Form 0285-8 Health Center Affiliation Certification

OMB No.: 0915-0285. Expiration Date: 8/31/2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

FORM 8: HEALTH CENTER AFFILIATION

CERTIFICATION/CHECKLIST

FOR HRSA USE ONLY

Application Tracking Number

Grant

Number

Does your organization have, or propose to establish as part of this application, any of the following Affiliation Types:

• Contract for a substantial portion of the approved scope of project

• Memorandum of Understanding (MOU)/Agreement (MOA) for substantial portion of the approved scope

• Contract with another organization or individual contract for core primary care providers

• Contract with another organization for staffing health center

• Contract with another organization for the Chief Medical Officer (CMO) or Chief Financial Officer (CFO)

• Merger with another organization

• Parent Subsidiary Model arrangement

• Acquisition by another organization

• Establishment of a New Entity (e.g. Network corporation)

[_] Yes (Please complete sections Organization Affiliations Section)

[_] No

[_] Not Applicable (Choose this option if you are NOT a CHC/MHC applicant)

NOTE: You must complete a checklist for each organization with which you have any of the above arrangements. Copies of all applicable documents must be included with the application.

Organization Affiliation Details
Organization Name
EIN
Physical Location Address
Affiliation Type (Check all that apply)
[_] Contract for a substantial portion of the approved scope of project [_] Memorandum of Understanding (MOU)/Agreement (MOA) for substantial portion of the approved scope [_] Contract with another organization or individual contract for core primary care providers [_] Contract with another organization for staffing health center [_] Contract with another organization for the Chief Medical Officer (CMO) or Chief Financial Officer (CFO) [_] Merger with another organization [_] Parent Subsidiary Model arrangement [_] Acquisition by another organization [_] Establishment of a New Entity (e.g. Network corporation)
Description

Health Center Affiliation Checklist

STAFFING	YES	NO
1) The center directly employs the CFO, CMO and the core staff of full-time primary care providers.	[ _ ]	[ _ ]
2) The center directly employs all non-provider health center staff.	[ _ ]	[ _ ]
3) If NO to question 1 or 2, the CEO of the center retains the authority to select and dismiss the CFO and CMO as well as other staff assigned to the center? Please cite reference document and page # (____________)	[ _ ]	[ _ ]

GOVERNANCE	YES	NO
4) The arrangements presented in the affiliation agreements, as defined above, do not compromise the Board authorities or limit its legislative and regulatory mandated functions and responsibilities as defined below. (Examples of compromising arrangements are: overriding approval or veto authority by another entity; dual majority requirements; super-majority requirements; or hiring and dismissal of the CEO).	[ _ ]	[ _ ]
	REFERENCE DOCUMENT	PAGE #
board composition
executive committee function and composition
selection of board chairperson
selection of board members
strategic planning
approval of the annual budget of the center
directly employs, selects/dismisses and evaluates the Chief Executive Officer/Executive Director
adoption of policies and procedures for personnel and financial management
establishes center priorities
establishes eligibility requirements for partial payment of services
provides for an independent audit
evaluation of center activities
adoption of center's health care policies including scope and availability of services, location, hours of operation and quality of care audit procedures
existence of a conflict of interest policy
contains appropriate provisions around the activities to be performed, time, schedules, the policies and procedures to be followed in carrying out the agreement, and the maximum amount of money for which the grantee may become liable to the contractor under the agreement;
requires the contractor to maintain appropriate financial, program and property management systems and records in accordance with 45 CFR Part 74 and provides the center, DHHS and the U.S. Comptroller General with access to such records;
requires the submission of financial and programmatic reports to the health center;
complies with Federal procurement standards or grant requirements including conflict of interest standards;

CONTRACTING	YES	NO
5) The center has justified the performance of the work by a third party. Please cite reference document and page # (____________)	[ _ ]	[ _ ]
6) Written affiliation agreement(s) comply with current Department of Health and Human Services (HHS) policies (PINs 97-27 and 98-24)	[ _ ]	[ _ ]

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915 0285. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857