Questions
for Addition of Site
|
Site
Name
|
Site
has not been selected.
|
Site
Address
|
|
*1.
Why do you want to add the service
site?
|
|
|
|
Needs
assessment indicated a high need for services at this
location.
|
Needs
assessment completed on (mm/dd/yyyy):
|
Community
asked us to provide services and provided supporting
needs data.
An
existing clinic is closing and we have an opportunity to
continue those services in the area.
Other
(Describe in the space provided below):
To
upload supporting attachments, visit the 'Supporting
Documents' section in this CIS Request.
|
|
|
*2.
|
Describe
how adding this site will benefit your health center and
the patients it will serve? (Please
provide a summary of one page or less.)
|
|
|
|
|
(Maximum
3,000 Characters)
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
|
|
|
*2a.
|
When
do you plan to add the site?
|
|
|
|
|
|
Effective
date for site addition (mm/dd/yyyy):
|
|
|
|
*3.
Information about target population to be served at the new
service site
|
|
3a.
Number
of patients to be served
|
|
(Format:
99)
|
|
3b.
Percentage
of patients below 200% of Federal Poverty Level
|
|
%
(Format: 9 or 9.99)
|
|
3c.
Percentage
of uninsured patients
|
|
%
(Format: 9 or 9.99)
|
*4.
|
Will
this site serve patients currently being served or
targeted to be served by other health centers (funded
FQHCs or FQHC Look-Alikes)?
|
|
|
|
|
Yes
|
No
|
|
|
|
4a.
If
Yes, provide below, the name and addresses of these
health centers.
|
|
|
|
|
4b.
|
If
available, append a letter of cooperation and/or
support from all other health centers’ governing
boards who currently serve patients that the proposed
new site will also serve.
|
|
|
|
|
To
upload supporting attachments, visit the 'Supporting
Documents' section in this CIS Request.
|
|
|
Final
action cannot be taken on your Change in Scope (CIS)
request without careful consideration of the impact of
this site on the operation of health centers currently
serving patients that the proposed new site will also
serve.
|
|
|
*5.
Does your Board of Directors currently have representation
from the area of the newly proposed site?
|
|
|
|
Yes
|
No
|
|
|
|
5a.
|
If
No, describe how you plan to obtain Board
representation from the new area.
|
|
|
|
|
*6.
|
Does
the budget include any special grant, foundation or other
funding that is time-limited, i.e., will only be
available for 1 or 2 years?
|
|
|
|
|
Yes
|
No
|
|
|
|
6a.
|
If
Yes, how will you support the site when these funds
are no longer available? (Please
provide a summary of one page or less.)
|
|
|
|
|