Skip Navigation HRSA - U.S Department of Health and Human Services, Health Resources and Service Administration U.S. Department of Health & Human Services
Home
Questions
Order Publications
 
Grants Find Help Service Delivery Data Health Care Concerns About HRSA
The Health Center Program:

Policy Information Notice 2009-04: Revision to Policy Information Notice 2003-21: Federally Qualified Health Center Look-Alike Guidelines and Application
 
DATE: January 14, 2009

TO: Federally Qualified Health Center Look-Alikes
Health Center Program Grantees
Primary Care Associations
Primary Care Organizations
National Cooperative Agreements

This Policy Information Notice (PIN) announces a revision to PIN 2003-21: Federally Qualified Health Center (FQHC) Look-Alike Application and Guidelines.  Effective immediately, the Office of Management and Budget (OMB) approval for information collection, control number 0915-0142, has been extended to November 30, 2011.

This OMB approval provides the Health Resources and Services Administration (HRSA) with the authority to continue to collect the data specified in PIN 2003-21 in order to make a determination on an organization’s compliance with FQHC Look-Alike requirements. Note the following changes in data submission requirements have been made to PIN 2003-21:

  • Race and ethnicity data is now collected as two separate data elements in Table 2, Part B, to meet OMB Standards for the Classification of Federal Data on Race and Ethnicity as well as Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity (62 Federal Register (FR)36874-36946 62 FR 58781-9 and OMB Bulletin #00-02).

FQHC Look-Alikes and applicants must use the attached tables in addition to the guidelines in PIN 2003-21 when making submissions.  Please note that all information provided regarding race and/or ethnicity will be used only to ensure compliance with statutory and regulatory Governing Board requirements set forth in section 330 of the Public Health Service Act.  Data on race and/or ethnicity collected on this form will not be used as a factor in recommending approval for FQHC Look-Alike designation, recertification, or change in scope of project. 

To access PIN 2003-21 and other relevant documents (e.g., PINs 2005-17 and 2006-06, and Program Assistance Letters 2006-01, and 2008-07), please visit HRSA’s Web site.

If you have any questions regarding this PIN or the FQHC Look-Alike Program, please contact the Office of Policy and Program Development at 301-594-4300.

 

James Macrae
Associate Administrato

TABLE 1 - SERVICES OFFERED AND DELIVERY METHOD TABLE 2 - PATIENTS


TABLE 2 - PART A PATIENTS BY AGE AND GENDER
Age Groups Male Patients Female Patients Prenatal Patients
1.) Under age 1      
2.) Ages 1-4      
3.) Ages 5-12      
4.) Ages 13-14      
5.) Ages 15-19      
6.) Ages 20-24      
7.) Ages 25-44      
8.) Ages 45-64      
9.) Ages 65-74      
10.) Ages 75-84      
11.) Ages 85 and over      
12.) Total Patients      

TABLE 2 - PART B PATIENTS BY ETHNICITY
Ethnicity Number of Patients Number in Service Area
1.) Hispanic or Latino    
2.) Unreported/Unknown    
3.) Total Patients    

TABLE 2 - PART B PATIENTS BY RACE
Race//Language Number of Patients Number in Service Area
1.) Asian    
2.) American Indian or Alaska Native    
3.) Black or African American    
4.) Native Hawaiian or Other Pacific Islander    
5.) White    
7.) Unreported/Unknown    
8.) Total Patients    
9.) Patients Needing Interpretation Services    

TABLE 2 - PART C PATIENTS BY INCOME LEVELS
Percent of Poverty Level Number of Patients Number in Service Area
1.) 100% and below    
2.) 101 - 200%    
3.) Above 200%    
4.) Unreported/Unknown    
5.) Total Patients    

TABLE 2 - PART D PATIENTS BY PAYMENT SOURCE
Payment Sources Number of Patients Percent of Patients
1.) Medicare    
2.) Medicaid    
3.) Other Public Insurance    
4.) Other Third Parties    
5.) Self-Pay    
6.) Total Patients   100%

TABLE 3 - PROVIDERS

Personnel by Major Service Categories
Total FTEs
Status (Place “X” if Employed directly “C” if by contract)
State License (Y/N)
Hospital Admitting Privileges (Y/N)
Board Certified (Y/N)
Total Encounters
Medical Providers (i.e., General Practitioners, Internists, Obstetrician/Gynecologists, Pediatricians, Other Physician Specialists, Nurse Practitioners, Certified Nurse Mid-Wives)            
             
             
             
             
             
             
             
             
             
             
             
Dental Providers            
(i.e., Dentists, Dental Hygienists)            
             
             
             
             
             
             
Mental Health & Substance Abuse Providers            
(i.e., Psychiatrists, other specialists)            
             
             
             
             

TABLE 4 - PATIENT SERVICE CHARGES, COLLECTIONS, AND SELF-PAY ADJUSTMENTS

Payment Source
Full Charges
Amount Collected
Adjustments
Medicare      
1.) Medicare Fee-for-Service      
2.) Medicare Capitated      
3.) Total Medicare (Lines 1 and 2)      
Medicaid      
4.) Medicaid Fee-for-Service      
5.) Medicaid Capitated      
6.) Total Medicaid (Lines 4 and 5)      
Other Public Payers      
7.) Other Public Fee-for-Service      
8.) Other Public Capitated      
9.) Total Other Public (Lines 7 and 8)      
Other Third Party      
10.) Other Third Party Fee-for-Service      
11.) Other Third Party Capitated      
12.) Total Other Third Party (Lines 10 and 11)      
Self-Pay      
13.) Self-Pay      
14.) Total (Lines 3, 6, 9, 12, and 13)      
Self-Pay Adjustment Type      
15.) Self-Pay Sliding Fee Adjustments      
16.) Other Self-Pay Adjustments (Self-Pay Bad Debt and Charity Care)      
17.) Total Self-Pay Adjustments (Lines 15 and 16)      

TABLE 5 - CURRENT BOARD MEMBER CHARACTERISTICS

Total Number/Range of Members Established in By-Laws or Articles of Incorporation:_______ Positions Filled:_____ as of __/__ / __

Name
Board Office Held
Patient Status (Y/N)
Area of Expertise
Live (L) or Work (W) in Service Area
Years of Continued Board Service
1.          
2.          
3.          
4.          
5.          
6.          
7.          
8.          
9.          
10.          

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: - Use additional pages if necessary.

  • If board member is not a Patient (i.e., "N" in column 3) indicate if that member derives more than 10% of his/her income from the health care industry (e.g., “N > 10%” or “N < 10%”).
  • Migrant/Seasonal Farmworkers should be noted under Area of Expertise, and should reflect a reasonable proportion to their share of the Patient population.