The cover sheet provides basic identifying information about the grantee, its leadership and the address of its service delivery locations.
Grantee Legal Name; Address of Grantee Administrative Offices :
• Provide the legal name and address of the recipient of the BPHC grant. If administrative offices are located separately from the clinical service delivery locations, use the address of the administrative offices.
• Provide the 9-digit zip code. The zip code is separated into two cells. The first cell contains the first five digits and the second cell contains the last four digits.
CEO/Executive Director or Project Director :
• Provide the name of the CEO, Executive Director, or Project Director of the grantee organization. Public health departments, other public entities, or other very large organizations (e.g., universities or hospitals) should list the individual responsible for directing the BPHC-funded project.
• Provide the phone number and e-mail address of the CEO, Executive or Project Director. BPHC and/or its contractor will use this e-mail address to contact you during the UDS editing process and will send the feedback report to this address.
CMO/Clinical Director :
• Provide the name of the Clinical Director for the grantee organization. Organizations with both Medical and Dental Clinical Directors should list the Medical Director.
• Provide the phone number and e-mail address of the Clinical Director. BPHC and/or its contractor will use this e-mail address to contact you during the UDS process and will send the feedback report to this address.
Chairperson of the Governing Board, Health Officer, or Other Accountable Individual (e.g. Chair of the Board of Supervisors, President of the Board of Trustees, etc.):
• Provide the name of the Chair of the grantee organization's Governing Board. State and local health departments receiving grants that do not include requirements for a Governing Board (e.g., Health Care for the Homeless grantees) should provide the name of the State Health Officer or Local Health Officer or other accountable individual, as appropriate.
Grantee Contact Person:
• Provide the name of the grantee staff person with primary responsibility for preparing the UDS report (do not list consultants, contractors or contracted employees). Two names may be listed if they prepare separate tables, but the first name listed should be the one for whom the phone number is provided.
• Provide the address with 9-digit zip code, phone/fax numbers, including area code, and e-mail address for the Grantee Contact Person. BPHC and/or its contractor will use this e-mail address to contact you during the UDS editing process and will send the feedback report to this address.
School Health Coordinator:
• Provide the name of the grantee staff person with primary responsibility for any school based health center activities managed by the grantee, regardless of whether or not BPHC funding supports the activities. If a name is listed here, the UDS will expect a report on Table 4, Line 23: Total school based health center patients.
Homeless Program Coordinator:
• Provide the name of the grantee staff person with primary responsibility for any homeless program managed by the grantee, regardless of whether or not BPHC funding supports the activities. If a name is listed here, the UDS will expect a report on Table 4, Line 22: Total Homeless patients.
Public Housing Program Coordinator:
• Provide the name of the grantee staff person with primary responsibility for any public housing program managed by the grantee, regardless of whether or not BPHC funding supports the activities.
Medicaid Provider Billing Number :
• If your agency has a single billing number , which you use for all Medicaid billing, other than for a pharmacy, enter it here. If you have multiple service delivery sites, with separate Medicaid billing numbers, record those numbers in the site information grids. If each provider uses their own number, report one number only , usually the Clinic Director's, or lead clinician's, for each service delivery site.
Medicaid Pharmacy Number :
• If your agency has a single billing number that you use for all Medicaid pharmacy billing, enter it here. If you do not have a separate identifier for pharmacy services, enter your Medicaid medical provider number. If you have multiple pharmacies, and each has its own billing number, record the number in the site information grids.
Number of Service Delivery Sites :
• Report the total number of service delivery sites supported by BPHC grant(s) ( Include only sites in your current approved scope of project ). This must match the number of site information grids reported. Only report sites where the services delivered generate encounters. Do not include administration-only or other non-service delivery locations such as warehouses or garages or WIC-only sites.
Number of NHSC Assignees :
• Report the total number of National Health Service Corps Assignees working at your service delivery location(s) as of December 31 of the reporting period. This is a count of individuals, not adjusted for FTE basis. Include all providers currently associated with the NHSC, including those fulfilling Federal NHSC scholarship or loan-repayment obligations, State loan repayment obligations under the federal/State SLRP program, Ready Responders, and members of the Public Health Service Commissioned Corps. Do not count individuals that are no longer employed by you or who are no longer serving an NHSC related obligation as of December 31, even if they had participated in the past.
Grantee Participation in an Integrated Services Network:
• Check one box (only) for participation in a horizontal network, a vertical network, or both. Grantees that do not participate in a network will check 'No ISN Participation'. An integrated services network is defined as a group of safety net providers collaborating through the redesign of practices to integrate services, optimize patient outcomes, and/or negotiate managed care contracts on behalf of the participating collaborators. Vertical integration is the collaboration of different types of providers, such as health centers, specialists, and hospitals. Horizontal integration is the collaboration occurring across the same type of provider, i.e. integration with other health centers and/or primary care providers.
• Report if the network received Integrated Services Development Initiative (ISDI) funds from BPHC during the current year by checking the ISDI box. Check this box whether or not the grantee is the direct recipient of the funds and regardless of whether the grant may have expired during the year.
Federal Tort Claims Act (FTCA) :
• Check the box indicating whether or not you were 'deemed' under the FTCA for any portion of the reporting period. (Note: No FTCA decision is impacted by information included on the cover sheet - this is for reporting purposes only.)
Drug pricing participation :
• Check the box indicating whether or not you participated in the 340(b) drug pricing program during the reporting period, regardless of whether or not you are reporting that you participated in an "alternative drug pricing program."
• Check the box if you participate in an alternate drug pricing program, regardless of whether or not you are reporting that you participated in a "340(b) drug pricing program." (Alternative drug pricing programs are programs, often sponsored by health care consortiums, designed to lower the cost of pharmaceuticals to members by facilitating group purchasing activities.)
Service Delivery Sites :
• A service delivery site is defined as any place where a health center provides clinical 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. The site must, however, be operated as part of the health center's current approved scope of project. In order to be considered a site:
• Encounters must be generated at the site 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; and
• Services at the site must be provided on behalf of the health center which retains control and authority over the provision of services (e.g, as applicable, billing and medical records).
• Service delivery sites may include , but are not limited to, health care facilities, schools, migrant camps, homeless shelters, and mobile vans where health services are provided. Site examples include:
• Any full-time or part-time clinic location - address of site should be listed;
• Primary care services at a homeless shelter for 4 hours every Thursday - address of site should be listed;
• Migrant clinic location open only during 6 months of the year - address of site should be listed.
• If a health center provides encounters at a number of similar locations (day care centers, soup kitchens, homeless shelters, migrant camps, etc.) the individual locations need not be listed, however a single "site" for "multiple (shelters, migrant camps, etc.) locations" should then be included for each type of location .
• If a mobile van 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
• Service delivery sites do not include other activities/locations where the only services delivered do not generate encounters (e.g. filling prescriptions, taking x-rays, giving immunizations, performing street outreach or providing health education, etc.). Examples of sites that should not be listed as service delivery sites include:
• 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 and nursing homes where providers follow their patients).
• Locations where the site is administrative only, including but not limited to voucher distribution sites.
• WIC-only sites
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.
Report the name and physical address of each service delivery site operating at the end of the reporting year , including the 9-digit zip code . Do not provide the mailing address - use the physical address of the site so it can be mapped. For each service delivery site, also:
• Indicate by checking the appropriate box whether the site operates year-round or less than year-round.
• Indicate by checking the appropriate box whether the service delivery location operates full-time or part-time. Full-time is defined as operational 35 or more hours per week. Part-time is operational less than 35 hours per week. If the site is part-time indicate how many hours per week it is operational.
• Indicate by checking the appropriate box whether the site is Urban or Rural. This is based upon the patients seen at the clinic, not the actual physical location of the site. (Note - each grantee has an overall "urban / rural" designation which is not affected by this selection. Some agencies may operate both rural and urban sites.)
• Indicate the location or type(s) of facility, using codes in the drop-down menu. Each service delivery location may be described by up to two site-types. These codes (#1-15) provide information on the type of facility in which the site is located, NOT the specific services offered at the site. Examples of coding are shown below:
• A community-based primary care service delivery location not located in a health department or substance abuse treatment clinic/facility should be coded as "1" - Community Based Primary Care Clinic.
• A primary care service delivery location located in a health department should be coded "5" - Health Department Clinic.
• A primary care service delivery location located in a substance abuse clinic should be coded "6" - Substance Abuse Treatment Clinic/Facility.
• A community-based homeless grantee service delivery location located in a mental health clinic operated by a local health department should be coded "5" - Health Department Clinic and "8" - Mental Health Clinic.
• If you have separate Medicaid billing numbers for each of your clinic or pharmacy sites, record those on the grid for each site as appropriate. If your agency uses a single billing number, leave these blank .
Patient By Zip Code :
Grantees must report the number of patients by zip code for all patients. This information will enable BPHC to better identify areas served by health centers as well as minimize problems arising as a result of service area overlap.
• It is the BPHC's goal to identify residence by zip code for all patients served, but it is understood that residence information may not be available for all patients. This is particularly true for centers that serve transient groups. Special instructions cover two of these groups:
• Homeless Patients: While many homeless patients live in shelters, transitional housing, and other locations for which a zip code can be obtained, others - especially those living on the street -- do not know or will not share an exact location. Where a zip code location cannot be obtained or the location offered is questionable, grantees should use the zip code of the location where the patient is being served as a proxy. Similarly, if the patient has no other zip code and receives services on a mobile van, the zip code of the site in which services are being offered should be cited where this information is available.
• Migrant Patients: Many Migrant Farm Workers may have a permanent residence in a community far from the location of their work and the site where they are receiving services. For the purpose of the UDS report, grantees are to use the zip code of the patient's temporary housing location near the service delivery location.
For the small number of patients for whom residence is not known or for whom a proxy is not available, residence should be reported as "Unknown".
Although grantees are expected to report residence by zip code for all patients, it is recognized that large centers, as well as those located in tourist or hunting/fishing locations may draw a small number of patients from a large number of zip codes. To ease the burden of reporting, zip codes with less than ten patients may be aggregated and reported in an "Other" category. At a minimum, health centers should report 80 percent of patients with known zip codes by individual zip code.
Questions and Answers for Center/Grantee Profile Cover Sheet
1. Are there any changes to this table?
Yes, grantees are no longer required to include the service delivery location alpha identifier, as assigned by BPHC with the service delivery sites information.
2 . Do we need to collect information on and report on the zip code of all of our patients?
Yes. Instead of asking that individual sites be identified by area served, grantees are to report on the zip codes of their patients. Although grantees are expected to report residence by zip-code for all patients, it is recognized that large centers may draw a small number of patients from a large number of zip-codes. To ease the burden of reporting, zip codes with less than 10 patients may be aggregated and reported in an "Other" category. At a minimum, health centers should report 80% of patients with known zip codes by individual zip code.
3. Does the number of patients reported by zip code need to equal the total number of unduplicated patients reported on Tables 3A and 3B?
Yes. The number of patients reported by zip code on the Cover Sheet Patients by Zip Code must equal the number of total unduplicated patients reported on Tables 3A and 3B. If zip code information is missing for a small number of patients, residence can be reported as unknown.
GRANTEE LEGAL NAME |
|
Address of Grantee Administrative Offices |
Street |
City |
State |
9-Digit zip code (required) |
- |
CEO/Executive Director or Project Director |
Name |
Phone |
Extension |
E-Mail |
Clinical Director |
Name |
Phone |
Extension |
E-Mail |
Chairperson, Governing Board, Health Officer, or other Accountable Individual (e.g. Chair of Board of Supervisors, President of the Board of Trustees, etc.) |
Name |
Grantee Contact Person
(Person completing report): |
Name |
Street |
City |
State |
Zip - |
Phone |
Extension |
Fax |
E-mail |
School Health Coordinator |
Name |
Homeless Program Coordinator |
Name |
Public Housing Program Coordinator |
Name |
Medicaid Provider Billing Number:
(Organization Wide Only) |
|
Medicaid Pharmacy Number:
(Organization Wide Only) |
|
Reporting Period: January 1, 2007 through December 31, 2007 OMB No. 0915-0193 Expiration Date:
CENTER/GRANTEE PROFILE
COVER SHEET
Number of service delivery sites supported by BPHC Grant(s) |
|
Number of NHSC Assignees as of 12/31 |
|
Grantee Participation in an Integrated Services Network
|
CHECK ONE BOX:
o Horizontal Network o Vertical Network
o Both (Horizontal & Vertical Integration) o No ISN Participation |
If participation in a network was indicated above, did the network receive ISDI funding from BPHC at any time in the past?
o Yes o No |
Federal Tort Claims Act (FTCA) Deemed? |
o Yes o No |
340(b) Drug Pricing Participation? |
o Yes o No |
Alternative drug discounting program? |
o Yes o No |
Reporting Period: January 1, 2007 through December 31, 2007 OMB No. 0915-0193 Expiration Date:
CENTER/GRANTEE PROFILE
COVER SHEET
NOTE : Use Location Codes listed below to describe the type of facility in which the service delivery site is located. More than one location code may apply for a given service delivery site. Use Medicaid numbers for service delivery sites only if applicable. For location code 11, School Based Health Center , include name of school in service delivery site name.
service delivery site |
service delivery site |
Year Round o Less than Year Round o
Full-time o Part-time o # Hrs/Wk ___
Urban o Rural o
Name:
Address:
Zip(9) (required)
Location Code(s):
Medicaid Number:
Medicaid Pharmacy Number: |
Year Round o Less than Year Round o
Full-time o Part-time o # Hrs/Wk ___
Urban o Rural o
Name:
Address:
Zip(9) (required)
Location Code(s):
Medicaid Number:
Medicaid Pharmacy Number: |
service delivery site |
service delivery site |
Year Round _ Less than Year Round _
Full-time _ Part-time o # Hrs/Wk ___
Urban _ Rural _
Name:
Address:
Zip(9) (required)
Location Code(s):
Medicaid Number:
Medicaid Pharmacy Number: |
Year Round o Less than Year Round _
Full-time _ Part-time _ # Hrs/Wk ___
Urban _ Rural _
Name:
Address:
Zip(9) (required)
Location Code(s):
Medicaid Number:
Medicaid Pharmacy Number: |
Location Codes to identify the type of facility or location:
• Community Based Primary Care Clinic
• Hospital or Worksite clinic
• Fully Equipped Mobile Health Van
• Community Based Social Service Center
• Health Department Clinic
• Substance Abuse Treatment Clinic/Facility |
7. HIV/AIDS Medical Care Clinic/Facility
8. Mental Health Clinic
9. Public Housing
10. Migrant Camp
11. School Based Health Center
12. Homeless Shelter
13. Soup Kitchen
• Dental
• Other (Please specify) |
Reporting Period: January 1, 2007 through December 31, 2007 OMB No. 0915-0193 Expiration Date:
CENTER/GRANTEE PROFILE
COVER SHEET
Patients BY ZIP CODE
Zip Code |
Patients |
|
|
|
|
|
|
|
|
|
|
|
|
Other Zip Codes |
|
Unknown Residence |
|
TOTAL |
|
