Questions
for Relocation of Service Site
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From
Site(s)
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Site
has not been selected.
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To
Site(s)
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Site has not been selected.
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*1.
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Describe
the reason for the relocation and how it will benefit the
total level or quality of health services provided to the
target population?
(Please
provide a summary of one page or less.)
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*2.
Is the relocation temporary or
permanent?
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Permanent
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Temporary
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*2a.
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When
do you plan to relocate the site(s)?
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Effective
date for site relocation (mm/dd/yyyy):
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*3.
Information about the impact of the relocation of service
site on the area currently served
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3a.
Will
the relocation cause a change in zip code(s) for your
service area?
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Yes
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No
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3b.
If
yes to 3a, describe the change in the space provided
below:
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*4.
Will the majority of patients have to travel further to
access care at the new address?
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Yes
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No
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4a.
If
yes, what is the additional distance patients will have to
travel to the site, on average?
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Distance:
miles (Format:
9 or 9.99)
Time:
hrs
mins (Format:
99)
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4b.
If
yes, will transportation services be available?
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4c.
If
yes, how far is the new site location from your current
site?
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Distance:
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miles (Format:
9 or 9.99)
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Travel
Time:
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hrs
mins (Format:
99)
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4d.
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If
yes, describe how you will address any barriers that
the new location may present. (Please
provide a summary of one page or less.)
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*5.
Is the new address of the site within your current service
area?
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Yes
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No
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5a.
If
No, are there other health centers (funded FQHCs or FQHC
Look-Alikes) near the new address?
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5b.
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If
Yes to 5a, identify below, and provide a letter of
cooperation and support from the neighboring health
centers if available.
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 neighboring health centers.
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*6.
Information comparing the current site and site at new
address through the First Year after the relocation.
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6a.
Number
of patients served at the service site
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Current
Service Site:
(Format:
99)
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Service
Site at new address:
(Format:
99)
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Current
Service Site:
(Format:
99)
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Service
Site at new address:
(Format:
99)
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Current
Service Site:
(Format:
9 or 9.99)
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Service
Site at new address:
(Format:
9 or 9.99)
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Current
Service Site:
(Format:
9 or 9.99)
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Service
Site at new address:
(Format:
9 or 9.99)
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Current
Service Site:
(Format:
9 or 9.99)
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Service
Site at new address:
(Format:
9 or 9.99)
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Current
Service Site:
(Format:
9 or 9.99)
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Service
Site at new address:
(Format:
9 or 9.99)
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*7.
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Does
the information above indicate that the expenses of
operating the relocated site exceed the expenses of the
original site by 20% or more?
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Yes
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No
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7a.
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If
Yes, submit Form 3: Income Analysis, showing the projected
number of encounters, payer mix, revenue projections, and
other sources of support for the relocated site specific
for
one year only.
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If
Form 3: Income Analysis Format, demonstrate that
additional funds will be necessary to support the
relocated site, the grantee must
provide specific budgetary information demonstrating how
the increased expenses
are to be covered.
(Additional
documents can be provided in the Other Information -
Supporting Documents section of the Grantee Handbook.)
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7b.
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Does
the information provided in Form 3: Income Analysis
indicate that the projected revenue from operating the
site will be adequate to support the activities at the new
site address?
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*8.
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Does
your Board of Directors currently have representation from
the area of the newly proposed site?
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8a.
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If
No, describe how you plan to obtain Board representation
from the new area?
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