applicant clearly identifies a request for a waiver of governance requirements, if applicable. If a waiver is requested, identify on Form 6-B (p. 65) which requirements are to be waived and discuss alternative arrangements proposed in lieu of required elements. [See PIN 98-12, “Implementation of Section 330 Governance Requirements” (signed April 28, 1998)]. No waiver allowable if CHC or SBHC funds are requested.

All SAC applications will be reviewed initially for eligibility (see Section III for eligibility requirements) and completeness (see Section IV for Application Sequence, and Section IX. for Application Completion Checklist). Those applications that are determined to be ineligible, incomplete or non-responsive will be returned to the applicant. Applicants are reminded that applications MUST NOT exceed 150 pages IN TOTAL, including all required and optional attachments, whether submitted on paper or electronically. Applications that exceed the specified limit of 150 pages will be deemed non-compliant and will be returned to the applicant without further consideration.

Those applications that are determined to be eligible, complete, and responsive will have the technical merit of the proposal evaluated using the review criteria presented in this application guidance with points assigned up to a maximum of 100 points total.

The Division of Independent Review (DIR) is responsible for managing objective reviews within HRSA. Applications competing for federal funds receive an objective and independent review performed by a committee of experts qualified with training and experience in particular field or disciplines related to the program being reviewed. In selecting review committee members, other factors in addition to training and experience may be considered to improve the balance of the committee (e.g. geographic distribution). Every attempt is made to avoid conflicts of interest and provide an objective and unbiased evaluation based on the review criteria in this guidance. The committee provides expert advice on the merits of each application to program official responsible for final selections for award.

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

Funding Preferences
There are no funding preferences, priorities or special considerations available under this guidance.

For FY 2005, applications received or postmarked by August 16, 2004, will be reviewed with funding decision announced on or about November 1, 2004. Applications received or postmarked by September 1, 2004, will be reviewed with funding decision announced on or about February 1, 2005. Applications received or postmarked by October 25, 2004, will be reviewed with funding decision announced on or about April 1, 2005. Applications received or postmarked by January 3, 2005, will be reviewed with funding decision announced on or about June 1, 2005.

Each applicant will receive written notification of the outcome of the objective review process, including a summary of the objective review committee’s assessment of the application’s merits and weaknesses, and whether the application was selected for funding. Organizations whose applications are selected for funding may be required to respond in a satisfactory manner to Conditions placed on their application before funds can be awarded. Letters of notification of funding do not provide authorization to begin performance. Successful applicants will receive a Notice of Grant Award from the Division of Grants Management Operations following the announcement of the funding decisions. The Notice of Grant Award, which is signed by the Grants Management Officer and is sent to the applicant agency’s Authorized Representative, is the authorizing document and will be sent prior to the applicable start date.

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

Successful applicants must comply with the administrative requirements outlined in 45 CFR Part 74 or 45 CFR Part 92, as appropriate.

PUBLIC POLICY ISSUANCE
Healthy People 2010
Healthy People 2010 is a national initiative led by HHS that sets priorities for all HRSA programs. The initiative has two major goals: (1) To increase the quality and years of a healthy life; and (2) Eliminate our country’s health disparities. The program consists of 28 focus areas and 467 objectives. HRSA has actively participated in the work groups of all the focus areas, and is committed to the achievement of the Healthy People 2010 goals.

Applicants must summarize the relationship of their projects and identify which of their programs objectives and/or sub-objectives relate to the goals of the Healthy People 2010 initiative.

Copies of the Healthy People 2010 may be obtained from the Superintendent of Documents or downloaded at the Healthy People 2010 website: http://www.health.gov/healthypeople/document/.

Smoke Free Workplace
The Public Health Service strongly encourages all award recipients to provide a smoke-free workplace and to promote the non-use of all tobacco products. Further, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children.

a. Comply with audit requirements of Office of Management and Budget (OMB) Circular A-133. Information on the scope, frequency, and other aspects of the audits can be found on the Internet at www.whitehouse.gov/omb/circulars;

b. Submit a Payment Management System Quarterly Report. The reports identify cash expenditures against the authorized funds for the grant. Failure to submit the report may result in the inability to access grant funds. Submit report to the:
Division of Payment Management
DPM/FMS/PSC/ASAM/HHS
PO Box 6021
Rockville, MD 20852
Telephone: (301) 443-1660;

c. Submit a Financial Status Report. A financial status report is required within 90 days of the end of each grant year. The report is an accounting of expenditures under the project that year;

d. Uniform Data System. All grantees will be expected to submit a Universal Report and Grant Report (if applicable) annually for the Uniform Data System (UDS). This report provides data on services, staffing and financing across all section 330 health centers. The UDS is an integrated reporting system the BPHC uses to collect data annually on its programs to ensure compliance with legislative mandates and to report to Congress, OMB, and other policy makers on program accomplishments.

VII. Agency Contacts

Applicants may obtain additional programmatic information regarding this grant announcement by contacting:

Preeti Kanodia
Public Health Analyst
Division of Health Center Development
Bureau of Primary Health Care, HRSA
4350 East West Highway, 3rd Floor
Bethesda, MD 20814
Telephone: 301.594.4300
Fax: 301.480.7225

Applicants may obtain additional information regarding business, administrative, or fiscal issues related to this grant announcement by contacting:

Beth Rosenfeld
Division of Grants Management Operation, OMPS
4350 East West Highway, 11th Floor
Bethesda, MD 20814
Telephone: 301.594.4237

Technical assistance regarding this funding announcement may be obtained by contacting: the appropriate State Primary Care Association (PCA), Primary Care Office (PCO) or Project Officer. Please see Attachment B of this guidance for a listing of PCAs and PCOs.

VIII. Other Information

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

In order for its employees to be deemed, a health center must have implemented policies and procedures that reduce the risk of malpractice; and have reviewed and verified the credentials of all licensed and certified health care practitioners. More specifically, a health center must have a governing board-approved quality assurance plan with a copy of the most recent minutes submitted with the deeming application and a credentialing and privileging policy that meets the requirements of BPHC PIN 2002-22. All licensed or certified health care practitioners must be credentialed and privileged before a health center deeming application can be approved. Finally, the health center must agree to fully cooperate with the Attorney General in defending any claims.

Organizations should be aware that participation in the FTCA program is not guaranteed. If a health center is not absolutely certain it can meet the requirements of the Act, the costs associated with the purchase of malpractice insurance should be included in the proposed budget. The search for malpractice insurance, if necessary, should begin as soon as possible.

Currently deemed existing grantees applying under the SAC funding opportunity must concurrently submit a new FTCA deeming application (PIN 99-08), to Susan Lewis at the address below. If the application for FTCA deeming is approved, a deeming letter will be issued.

New organizations should include the costs of appropriate malpractice insurance in the budget, as the deeming process may be lengthy, and FTCA deeming is not guaranteed. After funding is received, new organization may submit an application for FTCA deeming using PIN 99-08. If the application for FTCA deeming is approved, a deeming letter will be issued. Applications should be sent to:

Susan Lewis
HRSA Bureau of Primary Health Care
150 S. Independence Mall West
Suite 1172
Philadelphia, PA 19106-3499.

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

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

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

Budget Period: is each 12-month period within an approved project period (see below for definition). A complete budget presentation for each budget period in the proposed project period should be included in the application (5 years for existing grantees; 3 years for new organizations).

Existing Grantee: is an organization funded under section 330 who is submitting a competing continuation application at the end of their project period for support to continue providing services to their defined service area and population. Existing grantees include any ‘new starts’ (new grantee awarded through the New Access Point funding opportunity) whose project period is ending on or after 10/31/2004. Please review the Eligibility section for more information.

Full Operational Capacity: relates to the number of providers and the number of patients within the designated target population(s) that the center can realistically serve. This capacity should be determined using the provider levels required by the center to operate at its full level of services.

SAC organizations are expected to demonstrate that they are currently operating at full operational capacity. Full operational capacity for a center can be calculated based on the projected staffing levels. CHC applicants should use a physician to population ratio of 1:1,500 as a guide to calculate their full operational patient capacity. For midlevel practitioners (e.g., nurse practitioners, physician assistants, and certified nurse midwives), applicants may use a 1:750 provider to patient ratio. For example, a practice with a team of two full-time physicians and a full-time nurse practitioner would have a full operational capacity of 3 full-time equivalent (FTE) providers and 3,750 patients.

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

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

New Organization: is an existing and operational provider that is submitting a competing application for support to serve the defined service area and population in place of the existing grantee at the end of its project period. Please review the Eligibility section for more information.

Project Period: is defined as the total time for which Federal grant support has been approved. For existing grantees, a project period may be up to five years in length. For new organizations, a project period may be up to three years in length.

Scope of Project: is a description of the health center’s total approved project, specifically defining the services, sites, providers, target population(s), and service area(s), for which grant funds may be used, in whole or in part. This total project includes program income and other non-section 330 funds.

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

Service Site: A site is any place where a health center provides services to a defined geographic service area or population on a regular (e.g., daily, weekly, or monthly), scheduled basis. There is no minimum number of hours per week that services must be available. However, the site must be operated as part of the health center’s approved scope of project. In order to be considered a site:
• encounters must be generated at the site for the health center through documented face-to-face contact between patients and providers;
• encounters are provided by health care professionals who exercise independent judgment in the provision of services to the patient;
• services at the site must be provided on behalf of the health center, which retains control and authority over the provision of the services (e.g., as applicable, billing and Medical records).
Sites can include, but are not limited to, health care facilities, schools, migrant camps, homeless shelters, and mobile medical vans where health care services are provided.
 Site examples:
o Any full-time or part-time clinic location – address of site should be listed
o Primary Care Services at a homeless shelter for four hours every Thursday – address of site should be listed
o If a health center provides immunizations where an encounter is generated once a month at 15 different day care centers on a defined schedule, the individual day care centers need not be listed as sites; however, the category “day care center” should be listed.
o A mobile van that provides primary care services at multiple locations on a defined schedule. The locations where the van provides services do not need to be listed as sites; however the category of “mobile van” should be listed.
o Migrant clinic location open only during 6 months of the year – address of site should be listed.

Activities or locations where the only services delivered do not generate encounters (i.e., filling prescriptions, taking X-rays, performing street outreach or providing health education, etc.) should not be listed or added as a site. Administrative offices that do not provide services are not considered service sites; therefore, any changes in location of administrative offices do not require approval.
 Other activities/locations examples that are not considered sites and therefore should not be included:
o Locations for off-site activities required by the health center and documented as part of the employment agreement or contract between the health center and the provider (e.g., health center physicians providing coverage at the hospital emergency room or participating in hospital call for unassigned patients) should not need to be listed as sites.
o Locations where the site is administrative only, including but not limited to vouchers.
o Nursing homes that contract with a health center for staff providers to provide care at the nursing home on behalf of the nursing home.

BPHC recognizes that some delivery “activities/locations” described above have been approved as part of the scope of project and have therefore appeared on previously submitted Exhibit B Service Site Forms. Although not considered sites as defined above, these “activities/locations” will continue to be documented in continuation applications and to be considered part of the approved scope of project. Any new additions or deletions must be requested through the Change in Scope process, consistent with guidance provided in PIN 2002-07.

Sparsely Populated Rural Areas: is a geographical area with 7 people or less per square mile.

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

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

Target Population: A target population is usually a subset of the entire service area population but may include all residents of the service area. The description of the target population should include the major health problems of the target population and should serve as the basis for the center's service delivery plan. The target population for a center may be composed of a particular ethnic/socio-economic group or may be composed of a variety of different ethnic/socio-economic groups. In all cases, however, the health center must demonstrate that services are equally available to everyone. The target population may not be limited in terms of age or gender.

• For CHCs target population refers to the individuals within the service area to whom the center will direct its service delivery plan.
• For MHCs the target population refers to the migratory and seasonal farmworker individuals within the service area to whom the center will direct its service delivery plan.
• For HCHs the target population refers to the homeless individuals within the service area to whom the center will direct its service delivery plan.
• For PHPCs the target population refers to the residents of one or more public housing developments and the surrounding areas to whom the center will direct its service delivery plan.
• For SBHCs the target population refers to the students and other family members of students of a particular school or schools, and the surrounding areas as appropriate, to whom the center will direct its service delivery plan.

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

Include DUNS Number. You must include DUNS Number to have your application reviewed. Application will not be reviewed without a DUNS number. To obtain a DUNS number, access www.dunandbradstreet.com or call 1-866-705-5711. Please include the DUNS number next to OMB Approval Number on the application face page.

Keep your audience in mind. Reviewers will use only the information contained in the application to assess the application. Therefore, the applicant should be sure the application and responses to the program requirements and expectations are complete and clearly written. Do not assume that reviewers are familiar with the applicant organization. Keep the review criteria in mind when writing the application.

Start preparing the application early. Allow plenty of time to gather required information from various sources.

Follow the instructions in this guidance carefully. Place all information in the order requested in the guidance. Organizations submitting an application electronically should make sure all attachments print in the correct order prior to submission. If the information is not placed in the requested order, you may receive a lower score.

Be brief, concise, and clear. Make your points understandable. Provide accurate and honest information, including candid accounts of problems and realistic plans to address them. If any required information or data is omitted, explain why.

Be consistent. Make sure the data provided in each table, chart, attachment, etc., is consistent with the information in other tables and required forms. Be sure information provided in the health care plan, business plan and budget presentation accurately reflect information within the program narrative.

Be organized and logical. Many applications fail to receive a high score because the reviewers cannot follow the thought process of the applicant or because parts of the application do not fit together.

Be careful in the use of appendices. Do not use the appendices for information that is required in the body of the application. Be sure to cross-reference all tables and attachments located in the appendices to the appropriate text in the application.

Carefully proofread the application. Misspellings and grammatical errors will impede reviewers in understanding the application. Be sure pages are numbered (including all attachments) and that page limits are followed. Limit the use of abbreviations and acronyms, and define each one at its first use and periodically throughout application.

GUIDELINES FOR COMPLETION OF THE BUDGET FORMS
In completing the SAC application, an applicant should present a complete 12-month budget justification (and narrative, as needed) for each budget period for which the applicant is seeking support (five years for existing grantees, 3 years for new organizations). See ‘Section IV: Application And Submission Information’ (p. 12) for more information about the Budget and Budget Justification. This section explains the development and requirements for the preparation and presentation of a budget submitted as part of the application for Federal support under the Consolidated Health Center Program.

All budgets should be developed based on the estimated funding needs to accomplish the proposed project, as well as the target level of funding. The PHS 5161-1, Standard Form (SF) 424A budget forms the basis for the budget presentation that will enable reviewers to make judgments as to the appropriateness and reasonableness of the proposed costs as they relate to the project description, health care plan and business plan. Directions for completing the SF 424A (sections A, B, E and if applicable F, budget information may be found within the PHS 5161-1.

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

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

Instructions for the Completion of Form 3: Income Analysis
Remember to include a complete Form 3 for each year of funding requested.

Revenue information should be presented in a format that shows how projections for patient service revenue were made by breaking out revenue by payment source for each year. Note that self-payors need only be broken out by 100 percent payors, sliding scale, and nominal-fee payors.

If a capitated managed care program is included, the applicant should: describe each current capitated managed care arrangement, identifying the services for which the applicant is at risk; provide the current number of enrollees and support for the projected number of enrollees included in the total user count; and separately identify income and expenses based on the actual number of enrollees. Contact the Division of Health Center Development, Bureau of Primary Health Care for assistance in developing this information.

Projecting revenue should involve the following steps and must be presented using the FORM 3: Income Analysis for each year funding is requested.

(a) Enter in column a) the number of visits that will be covered by each type of payment source – Medicaid, Medicare, other third-party payors and patient self-pay (categorized by 100 percent pay, sliding fee pay and 0 percent self-pay).
(b) Enter in column b) the average charge per visit by payor category.
(c) Enter in column c) the total charges for each payment source. This may be obtained by multiplying column a) by column b).
(d) Enter in column d) the average adjustment of the average charge per visit. NOTE: Adjustments in this column relate to projected disallowance and sliding fee discounts to the average charge per visit.
(e) Enter in column e) the total amount billed by payment source. This is computed by subtracting from column c), total charges, the total estimated adjustments [column a) x column d)].
(f) Enter in column f) the estimated collection rate (%) by payor category.
(g) Enter in column g) the total projected income for the projected Budget Period. Multiply column e) by column f).
(h) Column h) represents the actual accrued income for the latest 12- month period for which data are available by payor category. The applicant should compare figures in columns g) and h) and explain in the budget presentation any significant increase or decrease in income.

(a) Enter in column a) the projected number of visits for enrollees under capitation arrangements for each major contract. Although by definition, capitation is not based on visits, an estimated number of total visits figure should be reported in this column.
(b) Enter in column e) the total gross capitation amount to be received under the capitation arrangement.
(c) Enter in column f) the collection rate excluding anticipated contractual withholds, if any.
(d) Enter in column g) the total projected income. This should be equal to net receipts [column e) x column f)].
(e) Enter in column h) the actual accrued income for the latest 12- month period for which data are available by payor category. The applicant should compare figures in columns g) and h) and explain in the budget presentation any significant increases or decreases in income.

Note: Charge-based income includes such revenues as insurance filing fees and surplus managed care distributions, and non-charge-based income includes interest receipts, contracts to serve as medical director of a nursing home, etc.

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

“SAMPLE” BUDGET JUSTIFICATION
Instructions: The sample budget justification shown below is provided as a broad outline. The examples used in this sample are for illustrative purposes only: please revise and amend this to best suit the needs of your proposed network. Be sure to provide additional information and detail as per the Budget Justification guidelines in narrative form, as appropriate.

REVENUE: (From FORM 3 – Income Analysis) Year 1 Year 2 Year 3 Year 4 Year 5

GUIDELINES FOR HEALTH CARE AND BUSINESS PLANS
The following components are intended for use in both the health care and business plans. Presenting the plans in "landscape" print format may facilitate easier reading and usage. Please refer to ‘Section IV: Application And Submission Information’ for more information about completing health care and business plans.

Problem/Need Statements are clearly and specifically defined descriptions of major needs or problems, quantified where possible. The problem/need statements should tie into and flow from the overall project description and the identified needs of the target population(s). For example, such statements in the health care plan may address (but are not limited to):
1. Needs of the overall health system, covering multiple programs and populations,
2. Identification of disparities in health outcomes among populations served,
3. Need for practice performance improvement in a targeted health disparity area,
4. Problems of a specific service or population,
5. Specific public health problems (e.g., high infant mortality; high prevalence of HIV disease; complications from diabetes; high prevalence of cocaine addiction), and
6. Need for sustaining and spreading health disparities collaborative.

Please refer to Section IV, ‘Part xii. Business Plan,’ for information that should be addressed in the business plan.

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

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

Column 3: Expected Outcome - Quantifiable (measurable and time-limited) documented outcomes to be achieved. This column must be completed for each key action step. Reference each expected outcome in the same manner as above for key action steps (i.e., A.1.a).

Column 4: Data, Evaluation, & Measurement - The source of data, evaluation method and measurement used to evaluate progress towards an objective or to identify the actual outcome distinguished in the objective. Reference each in the same manner as above for key action steps (i.e., A.1.a).

Column 5: Person/Area Responsible – The person or area of the operation responsible for the tracking, evaluation and completion of the objectives and key action steps. Reference each in the same manner as above for key action steps (i.e., A.1.a).

Column 6: Comments - Supplementary information for related entries in the plan. Reference each comment in the same manner as above for key action steps (i.e., A.1.a).

“Sample” Health Care & Business Plan Presentation

This sample Health Care and Business Plan presentation is provided for format as a broad outline.
Problem/Need Statement: Diabetes is a common diagnosis among patients of CHC, Inc. CHC, Inc. aims to improve care and quality of life for its clients with diabetes by redesigning the delivery of health care services.
Goals/Objectives Key Action Steps Expected Outcome Data, Evaluation & Measurement Person/Area Responsible Comments

A.1. At least 90% of patients will have had a retinal eye exam in the last 12 months by 5/06

A.2. Objective (2)

A.1.(a) Track patients to insure they have annual retinal eye exams and foot exams. Refer as needed
A.1 (b) Action step 2 for Objective 1
A.1.(c) Action step 3 for Objective 1

A.2.(a) Action step 1 for Objective 2
A.2 (b) Action step 2 for Objective 2
A.1.(a) By 5/06, 90% of patients have had a retinal eye exam in the last 12 mts
A.1.(b) Expected Outcome
A.1.(c) Expected Outcome

A.2.(a) Expected Outcome
A.2.(b) Expected Outcome
A.1(a) Medical Records
A.1(b) Data, Eval & Meas
A.1.(c) Data, Eval & Meas

A.2.(a) Data, Eval & Meas
A.2.(b) Data, Eval &Meas
A.1.(a) Nursing Staff
A.1.(b) Person/Area
A.1.(c) Person/Area

A.2.(a) Person/Area
A.2.(b) Person/Area
A.1.(a) Healthy People 2010 Goals and Obj (5-1 through 5-17).
A.1.(b) Comments
A.1.(c) Comments

A.2.(a) Comments
A.2.(b) Comments
Problem/Need Statement: Well-managed human resources are critical to the success of any organization.

B.1. Implement an annual performance evaluation and employee satisfaction program.

B.3. Objective (3)
B.1.(a) Each exam room will be fully equipped for all aspects of patient care.
B.1 (b) Action step 2 for Objective 1

B.2.(a) Action step 1 for Objective 2
B.2 (b) Action step 2 for Objective 2
B.1.(a) Exam rooms properly equipped
B.1.(b) Expected Outcome

B.2.(a) Expected Outcome
B.2.(b) Expected Outcome
B.1.(a) List of exam room equipment.
B.1.(b) Data, Evaluation & Measurement

B.2.(a) Data, Evaluation & Measurement
B.2.(b) Data, Evaluation & Measurement
B.1.(a) CQI Team and staff
B.1.(b) Person/Area

C.1. Objective (1)

C.1.(a) Action step 1 for Objective 2
C.1 (b) Action step 2 for Objective 2
C.1.(a) Expected Outcome
C.1.(b) Expected Outcome
C.1.(a) Data, Evaluation & Measurement
C.1.(b) Data, Evaluation & Measurement
C.1.(a) Person/Area
C.1.(b) Person/Area
C.1.(a) Comments
C.1.(b) Comments

DOCUMENTS TO BE INCLUDED WITH APPLICATION
ALL DOCUMENTS LISTED BELOW MUST BE INCLUDED WITH APPLICATION UNLESS SPECIFICALLY NOTED APPLICATION PAGE # (s)
GENERAL INFORMATION 11
PHS 5161-1 - Face Sheet (SF 424 – Application for Federal Assistance)
Abstract
Table of Contents
Form 1, Part A: General Information Worksheet
PHS 5161-1 - Standard Assurances (SF 424B – Non-Construction Programs)
PHS 5161-1 - Certifications (Pages 17-19)
PHS 5161-1 - Checklist (Pages 25 – 26)
BUDGET INFORMATION 10
Form 1, Part B: BPHC Funding Request Summary
PHS 5161-1 - Form SF 424A, Sections A F (2 pages)
Detailed Budget with Narratives for each Year of the requested new project period
Form 2: Proposed Staff Profile for first Year, include any anticipated changes within the project period.
Form 3: Income Analysis Format for first Year of the proposed project
BODY OF APPLICATION 60-70
Program Narrative
Health Care Plan
Business Plan
REQUIRED ATTACHMENTS 50-60
Form 4: Community Characteristics
Form 5, Part A: Services Provided
Form 5, Part B: Service Sites
Form 5, Part C: Other Activities/Locations
Form 6, Part A: Current Board Member Characteristics
Form 6, Part B: Request for Waiver of Governance Requirements, if applicable
Form 7: Compliance Checklist
Organization Chart and Service Area amp
Corporate Bylaws
Job or Position Description for Key Personnel, optional
Biographical Sketches for Key Personnel
Co-Applicant Agreement, if applicable
Other contracts, agreements, etc. as applicable or required
Most recent independent financial audit specifically including all management letter and balance sheets
Articles of Incorporation (seal page only)
Internal Revenue Service (IRS) Tax Exempt Certification for the Applicant, OR, if the Applicant is a public entity, the Co-Applicant Board, new organizations only
Letters of Support
Other Relevant Documents, optional

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

PLEASE REFER TO SECTION IV, ‘PART XII. PROGRAM SPECIFIC FORMS ’
FOR MORE INFORMATION

“Sample ” Budget Justification

Instructions: The sample budget justification shown below is provided as a broad outline. The examples used in this sample are for illustrative purposes only: please revise and amend this to best suit the needs of your proposed network. Be sure to provide additional information and detail as per the Budget Justification guidelines in narrative form, as appropriate.

REVENUE: (From FORM 3 – Income Analysis) Year 1 Year 2 Year 3 Year 4 Year 5

PATIENT SERVICE INCOME $6,207,434

(including Pharmacy)

LOCAL & STATE GRANTS $953,500

LOCAL FUNDING $150,000

FEDERAL BPHC 330 GRANT $681,000

OTHER FEDERAL FUNDING $

(Break out by fund source)

TOTAL: REVENUE $7,991,934

EXPENSES: Year 1 Year 2 Year 3 Year 4 Year 5

PERSONNEL: See Personnel by Position

and health center type $4,657,223

FRINGE BENEFITS: Break out:

FICA $951,849

Retirement, etc.

TOTAL: PERSONNEL & FRINGE $5,589,072

TRAVEL:

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

Nursing CME ($ per FTE) $

Other Professional CME ($ per FTE) $

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

Executive Director (2 meetings)

Board Chair (2 meetings)

Management & Board $

State and National Meetings $

Other Board/Management Travel $

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

TOTAL: TRAVEL $ 25,932

EQUIPMENT:

See attached Equipment Listing

TOTAL: EQUIPMENT $5,500

SUPPLIES:

Office & Printing Supplies $X.XX per encounter $

Medical & Dental Records $X.XX per encounter $

Medical Supplies $X.XX per encounter $

Pharmacy Supplies including Drugs

Average per # of Prescriptions $

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

Laboratory supplies per average # of procedures $

Building and Maintenance Supplies per # of sites $

TOTAL: SUPPLIES $1,452,940

Expenses Continued Year 1 Year 2 Year 3 Year 4 Year 5

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

“Patient Care Contracts”

Outside Reference Lab $

XYZ Company for any tests that cannot be

Performed in house (Avg # of procedures

X Avg Cost) $

Outside Contract Pharmacies (describe)

(Avg # of prescriptions X Avg Cost) $

GYN/OB Contract with ABC Company

(Avg # of Patients served X Avg Cost) $

Ophthalmologist with RST Company

(Avg # of patients @ Avg Cost) $

Temporary Nursing Coverage

(Avg # of days @ Avg Costs) $

Subtotal: Patient Care Contracts $

“Non-Patient Contracts”

Housekeeping Services with LMN Company

for # of sites $

Security Services with DEF Company for

# of hours per site $

Computer Maintenance Contract $

Subtotal: Non-Patient Contracts $

TOTAL: CONTRACTUAL $398,020

EQUIPMENT:

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

1 PC and related software (1 @ 3,500) $

TOTAL EQUIPMENT $

OTHER:

Payroll Processing Services $

Audit Services with JKL Company $

Legal Fees with WXY Company fee per hour $

Association Dues $

Building Contents Insurance $

Telephone Service $

Answering Services $

Postage $

Utilities $

Rent (describe per site) $

Marketing/Outreach $

Any special taxes (describe) $

Technical Assistance $

TOTAL: OTHER $580,470

Year 1 Year 2 Year 3 Year 4 Year 5

TOTAL: ALL BUDGET $7,991,934

Guidelines for Health Care and Business Plans

The following components are intended for use in both the health care and business plans. Presenting the plans in "landscape" print format may facilitate easier reading and usage. Please refer to ‘Section IV: Application And Submission Information’ for more information about completing health care and business plans.

Problem/Need Statements are clearly and specifically defined descriptions of major needs or problems, quantified where possible. The problem/need statements should tie into and flow from the overall project description and the identified needs of the target population(s). For example, such statements in the health care plan may address (but are not limited to):

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

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

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

4. Problems of a specific service or population,

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

6. Need for sustaining and spreading health disparities collaborative.

Please refer to Section IV, ‘Part xii. Business Plan,’ for information that should be addressed in the business plan.

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

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

Column 3: Expected Outcome - Quantifiable (measurable and time-limited) documented outcomes to be achieved. This column must be completed for each key action step. Reference each expected outcome in the same manner as above for key action steps (i.e., A.1.a).

Column 4: Data, Evaluation, & Measurement - The source of data, evaluation method and measurement used to evaluate progress towards an objective or to identify the actual outcome distinguished in the objective. Reference each in the same manner as above for key action steps (i.e., A.1.a).

Column 5: Person/Area Responsible – The person or area of the operation responsible for the tracking, evaluation and completion of the objectives and key action steps. Reference each in the same manner as above for key action steps (i.e., A.1.a).

Column 6: Comments - Supplementary information for related entries in the plan. Reference each comment in the same manner as above for key action steps (i.e., A.1.a).

“Sample” Health Care & Business Plan Presentation

This sample Health Care and Business Plan presentation is provided for format as a broad outline.

Problem/Need Statement: Diabetes is a common diagnosis among patients of CHC, Inc. CHC, Inc. aims to improve care and quality of life for its clients with diabetes by redesigning the delivery of health care services.

Goals/Objectives

Key Action Steps

Expected Outcome

Data, Evaluation & Measurement

Person/Area Responsible

Comments

A. To improve the health status of patients with diabetes

A.1. At least 90% of patients will have had a retinal eye exam in the last 12 months by 5/06

A.2. Objective (2)

A.1.(a) Track patients to insure they have annual retinal eye exams and foot exams. Refer as needed

A.1 (b) Action step 2 for Objective 1

A.1.(c) Action step 3 for Objective 1

A.2.(a) Action step 1 for Objective 2

A.2 (b) Action step 2 for Objective 2

A.1.(a) By 5/06, 90% of patients have had a retinal eye exam in the last 12 mts

A.1.(b) Expected Outcome

A.1.(c) Expected Outcome

A.2.(a) Expected Outcome

A.2.(b) Expected Outcome

A.1(a) Medical Records

A.1(b) Data, Eval & Meas

A.1.(c) Data, Eval & Meas

A.2.(a) Data, Eval & Meas

A.2.(b) Data, Eval &Meas

A.1.(a) Nursing Staff

A.1.(b) Person/Area

A.1.(c) Person/Area

A.2.(a) Person/Area

A.2.(b) Person/Area

A.1.(a) Healthy People 2010 Goals and Obj (5-1 through 5-17).

A.1.(b) Comments

A.1.(c) Comments

A.2.(a) Comments

A.2.(b) Comments

Problem/Need Statement: Well-managed human resources are critical to the success of any organization.

B. Maintain well-qualified staff for health center.

B.1. Implement an annual performance evaluation and employee satisfaction program.

B.2. Objective (2)

B.3. Objective (3)

B.1.(a) Each exam room will be fully equipped for all aspects of patient care.

B.1 (b) Action step 2 for Objective 1

B.2.(a) Action step 1 for Objective 2

B.2 (b) Action step 2 for Objective 2

B.1.(a) Exam rooms properly equipped

B.1.(b) Expected Outcome

B.2.(a) Expected Outcome

B.2.(b) Expected Outcome

B.1.(a) List of exam room equipment.

B.1.(b) Data, Evaluation & Measurement

B.2.(a) Data, Evaluation & Measurement

B.2.(b) Data, Evaluation & Measurement

B.1.(a) CQI Team and staff

B.1.(b) Person/Area

B.2.(a) Person/Area

B.2.(b) Person/Area

B.1.(a) Comments

B.1.(b) Comments

B.2.(a) Comments

B.2.(b) Comments

C. Goal

C.1. Objective (1)

C.1.(a) Action step 1 for Objective 2

C.1 (b) Action step 2 for Objective 2

C.1.(a) Expected Outcome

C.1.(b) Expected Outcome

C.1.(a) Data, Evaluation & Measurement

C.1.(b) Data, Evaluation & Measurement

C.1.(a) Person/Area

C.1.(b) Person/Area

C.1.(a) Comments

C.1.(b) Comments

DOCUMENTS TO BE INCLUDED WITH APPLICATION
ALL DOCUMENTS LISTED BELOW MUST BE INCLUDED WITH APPLICATION UNLESS SPECIFICALLY NOTED	APPLICATION PAGE # (s)
GENERAL INFORMATION	11
PHS 5161-1 - Face Sheet (SF 424 – Application for Federal Assistance)
Abstract
Table of Contents
Form 1, Part A: General Information Worksheet
PHS 5161-1 - Standard Assurances (SF 424B – Non-Construction Programs)
PHS 5161-1 - Certifications (Pages 17-19)
PHS 5161-1 - Checklist (Pages 25 – 26)
BUDGET INFORMATION	10
Form 1, Part B: BPHC Funding Request Summary
PHS 5161-1 - Form SF 424A, Sections A‑F (2 pages)
Detailed Budget with Narratives for each Year of the requested new project period
Form 2: Proposed Staff Profile for first Year, include any anticipated changes within the project period.
Form 3: Income Analysis Format for first Year of the proposed project
BODY OF APPLICATION	60-70
Program Narrative
Health Care Plan
Business Plan
REQUIRED ATTACHMENTS	50-60
Form 4: Community Characteristics
Form 5, Part A: Services Provided
Form 5, Part B: Service Sites
Form 5, Part C: Other Activities/Locations
Form 6, Part A: Current Board Member Characteristics
Form 6, Part B: Request for Waiver of Governance Requirements, if applicable
Form 7: Compliance Checklist
Organization Chart and Service Area amp
Corporate Bylaws
Job or Position Description for Key Personnel, optional
Biographical Sketches for Key Personnel
Co-Applicant Agreement, if applicable
Other contracts, agreements, etc. as applicable or required
Most recent independent financial audit specifically including all management letter and balance sheets
Articles of Incorporation (seal page only)
Internal Revenue Service (IRS) Tax Exempt Certification for the Applicant, OR, if the Applicant is a public entity, the Co-Applicant Board, new organizations only
Letters of Support
Other Relevant Documents, *optional*

DOCUMENTS

AVAILABLE ON SITE

MANAGEMENT AND FINANCE

Personnel Policies and Procedures

Data Collection and Information Systems

Schedule of discounts (Sliding Fee Schedule) (If Applicable)

Agreements with Medicaid and Medicare

Billing and Collection Policies and Procedures

Procurement Policies and Procedures

Travel Policies

Fee Schedule

Accounting Policies and Procedures Manual

Documentation of FQHC rates

Contracts with Agencies, Vendors, etc.

CLINICAL PROGRAM

Patient Confidentiality Policy and Procedures

Principles of Practice (As applicable)

List of Non-Physician Supervision Protocols

Health Maintenance Protocols by Age Group

Other Clinical Protocols (Provide List)

Continuing Professional Education Policies

Patient Flow

Sample Medical Record

Clinical Information and Tracking Systems

Patient Grievance Policy and Procedure

Quality Management and/or Assurance Plan

Malpractice Coverage and/or FTCA Deeming/Malpractice Coverage

OSHA Documents

CLIA Documents

Credentialing Policy and Procedures

NOTE: ADD ADDITIONAL PAGES, IF NEEDED

SAMPLE: FORM 5 - PART C

OTHER ACTIVITIES/LOCATIONS*

Please see definition of service site on p. 44 to determine those activities or locations that should be listed on this Form. Service sites should be listed on Form 5-Part B.

ACTIVITY/LOCATION #1	ACTIVITY/LOCATION #2
TYPE/DESCRIPTION OF ACTIVITY: TYPE OF LOCATION(S) WHERE ACTIVITY IS CONDUCTED:	TYPE/DESCRIPTION OF ACTIVITY: TYPE OF LOCATION(S) WHERE ACTIVITY IS CONDUCTED:
ACTIVITY/LOCATION #3	ACTIVITY/LOCATION #4
TYPE/DESCRIPTION OF ACTIVITY: TYPE OF LOCATION(S) WHERE ACTIVITY IS CONDUCTED:	TYPE/DESCRIPTION OF ACTIVITY: TYPE OF LOCATION(S) WHERE ACTIVITY IS CONDUCTED:
ACTIVITY/LOCATION #5	ACTIVITY/LOCATION #6
TYPE/DESCRIPTION OF ACTIVITY: TYPE OF LOCATION(S) WHERE ACTIVITY IS CONDUCTED:	TYPE/DESCRIPTION OF ACTIVITY: TYPE OF LOCATION(S) WHERE ACTIVITY IS CONDUCTED:

*Current grantees may NOT request support of a new site under this application. See PIN 2002-07 for information to submit a Change of Scope.

FORM 6 – PART A: CURRENT BOARD MEMBER CHARACTERISTICS

BOARD MEMBER NAME	BOARD OFFICE HELD	AREA OF EXPERTISE	INDICATE IF USER OF HEALTH CENTER SERVICES (YES/NO)	LIVE (L) OR WORK (W) IN SERVICE AREA	YEARS OF CONTINUOUS BOARD SERVICE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Indicate # Board Members by Sex: F = _______ M = ______

Indicate # Board Members by Race/Ethnicity:

White: _______ Hispanic or Latino: _______ Black/African American: ______

Asian/Pacific Islander______ American Indian & Alaska Native:_____

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

(2) MHC, HCH, and/or PHPC applicants requesting a waiver of the governance requirements must complete Form 6 – Part B and describe any alternative arrangement for addressing Board requirements including the mechanism for receiving consumer input.

(3) Tribal entities are exempt from Governance Requirements.

(4) Add additional pages, if needed.

FORM 6 - PART B

REQUEST FOR WAIVER OF GOVERNANCE REQUIREMENTS

For health centers that are seeking support for MHC, HCH, or PHPC Only as Necessary. REQUESTS FOR WAIVERS WILL NOT BE GRANTED IF APPLICANT ALSO RECIEVES OR IS APPROVED FOR CHC OF SBHC FUNDING,

Name of Organization: _______________________________________

Name of Sponsoring Organization (if different): _______________________________________

If existing grantee with Waiver Approval:

1. Date of Original Governance Waiver Request: _______________________________________

2. Date of Waiver Approval by BPHC Director: _______________________________________

3. Date of Most Recent approval of

Continuation of Waiver Request (if different): ______________________________________

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

___ Monthly Meetings

5. Are you requesting the waiver be continued? ___ Yes (Complete questions 1. and 2. below)

___ No (Governing Board is in Full Compliance)

If Yes, is your waiver request based on arrangements that are different from your original request? ___ Yes ___ No

Progress made toward meeting full compliance?

____________________________________________________________________________________________________________________________________________________________________

Nature of Items for New Waiver Request: ___ 51 Percent User Majority

___ Monthly Meetings

All organizations Requesting Waiver:

Describe below the arrangements that are in place to assure appropriate user input and involvement is achieved, as well as plans for achieving compliance. Use additional space as needed. (See PIN 98-12 for additional guidance).

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________ _______________________

Signature of CEO or other Authorized Representative Date

FORM 7 – COMPLIANCE CHECKLIST

Page 1 of 2

		YES	NO
1.	Is the applicant organization a non-profit or public entity?
2.	Does the applicant organization demonstrate the need for primary health care services in the community(ies) that make up its service area based on geographic, demographic, and economic factors?
3.	Does the applicant organization serve, in whole or in part, a designated MUA or MUP? (Requested, not required for HCH, PHPC or MHC applicants)
4.	Does the applicant organization have a system of care that contributes to the availability, accessibility, quality, comprehensiveness and coordination of health services in the service area?
5.	Does the applicant organization provide ready access for all persons to all of the required primary, preventive and supplemental health services, including oral health care, mental health care and substance abuse services without regard to ability to pay either directly on-site or through established arrangements?
6.	Does the applicant organization provide all additional health services as appropriate and necessary?
7.	Does the applicant organization have patient case management services (including counseling, referral and follow-up services) designed to assist health center patients in establishing eligibility for and gaining access to Federal, State and local programs that provide or financially support the provision of medical, social, educational or other related services?
8.	Does the applicant organization collaborate appropriately with other health and social service providers in their area?
9.	Are all contracted services (including management agreements, administrative services contracts, etc.) under the governance, administration, quality assurance and clinical management policies of the applicant organization?
10.	Does the applicant organization arrange referrals to providers as may be appropriate to assure ready access for all persons to all of the required primary, preventive and supplemental health services without regard to ability to pay?
11.	Are all services available to all persons in the service area or target population regardless of age, gender, or the patient’s ability to pay?
12.	Does the applicant organization maintain a core staff of primary care providers appropriate for the population served?
13.	Are the primary care providers working at the health center licensed to practice in the State where the center is located?
14.	Have all providers been properly credentialed and privileged according to PINs 99-08 and 2001-11?
15.	Do the applicant organization’s physicians have admitting privileges at their referral hospital(s), or other such arrangement to ensure continuity of care?
16.	Does the applicant organization use a charge schedule with a corresponding discount schedule based on income for persons between 100 percent and 200 percent of the Federal poverty level?
17.	Is the health center open to provide services at the times that meet the needs of the majority of potential users?

FORM 7 – COMPLIANCE CHECKLIST

Page 2 of 2

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

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

Signature of Governing Board Chairperson Date

Printed Name

ALABAMA
Al Fox
AL Primary Health Care Association
6008 E. Shirley Lane, Suite A
Montgomery, AL 36117
334-271-7068; 334-271-7069
AFOX@ALPHCA.COM

ALASKA
Marilyn Kasmar, RNC, MBA
Alaska Primary Care Assn., Inc.
903 W. Northern Lights Blvd., Suite 105
Anchorage, AK 99503
907-929-2722; 907-929-2734
MARILYN@ALASKAPCA.ORG

ARIZONA
Joseph Coatsworth
Arizona Assn. of CHC, Inc.
320 E. McDowell Street, Suite 225
Phoenix, AZ 85004
602-253-0090; 602-252-3620
COATSWORTH@AACHC.ORG

ARKANSAS
Sip B. Mouden
CHCs of Arkansas, Inc.
420-A West 4th Street
North Little Rock, AR 72113
501-374-8225; 501-374-9734
SBMOUDEN@CHC-AR.ORG

CALIFORNIA
Carmela Castellano
CA Primary Care Assn.
1215 K Street, Suite 700
Sacramento, CA 95814
916-440-8170; 916-440-8172
CCASTELLANO@CPCA.ORG

COLORADO
Annette Kowal
CO Community Health Network
800 Grant, Suite 505
Denver, CO 80203
303-861-5165 ex 228; 303-861-5315
ANNETTE@CCHN.ORG

COLORADO
Julie Hulstein
Comm. Health. Assoc. Mtn./Plains (CHAMPS)
800 Grant Street, Suite #505
Denver, CO 80203
303-861-5165 ex 226; 303-861-5315
JULIE@CHAMPSONLINE.ORG

CONNECTICUT
Evelyn Barnum
CT Primary Care Association
90 Brainard Road, Suite 101
Hartford, CT 06114-1685
860-727-0004; 860-727-8550
EBARNUM@CTPCA.ORG

DISTRICT OF COLUMBIA
Sharon Baskerville
DC PCA
1411 K Street, NW, Suite 400
Washington, DC 20005
202-638-0252; 202-638-4557
SBASKERVILLE@DCPCA.ORG

FLORIDA
Andrew Behrman, Executive Director
Florida Assn. of Comm. Health
1203 Governor Sq. Blvd., Suite 202
Tallahassee, FL 32301
850-942-1822; 850-942-9902
ANDREWBEHRMAN@FACHC.ORG

GEORGIA
Duane Kavka, Executive Director
GA Assn. for Primary Health Care, Inc.
44 Broad Street, NW, Suite 410
Atlanta, GA 30303
404-659-2861; 404-659-2801
DKAVKA@GAPHC.ORG

HAWAII
Beth Giesting
HI Primary Care Association
345 Queens Street, Suite 601
Honolulu, HI 96813-4718
808-536-8442; 808-524-0347
BGIESTING@HAWAIIPCA.NET

IDAHO
Bill Foxcroft
Idaho PCA
1276 W. River Street, Suite 202
Boise, ID 83702
208-345-2335; 208-386-9945
BILLF@IDAHOPCA.ORG

ILLINOIS
Bruce Johnson
Illinois PHCA
225 S. College, Suite 200
Springfield, IL 62704
217-541-7305; 217-541-7306
BJOHNSON@IPHCA.ORG
WWW.IPHCA.ORG

INDIANA
G. Eric Carpenter
Indiana PHCA, Inc.
1006 E. Washington Street, Suite 200
Indianapolis, IN 46202
317-630-0845; 317-630-0849
ECARPENTER@ORI.NET

IOWA-NEBRASKA
Theodore Boesen, Jr.
Iowa-Nebraska, PCA
601 E. Locust Street, Suite 102
Des Moines, IA 50309
515-244-9610; 515-243-3566
IANEPCA@AOL.COM

KANSAS
Judy Eyerly
KS Assn./The Medically Underserved
112 SW 6th Street, Suite 202
Topeka, KS 66603
785-233-8483; 785-233-8403
JEYERLY@KSPCA.ORG

KENTUCKY
Joseph E. Smith
Kentucky PCA
226 W. Main Street, 2nd Floor
Frankfort, KY 40602
502-227-4379; 502-223-7654
JESMITH@FEWPB.NET
KPCA@FEWPB.NET

LOUISIANA
Rhonda Litt, Interim
Louisiana PCA Inc.
P.O. Box 966
Baton Rouge, LA 70821-0966
225-383-8677; 225-383-8678 RHONDA@LPCA.NET

MAINE
Kevin Lewis
Maine Primary Care Association
73 Winthrop Street
Augusta, ME 04330
207-621-0677; 207-621-0577
KALEWIS@MEPCA.ORG

MARYLAND/DELAWARE
Miguel Mcinnis, MPH
MACHC
4483-B Forbes Boulevard
Forbes Center Building II
Lanham, MD 20706
301-577-0097; 301-577-4789
MIGUEL.MCINNIS@MACHC.COM

MASSACHUSETTS
Jim Hunt
Massachusetts League of CHCs
100 Boyston Street, Suite 700
Boston, MA 02116
617-426-2225; 617-426-0097
JHUNT@MASSLEAGUE.ORG

MICHIGAN
Kim Sibilsky
Michigan PCA
2525 Jolly Road, Suite 280
Okemos, MI 48864
517-381-8000; 517-381-8008
KSIBILSKY@MPCA.NET

MINNESOTA
Rhonda Degelau, Executive Director
Minnesota PCA, Inc.
1113 E. Franklin Ave, Suite 211
Minneapolis, MN 55404
612-253-4175; 612-872-7849
RHONDA.DEGELAU@MNPCA.NET

MISSISSIPPI
Robert Pugh
Mississippi PHCA
6400 Lakeover Road, Suite A
Jackson, MS 39213
601-981-1817; 601-981-1217
RMPUGH@MPHCA.COM

MISSOURI
Joseph Pierle
MO Coalition For PHC & Heartland
3325 Emerald Lane
Jefferson City, MO 65109
573-636-4222; 573-636-4585
JPIERLE@MO-PCA.ORG
WWW.MO-PCA.ORG

MONTANA
Alan Strange, Ph.D.
Montana PCA
900 N. Montana Ave., Suite 3b
Helena, MT 59601
406-442-2750; 406-449-2460
ASTRANGE@MTPCA.ORG

NEVADA
Roger Volker, Executive Director
Great Basin PCA
515 W. 4th Street
Carson City, NV 89703
775-887-0417 ex 101; 775-887-3562
VOLKER@GBPCA.ORG
WWW.GBPCA.ORG

NEW HAMPSHIRE/VERMONT
Tess Stack Kuenning
NH Bi-State
3 South Street
Concord, NH 03301
603-228-2830; 603-228-2464
TKUENNING@BISTATEPCA.ORG

NEW JERSEY
Katherine Grant-Davis
New Jersey
14 Washington Road, Suite 211
Princeton Junction, NJ 08550-1030
609-275-8886; 609-936-7247
NJPCA2@AOL.COM

NEW MEXICO
David Roddy
New Mexico PCA
4545 McLeod, NE, Suite D
Albuquerque, NM 87109
505-880-8882; 505-880-8885
DRODDY@NMPCA.ORG

NEW YORK
Sheila Kee, Executive Director
CHC Assn. of NY State, Inc.
254 W. 31st Street, 9th
New York, NY 10001
212-279-9686, ex 656; 212-279-3851
SKEE@CHCANYS.ORG

NORTH CAROLINA
Sonya Bruton
North Carolina PHCA
875 Walnut Street, Suite 150
Cary, NC 27511
919-469-5701; 919-469-1263
BRUTONS@NCPHCA.ORG

NORTH DAKOTA
Janelle Johnson
ND Branch Office CHCA
P.O. Box 1734
Bismarck, ND 58502-1734
701-221-9824; 701-258-3161
JANELLE@COMMUNITYHEALTHCARE.NET

OHIO
Joseph Doodan
Ohio PCA
51 Jefferson Ave
Columbus, OH 43215-3840
614-224-1440; 614-224-2320
JDOODAN@OHIOPCA.ORG

OKLAHOMA
Greta Shepherd-Stewart, MPH
Oklahoma Primary Care Assn.
4300 N. Lincoln Blvd., Suite 203
Oklahoma City, OK 73105-5106
405-424-2282 ex 101; 405-242-1111
GSHEPHERD@OKPCA.ORG
OREGON
Craig Hostetler, Executive Director
Oregon PCA
812 SW 10th Ave., Suite 204
Portland, OR 97205
503-228-8852; 503-228-9887
CHOSTETLER@NORTHWEST.COM
WWW.ORPCA.ORG

PENNSYLVANIA
Henry Fiumelli
Pennsylvania Forum for PHC
1035 Mumma Road, Suite 1
Wormleysburg, PA 17043-1147
717-761-6443; 717-761-8730
HENRY@PAFORUM.COM

PUERTO RICO
Alicia Suárez, M.A., Exe. Dir.
Asociacion De Salud Primaria
De Puerto Rico, Inc.
Edificio La Euskalduna
Calle Navarro #56
Hato Rey, PR 00918
787-758-3411; 787-758-1736
ACSPPR@COQUI.NET
WWW.SALUDPRIMARIAPR.ORG

RHODE ISLAND
Kerrie Jones Clark
Rhode Island HCA
235 Promenade Street, Suite 104
Providence, RI 02908
401-274-1771; 401-274-1789
KCLARK@RIHCA.ORG

SOUTH CAROLINA
Lathran Woodard
South Carolina PHCA
2211 Alpine Road Extension
Columbia, SC 29223
803-788-2778; 803-788-8233
LATHRAN@SCPHCA.ORG

SOUTH DAKOTA
Scot Graff
Community Health Care Assn., Inc.
1400 W. 22nd Street
Sioux Falls, SD 57105-1570
605-357-1515; 605-357-1510
SGRAFF@USD.EDU

TENNESSEE
Kathy Wood-Dobbins
Tennessee PCA
210 25th Avenue North, Suite 1112
Nashville, TN 37203
615-329-3836, ex16; 615-329-3823
KATHY@TNPCA.ORG

TEXAS
Jose Camacho
TACHC, Inc.
2301 S. Capital Of Texas Hwy, Building
Austin, TX 78746
512-329-5959; 512-329-9189
JCAMACHO@TACHC.ORG

UTAH
Bette Vierra
Association/Utah Community Health
2570 West 1700 South, Suite 153
Salt Lake City, UT 84104
801-974-5522; 801-974-5563
BETTEVIERRA@AUCH.ORG

VERMONT/ NEW HAMPSHIRE
Tess Stack Kuenning
VT Bi-State
61 Elm Street
Montpellier, VT 05602-2818
802-229-0002; 802-223-2336
TKUENNING@BISTATEPCA.ORG

VIRGINIA
Neal Graham
Virginia PCA, INC.
10800 Midlothian Turnpike, Suite 265
Richmond, VA 23235
804-378-8801 ex 17; 804-379-6593
NGRAHAM@VPCA.COM

WASHINGTON
Gloria Rodriguez
WA Association of CMHC
19226 66th Avenue South, Suite L-102
Kent, WA 98032
425-656-0848; 425-656-0849
GROD@WACMHC.ORG

WA NORTH WEST REGIONAL
Marcia Miller
North West Regional PCA
6512 23rd Avenue, NW, Suite 305
Seattle, WA 98117
206-783-3004; 206-783-4311
MMMILLER@NWRPCA.ORG

WEST VIRGINIA
Jill Hutchinson, Executive Director
West Virginia PCA, Inc.
1219 Virginia Street, East
Charleston, WV 25301
304-346-0032; 304-346-0033
BENOIT32@AOL.COM
WWW.WVPCA.ORG

WISCONSIN
Sarah Lewis
WI Primary Health Care Assn.
49 Kessel Court, Suite 210
Madison, WI 53711
608-277-7477; 608-277-7474
SVLEWIS@WPHCA.ORG

WYOMING
Sharon Montagnino
Executive Director
Wyoming Primary Care Assn.
P.O. Box 113
Cheyenne, WY 82003
307-632-5743; 307-638-6103
WYPCA@WYPCA.ORG
WWW.WYPCA.ORG

ALABAMA
Clyde Barganier, DrPH
AL Dept. of Public Health
Bureau of Planning & Resource Dev.
P.O. Box 303017
Montgomery, AL 36130-3017
334-206-5396; 334-206-5434
CBARGANIER@ADPH.STATE.AL.US

ALASKA
Patricia Carr, MPH, Unit Manager
AK Dept of Health & Social Services
P.O. Box 110616
Juneau, AK 99811-0616
907-465-8618; 907-465-6861
PAT_CARR@HEALTH.STATE.AK.US

ARIZONA
Patricia Tarango
AZ Dept. of Health Service
1740 W. Adams, Rm 302
Phœnix, AZ 85007
602-542-1219; 602-542-2011
PTARANG@HS.STATE.AZ.US

ARKANSAS
Bill Rodgers
AR Dept. of Health
Division of Public Health
4815 W. Markham Street, Slot 22
Little Rock, AR 72202
501-661-2244; 501-280-4706
WRODGERS@HEALTHYARKANSAS.COM

CALIFORNIA
Earl Green
Office/Statewide Health Planning & Dev.
1600 9th Street, Room 440
Sacramento, CA 95814
916-654-2087; 916-654-3138
EGREEN@OSHPD.STATE.CA.US

COLORADO
Diane Brunson
CO Dept. of Health
4300 Cherry Creek Drive
Denver, CO 80246-1530
303-692-2369; 303-782-5576
DIANE.BRUNSON@STATE.CO.US

CONNECTICUT
Beth Weinstein
CT State Dept. of Public Health
Family Health Division
410 Capitol Avenue, MS #22apv
Hartford, CT 06134-0308
860-509-7832; 860-509-7720
BETH.WEINSTEIN@PO.STATE.CT.US

DELAWARE
Kathy Collison
DE State Dept. Of Health
P.O. Box 637
Dover, DE 19903
302-739-4787; 302-739-6653
KCOLLISON@STATE.DE.US

DISTRICT OF COLUMBIA
Marcia Harrison
DC Dept. of Health
Office of Health Planning & Develop.
825 N. Capitol St., NE, Rm. 3173
Washington, DC 20002
202-442-5875; 202-442-4824
MARCIA.HARRISON@DC.GOV

FLORIDA
Kathy Winn
Div./ EMS & Comm. Health Resources
2020 Capital Circle SE, BIN#C15
Tallahassee, FL 32388-1735
850-245-4446 ex 2709; 850-922-6296
KATHY_M_WINN@DOH.STATE.FL.US

GEORGIA
Isiah Lineberry
GA Dept. of Community Health
Office of Rural Health Services
P.O. Box 310
Cordele, GA 30315
229-401-3085; 229-401-3077
ILINEBERRY@DCH.STATE.GA.US

HAWAII
Charlene Gaspar
HI State Dept. of Health,
Family Health Ctrs.
3652 Kilauea Avenue
Honolulu, HI 96816
808-733-9017; 808-733-8369
CHARLENE.GASPAR@FHSD.HEALTH.STATE.HI.US

IDAHO
Laura Rowen
ID Primary Care Program
P.O. Box 83720
Boise, ID 83720-0036
208-334-5993; 208-332-7262
ROWENL@IDHW.STATE.ID.US

ILLINOIS
Mary Ring
Illinois Dept. of Health
535 W. Jefferson Street
Springfield, IL 62761
217-782-1624; 217-782-2547
MRING@IDPH.STATE.IL.US

INDIANA
Raymond Guest
Indiana State Dept. of Health
2 N. Meridian Street, 8th Floor
Indianapolis, IN 46204
317-233-7827; 317-233-7761
RGUEST@ISDH.STATE.IN.US

IOWA
Carl Kulczyk
IA Dept. /Public Health, Health Dept.
321 E. 21st Street
Des Moines, IA 50319
515-281-7223; 515-242-6384
CKULCZYK@IDPH.STATE.IA.US

KANSAS
Barbara Gibson
KS Dept. of Health & Environment
Curtis State Office Building
1000 SW Jackson, Rm 1051-S
Topeka, KS 66612-1290
785-296-1200; 785-296-1231
BGIBSON@KDHE.STATE.KS.US

KENTUCKY
Danise Newton
KY State Department of Health
275 E. Main Street
Frankfort, KY 40621
502-564-8966; 502-564-6533
DANISE.NEWTON@MAIL.STATE.KY.US

LOUISIANA
Robert Showers
LA Dept of Health & Hosp.
Office of Mgmt
1201 Capitol Access Rd., 3rd Fl., Bin 30
Baton Rouge, LA 70821
225-342-2256; 225-342-5839
RSHOWERS@DHH.STATE.LA.US

MAINE
Sophie Glidden, Director
ME Dept. of Human Services
Office of Rural Health & Primary Care
35 Anthony Ave., Station #11
Augusta, ME 04333-0011
207-624-5424; 207-287-5431
SOPHIE.E.GLIDDEN@STATE.ME.US

MARYLAND
Antoinette Coward
MD Dept./ Health & Mental Hygiene
Primary Care Unit
201 W. Preston Street
Baltimore, MD 21201
410-767-5602; 410-333-7501
COWARDA@DHMH.STATE.MD.US

MASSACHUSETTS
Catharine Sibble
MA Dept. of Public Health
250 Washington Street, 5th
Boston, MA 02108-4619
617-624-6043; 617-624-6062
CATHARINE.SIBBLE@STATE.MA.US

MICHIGAN
Lonnie Barnett
MI Dept./Comm. Hlth, Hlth Leg. & Pol. Deve.
320 S. Walnut Street
Lansing, MI 48913
517-241-2963; 517-241-0084
BARNETTL@MICHIGAN.GOV

MINNESOTA
Sheila Brunelle
MN Dept. Of Health, Orhpc
P.O.Box 64975
St. Paul, MN 55164-0975
651-282-3853; 651-297-5808
SHEILA.BRUNELLE@HEALTH.STATE.MN.US

MISSISSIPPI
Perelia Taylor
MS State Dept. of Health
Office of Primary Liaison
P.O. Box 1700
Jackson, MS 39215-1700
601-576-7216; 601-576-7230
PTAYLOR@MSDH.STATE.MS.US

MISSOURI
Harold Kirbey
MO Dept. of Health, Div. of Hlth Resources
P.O. Box 570
Jefferson City, MO 65102
573-751-6272; 573-526-4102
KIRBEH@MAIL.HEALTH.STATE.MO.US

MONTANA
Marge Levine
MT Dept. Public Health Human Svcs
P.O. Box 202951
Helena, MT 59620-2951
406-444-4748; 406-444-1861
MLEVINE@STATE.MT.US

NEBRASKA
Thomas Rauner
NE Dept of Health,
Office of Rural Health
P.O. Box 95007
Lincoln, NE 68509
402-471-0148; 402-471-0180
THOMAS.RAUNER@HHSS.STATE.NE.US

NEVADA
Judy Wright, Acting
NV Dept. of Human Resources
505 E. King Street, Rm 203
Carson City, NV 89701-3711
775-684-4220; 775-684-4046
JWRIGHT@NVHD.STATE.NV.US

NEW HAMPSHIRE
Bryan Ayars
NH Primary Care Services
6 Hazen Drive
Concord, NH 03301-6527
603-271-4741; 603-271-4506
BAYARS@DHHS.STATE.NH.US

NEW JERSEY
Linda Anderson
Family/Comm Health Svcs, Cap. Plaza
50 E. State Street
Trenton, NJ 08625-0364
609-292-1495; 609-292-9599
LANDERSON@DOH.STATE.NJ.US

NEW MEXICO
Harvey Licht
NM Dept. of Health/Public Health Div.
P.O. Box 26110
Santa Fe, NM 87502-6110
505-827-0642; 505-827-0924
HARVEY.LICHT@ACCESS.GOV

NEW YORK
Barry Gray
Workforce Planning, Policy/ Resources Dev.
E.S.P. Corning Tower, Rm. 1084
Albany, NY 12237-0053
518-473-4700; 518-474-0572
BMG01@HEALTH.STATE.NY.US

NORTH CAROLINA
Tom Tucker
Office /Rural Health & Resources, Deve.
311 Ashe Avenue
Raleigh, NC 27606
919-733-2040; 919-733-8300
TOMTUCKER@MINDSPRING.COM

NORTH DAKOTA
Gary Garland
ND Dept. of Health
Office of Community Assistance
600 E. Boulevard Avenue
Bismarck, ND 58505-0200
701-328-4839; 701-328-1890
GGARLAND@STATE.ND.US

OHIO
Joel Mariotti
OH Dept./Health Office of Rural Health
246 N. High Street, 6th Floor
Columbus, OH 43215
614-644-8508; 614-644-9850
JMARIOTT@GW.ODH.STATE.OH.US

OKLAHOMA
Michael Brown
OK State Dept. of Health
1000 NE 10th Street, Room 1113
Oklahoma City, OK 73117-1229
405-271-8428; 405-271-1225
MIKEBR@HLTH.STATE.OK.US

OREGON
Joel Young, Manager
Office of Comm Services, OR Hlth Div
800 NE Oregon Street, Suite 930
Portland, OR 97232
503-731-4017; 503-731-4078
JOEL.YOUNG@STATE.OR.US

PENNSYLVANIA
Joseph May
PA Department of Health
P.O. Box 90, Room 709
Harrisburg, PA 17108
717-772-5298; 717-705-6525
JMAY@STATE.PA.US

PUERTO RICO
Nadia Gardana
PR Dept. of Health, Office of Fed. Affairs
P.O. Box 70139
San Juan, PR 00936-8139
787-274-7735; 787-759-6552
NGARDANA@SALUD.GOV.PR

RHODE ISLAND
Mary Ann Miller
RI Dept. of Health, Preventive Health Svcs
3 Capitol Hill, Rm. 408
Providence, RI 02908
401-222-1171; 401-222-4415
MARYANNEM@DOH.STATE.RI.US

SOUTH CAROLINA
Mark Jordan
SC DHEC Office of Primary Care
P.O. Box 101106
Columbia, SC 29211
803-898-0766; 803-898-0445
JORDANMA@DHEC.STATE.SC.US

SOUTH DAKOTA
Bernard Osberg, Director
SD Dept./ Health, Office of Rural Health
445 E. Capitol
Pierre, SD 57501
605-773-3364; 605-773-5904
BERNIEO@DOH.STATE.SD.US

TENNESSEE
Susan Veale
Health Access & Rural Health, Tdh
710 Hart Lane
Nashville, TN 37247
615-227-7070; 615-262-6139
SVEALE@MAIL.STATE.TN.US

TEXAS
Connie Berry, Manager
TX Primary Care Office
1110 W. 49th Street
Austin, TX 78756
512-458-7518; 512-458-7235
CONNIE.BERRY@TDH.STATE.TX.US

UTAH
Marilyn Haynes-Brokopp
Bureau/Primary Care & Rural Health
P.O. Box 142005
Salt Lake City, UT 84114-2005
801-538-6113; 801-538-6387
MBROKOPP@DOH.STATE.UT.US

VERMONT
Craig Stevens
VT Dept. of Health
P.O. Box 70
Burlington, VT 05402-0070
802-863-7606; 802-651-1634
CSTEVEN@VDH.STATE.VT.US

VIRGIN ISLANDS
Alric Simmonds, Deputy Chief of Staff
VI PCO
21-22 Kongens Gade
Government House
St. Thomas, VI 00802
340-693-4315; 340-693-4374
AVSIMMONDS@YAHOO.COM

VIRGINIA
Bunny Caro-Justin
VA Dept. of Health
Center of Primary Care/Rural Health
1500 E. Main Street, Suite 227
Richmond, VA 23219
804-786-4767; 804-371-0116
BCARO-JUSTIN@VDH.STATE.VA.US

WASHINGTON
Mary Looker
WA Department of Health
Office of Community & Rural Health
P.O. Box 47834
Olympia, WA 98504-7834
360-705-6764; 360-664-9273
MARY.LOOKER@DOH.WA.GOV

WEST VIRGINIA
Nancye Bazzle
Div. of Primary Care, OCRHS, BPH
350 Capitol Street, Room. 515
Charleston, WV 25301-3716
304-558-4007; 304-558-1437
NANCYEBAZZLE@WVDHHR.ORG

WISCONSIN
Char White
WI Dept. of Health,
Div. of Public Health
P.O. Box 2659
Madison, WI 53701-2659
608-267-7735; 608-267-2832
WHITECA@DHFS.STATE.WI.US

WYOMING
Gerald Bronnenberg,
Douglas Thiede
WY Dept. of Health, PCO
2020 Carey Avenue, 5th Floor
Cheyenne, WY 82002
307-777-6918; 307-777-7127
GBRONN@STATE.WY.US
DTHIED@STATE.WY.US

Project Period Ending:	Application deadline:

October 31, 2004	September 1, 2004
November 30, 2004
December 31, 2004
January 31, 2005
February 28, 2005
March 31, 2005	October 25, 2004
May 31, 2005	January 3, 2005
June 30, 2005
August 31, 2005

Project Period ENDING:	Application deadline is:

October 31, 2004	August 16, 2004
November 30, 2004
December 31, 2004
January 31, 2005	September 1, 2004
February 28, 2005	September 1, 2004
March 31, 2005	October 25, 2004
May 31, 2005	January 3, 2005
June 30, 2005
August 31, 2005

	TOTAL section 330 Federal Funding Requested	TOTAL Annual Budget
Year 1
Year 2
Year 3
Year 4*
Year 5*

	CURRENT USERS	CURRENT ENCOUNTERS
General Community
Migrant/Seasonal Farmworkers
Public Housing Residents
Homeless Persons
School-based health center users
TOTAL

UNDUPLICATED COUNTS	CURRENT NUMBERS
Medical Users
Medical Encounters
Dental Users
Dental Encounters
Mental Health Users
Mental Health Encounters
Substance Abuse Service Users
Substance Abuse Service Encounters

Service Area Competition (including all competing continuations) Funding for the
Consolidated Health Center Program
HRSA 05-086
New and Competing Continuation Grants
Catalog of Federal Domestic Assistance (CFDA) No. 93.224
Program Guidance

Fiscal Year 2005

“Sample ” Budget Justification

Guidelines for Health Care and Business Plans

ATTACHMENT A:

PROGRAM SPECIFIC FORMS

NOTE: ADD ADDITIONAL PAGES, IF NEEDED

PROVIDER TYPE	CURRENT NUMBER of PROVDERS
TOTAL FTE Medical Providers (Physicians, Nurse Practitioners, Physicians Assistants, etc.)
TOTAL FTE Dental Providers (Dentists and hygienists)
TOTAL FTE Mental Health Providers (Psychiatrists, psychologists, MSWs, etc.)
TOTAL FTE Substance Abuse Service Providers

PERSONNEL BY CATEGORY	TOTAL FTEs PROPOSED { a }	ANNUAL SALARY OF POSITION { b }	TOTAL SALARY { a * b }
PERSONNEL BY CATEGORY	(All sites included in Form 5 – Part B)	ANNUAL SALARY OF POSITION { b }	TOTAL SALARY { a * b }
ADMINISTRATION
Executive Director
Finance Director
Chief Operating Officer
Administrative Support Staff
MEDICAL STAFF
Medical Director
Family Practitioners
General Practitioners
Internists
OB/GYNs
Pediatricians
Psychiatrists
Other Specialty Physicians (attach list by type)
Physician Assistants/Nurse Practitioners
Certified Nurse Midwives
Nurses (RNs)
Pharmacist
Other Medical Personnel (attach list by type)
Laboratory Personnel
X-ray Personnel
Clinical Support Staff
DENTAL STAFF
Dentists
Dental Hygienists
Dental Assistants, Aides, Technicians
MENTAL HEALTH STAFF
Mental Health Specialists
Substance Abuse Specialists
Case Managers
Other Professional Personnel
OTHER STAFF
Patient Education Specialist
Homemaker/Aide
Outreach
Other Enabling
Other staff

PAYOR CATEGORY	NUMBER OF VISITS	AVERAGE CHARGE PER VISIT	TOTAL CHARGES *(a b)**	AVERAGE ADJUSTMENT PER VISIT	AMOUNT BILLED *[c-(ad)]**	COLLECTION RATE (%)	PROJECTED INCOME *(e f)**	ACTUAL ACCRUED INCOME (most recent 12 months)
PAYOR CATEGORY	(a)	(b)	(c)	(d)	(e)	(f)	(g)	(h)
FEE FOR SERVICE
Medicaid: Fee for Services
Medicaid: EPSDT
Medicaid: Capitated
Subtotal: Medicaid
Medicare: Fee for Services
Medicare: Capitated
Subtotal: Medicare
Private Insurance
Self-Pay: 100 percent
Self-Pay: Sliding Fee Scale
Self-Pay: 0 percent
Other: Capitation
Other: Contracts
SUB-TOTAL
OTHER INCOME
Contributions/Donations
Fund Raising
330 BPHC Grant
Other Federal Grants
State Grants
Local Support
Foundation Grants
Other
GRAND TOTAL

	CHARACTERISTIC	COMMUNITY WIDE DATA # %	TARGET POPULATION DATA # %
RACE/ETHNICITY	White (non-Hispanic)
	Black or African-American (non-Hispanic)
	Hispanic
	American Indian or Alaskan Native
	Asian
	Native Hawaiian or Other Pacific Islander
	Other
	Total Population
INCOME AS A PERCENT OF POVERTY LEVEL	Below 100%
	100-199 percent
	200 percent and above
	Unknown
PRIMARY THIRD PARTY PAYMENT SOURCE	Medicaid/Capitated
	Medicaid/Not Capitated
	Medicare
	Other Public Insurance
	Private Insurance, including capitation
	None/Uninsured
SPECIAL POPULATIONS	Migrant/Agricultural worker
	Seasonal Agricultural worker
	Homeless People
	People with AIDS
	HIV-infected
	Substance Abuser
	Public Housing Residents
	Low Income School Children/Adolescents
	Other

APPLICANT’S NAME: LOCATION:
SERVICE TYPE		PROVIDED BY Applicant	BY REFERRAL/ Applicant PAYS	BY REFERRAL/ Applicant DOESN’T PAY	SERVICE TYPE		PROVIDED BY Applicant	BY REFERRAL/ Applicant PAYS	BY REFERRAL/ Applicant DOESN’T PAY
PRIMARY MEDICAL CARE SERVICES	General Primary Medical Care				OTHER SERVICES	Environmental Health
	Diagnostic Laboratory					Hearing Screening
	Diagnostic X-Ray					Nutrition (not WIC)
	Diagnostic Tests/Screens					Occ./Voc. Therapy
	Urgent Medical Care					Physical Therapy
	24-Hour Coverage					Pharmacy
	Family Planning					Podiatry
	HIV Testing					Vision Screening
	Immunizations					WIC
	Following Hospitalized Patients				ENABLING SERVICES	Case Management
OB/GYN CARE	Gynecological Care					Child Care
OB/GYN CARE	Obstetrical Care					Discharge Planning
SPECIALTY SERVICES	TB Therapy					Eligibility Assistance
	Other					Emp./Ed. Counseling
	Other					Food Bank/Meals
DENTAL SERVICES	Preventive					Health Education
	Restorative					Homemaker/Aide
	Emergency					Housing Assistance
	Other					Translation
MENTAL HEALTH SERVICES	Treatment/Counseling					Nursing Home and Other Placement
	Developmental Screening					Outreach
	24-Hour Crisis					Transportation
	Other Mental Health					Other:
	Substance Abuse					Other:
	Other Substance Abuse					Other:

SITE #1	SITE #2
G Year-Round G Seasonal Full-Time Part-Time # of hours per week services are available at the site: Date site was opened: Name of service site: Physical Address: City State Zip (9 digit required) Phone No. Fax No. Congressional District: County Name: Service Area: Urban/Rural/Sparsely Populated: Other HRSA Funding Sources:	G Year-Round G Seasonal Full-Time Part-Time # of hours per week services are available at the site: Date site was opened: Name of service site: Physical Address: City State Zip (9 digit required) Phone No. Fax No. Congressional District: County Name: Service Area: Urban/Rural/Sparsely Populated: Other HRSA Funding Sources:
SITE #3	SITE #4
G Year-Round G Seasonal Full-Time Part-Time # of hours per week services are available at the site: Date site was opened: Name of service site: Physical Address: City State Zip (9 digit required) Phone No. Fax No. Congressional District: County Name: Service Area: Urban/Rural/Sparsely Populated: Other HRSA Funding Sources:	G Year-Round G Seasonal Full-Time Part-Time # of hours per week services are available at the site: Date site was opened: Name of service site: Physical Address: City State Zip (9 digit required) Phone No. Fax No. Congressional District: County Name: Service Area: Urban/Rural/Sparsely Populated: Other HRSA Funding Sources:
SITE #5	SITE #6
G Year-Round G Seasonal Full-Time Part-Time # of hours per week services are available at the site: Date site was opened: Name of service site: Physical Address: City State Zip (9 digit required) Phone No. Fax No. Congressional District: County Name: Service Area: Urban/Rural/Sparsely Populated: Other HRSA Funding Sources:	G Year-Round G Seasonal Full-Time Part-Time # of hours per week services are available at the site: Date site was opened: Name of service site: Physical Address: City State Zip (9 digit required) Phone No. Fax No. Congressional District: County Name: Service Area: Urban/Rural/Sparsely Populated: Other HRSA Funding Sources:

Service Area Competition (including all competing continuations) Funding for the Consolidated Health Center Program HRSA 05-086 New and Competing Continuation Grants Catalog of Federal Domestic Assistance (CFDA) No. 93.224 Program Guidance Fiscal Year 2005

“Sample” Budget Justification

Guidelines for Health Care and Business Plans

ATTACHMENT A:

PROGRAM SPECIFIC FORMS

NOTE: ADD ADDITIONAL PAGES, IF NEEDED

Service Area Competition (including all competing continuations) Funding for the
Consolidated Health Center Program
HRSA 05-086
New and Competing Continuation Grants
Catalog of Federal Domestic Assistance (CFDA) No. 93.224
Program Guidance

Fiscal Year 2005

“Sample ” Budget Justification