This table indicates the types of services provided by the grantee and reports whether these services are provided directly or through formal referral arrangements. Table 2 is included only in the Universal Report. Only services included within the scope of the federally-approved project(s) should be reported. This table is a compilation of the wide array of services provided through different BPHC grants. Individual grantees will rarely provide or refer for all of the services listed in this table. Also, since more than one delivery method may apply for a given service more than one of the columns may be checked on any given line.
1. Service Type . This table lists medical, dental, behavioral, and other services that may be provided by BPHC grantees. Service definitions appear in Appendix B.
2. Delivery Method. Check the delivery method(s) applicable to the particular service type. If the service is not offered, leave the row blank.
· Provided by Grantee - Includes services rendered by salaried employees, contracted providers, National Health Service Corps Staff, volunteers and others such as out-stationed eligibility workers who render services in the grantee's name.
· By Referral - Grantee Pays - I ncludes services provided by another organization under a formal arrangement, only when the grantee pays for provision of the service, though the grantee may also bill the patient or a third party payor for the service. The arrangement may involve discounted payment (i.e., payment less than the provider's "usual, customary and reasonable" charge, but payment is generally at least equivalent to Medicaid payments). These services are generally provided off site.
· By Referral - Grantee Does Not Pay - Includes services that are provided by another organization or individual under a formal referral arrangement where the grantee DOES NOT pay for or bill for the service.
A formal referral arrangement means either a written agreement or the ability to document the service in the patient record.
Questions and Answers for Table 2
1. Are there any changes to this table?
There are no changes to this table since the CY 2004 reporting year.
Reporting Period: January 1, 2006 through December 31, 2006
TABLE 2 -
SERVICES OFFERED AND DELIVERY METHOD ( Page 1 of 3 )
Service Type
Note: not all centers will provide all services
(See Appendix B for definitions) |
Delivery Method
Mark (X) if Applicable
[ More than one method may apply for a given service] |
Provided by
Grantee
(a) |
By Referral/
Grantee Pays
(b) |
By Referral/
Grantee
Doesn't Pay
(c) |
Primary Medical Care Services |
1. |
General Primary Medical Care (other than listed below) |
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2. |
Diagnostic Laboratory (technical component) |
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3. |
Diagnostic X-Ray Procedures (technical component) ccomponent) |
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4. |
Diagnostic Tests/Screenings (professional component) component) |
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5. |
Emergency medical services |
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6. |
Urgent medical care |
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7. |
24-hour coverage |
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8. |
Family Planning |
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9. |
HIV testing and counseling |
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10. |
Testing for Blood Lead Levels |
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11. |
Immunizations |
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12. |
Following hospitalized patients |
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Obstetrical and Gynecological Care |
13. |
Gynecological Care |
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14. |
Prenatal care |
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15. |
Antepartum fetal assessment |
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16. |
Ultrasound |
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17. |
Genetic counseling and testing |
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18. |
Amniocentesis |
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19. |
Labor and delivery professional care |
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20. |
Postpartum care |
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Specialty Medical Care |
21. |
Directly observed TB therapy |
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22. |
Respite Care |
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23. |
Other Specialty Care |
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Dental Care Services |
24. |
Dental Care - Preventive |
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25. |
Dental Care - Restorative |
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26. |
Dental Care - Emergency |
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27. |
Dental Care - Rehabilitative |
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Mental Health/Substance Abuse Services |
28. |
Mental Health Treatment/Counseling |
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29. |
Developmental Screening |
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30. |
24-hour Crisis Intervention/Counseling |
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31. |
Other Mental Health Services |
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32. |
Substance Abuse Treatment/Counseling |
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Reporting Period: January 1, 2006 through December 31, 2006
TABLE 2 -
SERVICES OFFERED AND DELIVERY METHOD (Page 2 of 3)
Service Type
Note: not all centers will provide all services
(See Appendix B for definitions) |
Delivery Method
Mark (X) if Applicable
[ More than one method may apply for a given service ] |
Provided by
Grantee
(a) |
By Referral/
Grantee Pays
(b) |
By Referral/
Grantee
Doesn't Pay
(c) |
Mental Health/Substance Abuse Services |
33. |
Other Substance Abuse Services |
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33a. |
Comprehensive mental health / Substance abuse screening |
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Other Professional Services |
34. |
Hearing Screening |
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35. |
Nutrition Services Other Than WIC |
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36. |
Occupational or Vocational Therapy |
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37. |
Physical Therapy |
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38. |
Pharmacy - Licensed Pharmacy staffed by Registered Pharmacist |
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39. |
Pharmacy - Provider Dispensing |
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40. |
Vision Screening |
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41. |
Podiatry |
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42. |
Optometry |
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Enabling Services |
43. |
Case management |
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44. |
Child Care ( during visit to center ) |
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45. |
Discharge planning |
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46. |
Eligibility Assistance |
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47. |
Environmental Health Risk Reduction
( via detection and/or alleviation ) |
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48. |
Health Education |
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49. |
Interpretation/Translation services |
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50. |
Nursing home and assisted-living placement |
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51. |
Outreach |
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52. |
Transportation |
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53. |
Out Stationed Eligibility Workers |
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54. |
Home Visiting |
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55. |
Parenting Education |
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56. |
Special Education Program |
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57. |
Other (specify:____________________________) |
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Reporting Period: January 1, 2006 through December 31, 2006
TABLE 2 -
SERVICES OFFERED AND DELIVERY METHOD (Page 3 of 3)
Service Type
Note: not all centers will provide all services
(See Appendix B for definitions) |
Delivery Method
Mark (X) if Applicable
[ More than one method may apply for a given service ] |
Provided by
Grantee
(a) |
By Referral/
Grantee Pays
(b) |
By Referral/
Grantee
Doesn't Pay
(c) |
Preventive Services Related to Target Clinical Areas |
I. Cancer |
58. |
Pap test |
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59. |
Fecal occult blood test |
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60. |
Sigmoidoscopy |
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61. |
Colonoscopy |
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62. |
Mammograms |
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63. |
Smoking cessation program |
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II. Diabetes |
64. |
Glycosylated hemoglobin measurement for people with diabetes |
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65. |
Urinary microalbumin measurement for people with diabetes |
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66. |
Foot exam for people with diabetes |
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67. |
Dilated eye exam for people with diabetes |
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II. Cardiovascular Disease |
68. |
Blood pressure monitoring |
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69. |
Weight reduction program |
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70. |
Blood cholesterol screening |
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IV. HIV/AIDS - See line 9. HIV testing and counseling |
V. Infant Mortality -- Also see line 14. Prenatal Care |
71. |
Follow-up testing and related health care services for abnormal newborn bloodspot screening |
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VI. Immunizations -- See line 11. Immunizations |
Other Services |
72. |
WIC services |
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73. |
Head Start services |
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74. |
Food banks / Delivered meals |
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75. |
Employment / Educational Counseling |
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76. |
Assistance in obtaining housing |
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