Form 1 Checklist for Adding a New Service Delivery Site

CIS Editable Checklist – Grantee Checklist – Add Service Site

Change Checklist

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration CHECKLIST FOR ADDING A SITE (CHKLST003)	Grantee Name:
	Grantee Number:
	CIS Tracking Number:

Questions for Addition of Site

Site Name		Site Address
When do you plan to start providing services at the site?

1. NEED
Clearly address why and how the addition of the proposed site will address unmet need and further the mission of the health center by maintaining or increasing access and maintaining or improving quality of care for the target population.

1a. How was the need for the proposed site identified (check all applicable reasons)?

UDS Trend Data (e.g. Patient Origin Data) and/or a needs assessment indicated a high need for a site at this location (e.g. health center is exceeding patient capacity at existing sites, health center is seeing significant number of patients from the proposed area).
UDS Data Year (20 ) Needs assessment completed on (mm/dd/yyyy):
The site is located in a Medically Underserved Area (MUA). The site is located in a Medically Underserved Area (MUA).
Health center verified MUA Designation is current in HRSA Database on (mm/dd/yyyy):
The site will serve a Medically Underserved Population (MUP). The site will serve a Medically Underserved Population (MUP).
Health center verified MUP Designation is current in HRSA Database on (mm/dd/yyyy):
An existing health center site (section 330 grantee or FQHC Look-Alike) in the proposed area is closing and/or another safety net provider(s) is no longer offering services to our target population in this area.
One or more of my current sites is under renovation and we need to add a temporary site to scope where we will provide services until the current site(s) under renovation are ready. Once the health center re-opens the existing site in scope that is currently under renovation, if they will no longer be utilizing the temporary site added through this change in scope, they will need to submit a change in scope to REMOVE the temporary site from scope via a Site Deletion request.
The site will replace a site I have already removed from scope and/or plan to remove from scope in the future, and these two actions (closure of original site and opening of new site to replace the original site) will NOT be accomplished within 120 days or less.
Other (Describe in the space provided below):
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

1b. Using the most recent UDS data and/or other data specific to your target population and/or service area, describe the:

• specific access barriers (e.g. Ratio of Population to One FTE Primary Care Physician, Distance (miles) OR Travel Time (minutes) to Nearest Primary Care Provider Accepting New Medicaid and/or Uninsured Patients: private practitioner, health center, etc.) and

• specific risk factors (e.g., occupational, environmental, behavioral, social/cultural, or housing status) of the patient population to be served at the proposed site that supports the need for and/or benefit of the proposed site.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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1c. Provide evidence that the proposed site will appropriately serve the current patient and/or target population by providing the following information about the population that will utilize the new site.

Number of patients projected to be served annually
This is the anticipated number of patients that will utilize the proposed site in the coming calendar year.

Number:

(Format: 99)

Data Source Used for Projection:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Percentage of projected patients at or below 200% of Federal Poverty Guidelines
This is the anticipated % of patients with incomes at or below 200% of the Federal Poverty Guidelines that will utilize the proposed site in the coming calendar year.

Percentage:
%
(Format: 9 or 9.99)

Data Source Used for Projection:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Percentage of projected uninsured patients
This is the anticipated % of uninsured patients that will utilize the proposed site in the coming calendar year.

Percentage:
%
(Format: 9 or 9.99)

Data Source Used for Projection:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

1d.Provide a brief narrative description on how the projections in 1c. were derived.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

2. Service Area Analysis:

Describe how the health center has analyzed the service area, utilizing UDS Mapper and/or other similar resources, where the proposed site will be located. (Attach analysis documentation) Responses should be consistent with data and narrative on unmet need and projected patients provided in Question 1.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Service Area Analysis (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

Service Area Analysis Resources
Service Area Overlap Policy and Process: http://bphc.hrsa.gov/policiesregulations/policies/pin200709.html
UDS Mapper: http://www.udsmapper.org
HRSA Data Warehouse: http://datawarehouse.hrsa.gov

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2a. Select the appropriate statement. The proposed site is being added to:

For the purposes of this question:

• Service area is defined by the service area zip codes associated with your Form 5B sites.

• Patient population is defined by your current UDS Patient Origin Data.

• Target population is defined in your most recent approved application.

provide increased access and/or capacity for the existing patient/target population within the existing service area. Continue to Question 3.

provide increased access in whole or in part to a new patient/target population and/or a new service area that is not currently served by your health center. Continue to Question 2b.

Provide comments related to selection
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

2b. Will the proposed site serve all or part of the service area of another health center (section 330 grantee or Look-Alike) and/or of another primary care safety net provider (rural health clinics, critical access hospitals, health departments, etc.)?

Yes

No

N/A

If Yes, list these other health centers and/or safety net providers and discuss how the proposed site will complement these existing primary care resources so as to minimize the potential for unnecessary duplication and/or overlap in services, sites, or programs. Continue to 2c only if the site will serve all or part of the service area of another health center (section 330 grantee or Look-Alike). Otherwise, continue to Question 3.

If No, continue directly to Question 3.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

2c. As the proposed site will serve all or part of the service area of another health center, discuss if and how one or more of the following apply to your proposal (See PIN 2007-09: Service Area Overlap Policy and Process for more information on HRSA’s principles for assessing individual situations of service area overlap):

• The proposed site will serve a newly identified sub-group of underserved people within a community already served by another health center(s) site(s) (e.g., homeless people, populations with limited English proficiency within the service area), where the health care needs of the relevant medically underserved population group within the new service area are not being met by another health center’s site(s).

• The proposed site will serve an area where unmet need exceeds the capacity of the existing health center's site(s) in the new service area.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Once completed, continue to Question 3.

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3. Service Area Collaboration

For the purpose of this question:
Collaborative relationships are those that assist in contributing to one or both of the following goals relative to the proposed site:
(1) maximizing access to required and additional services within the scope of the health center project to the target population that will be served at the proposed site; and/or
(2) promoting continuity of care to health care services for health center patients served at the proposed site beyond the scope of the project.

Collaboration Resources
Collaboration PAL: http://bphc.hrsa.gov/policiesregulations/policies/pal201102.html
UDS Mapper: http://www.udsmapper.org

3a. Describe established collaboration and new collaborative efforts under development with existing health centers (section 330 grantee and Look-Alikes) within or adjacent to the service area of the proposed site. In addition, list the names and addresses of these health centers and/or refer to the attached Service Area Analysis from Question 2 if listed there). If service area collaboration has already been discussed in Service Area Analysis Question 2b, refer back to these responses.

If a formal affiliation (e.g. MOA, MOU, contract, etc.) and/ or letter of collaboration or support from the neighboring health center(s) is available, attach these documents below. Only documents that speak to the proposed change in scope request for the site addition should be included.

✓ If no other health centers exist within or adjacent to the service area state this.
✓ If documentation of collaboration or support from service area health centers cannot be obtained, include documentation of efforts made to obtain such documents and an explanation for why they could not be obtained.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Collaboration Documentation (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

3b. Describe established collaboration and new collaborative efforts under development with other safety net providers (e.g. rural health clinics, critical access hospitals, health departments, etc.) within or adjacent to the service area of the proposed site. In addition, list the names and addresses of these other safety net providers and/or refer to the attached Service Area Analysis from Question 2 if listed there). If service area collaboration has already been discussed in Service Area Analysis Question 2b, refer back to these responses.

If a formal affiliation (e.g. MOA, MOU, contract, etc.) and/or letter of collaboration or support relevant to the proposed site addition is available, attach these documents below. Only documents that speak to the proposed change in scope request for the site addition should be included.
✓ If no other safety net providers exist within or adjacent to the service area state this.
✓ If documentation of collaboration or support from service area safety net providers cannot be obtained, include documentation of efforts made to obtain such documents and an explanation for why they could not be obtained.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Collaboration Documentation (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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4. Governance

Discuss whether the addition of the proposed site will have any impact on the health center’s ability to maintain compliance with the Health Center Program Board Composition Governance Requirements.

Consider and discuss any plans to address, the following applicable aspects of the Board Composition Requirement that may be impacted by a site addition:

• Will the addition of the new site significantly change the overall demographics of the patients served by the health center as a whole (i.e. across all sites) in terms of race, ethnicity and sex and thus potentially impact the representativeness of the composition of the health center’s current patient majority governing board (unless waived for Health Center Program grantees funded and look-alikes designated only under sections 330(g), (h), and/or (i) of the Public Health Service (PHS) Act)?

• Will the addition of the new site significantly change the size and complexity of the overall health center organization and potentially create the need to recruit additional patient and/or non-patient board members (i.e. increase the board’s size)?

• Will the addition of the new site impact the need to recruit additional non-patient board members with expertise in areas not currently reflected on the board?

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

5. Site Ownership and Operation:

For sites that will be operated through a contractual or subrecipient arrangement (i.e. not directly by the health center):

Will services at the contracted or subrecipient operated site be provided on behalf of the health center to health center patients?

Yes

No

Will the health center’s governing board retain control and authority over the provision of the services to health center patients at the contracted or subrecipient operated site?

Yes

No

Briefly justify why the health center has chosen to operate the site through such third party arrangements.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)


Health centers are reminded of their responsibilities to obtain any required prior approval from HRSA for aspects of the program conducted by subrecipients or contractors before a subrecipient or contractor can undertake an activity or make a budget change requiring that approval e.g., approval to extend the period of performance of a subaward to a subrecipient if it would extend beyond the end of the grant’s project period).

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5a. FOR SITES OPERATED BY CONTRACT: If the proposed site is owned and/or operated by a third party on behalf of the health center through a written contractual agreement between the health center and the third party (i.e. the health center is purchasing a specific set of goods and services from the third party-such as the operation of a site), does the contract state, address or include:

The activities to be performed by the contractor in the operation of the site, specifically including:

• How the services provided at the site will be documented in the health center patient record?

• How the health center will bill and/or pay for the services provided to health center patients at the site?

Yes

No

List Page #(s):

The time schedule for such activities (e.g. hours of site operation)?

Yes

No

List Page #(s):

The policies and requirements that apply to the contractor, including those required by 45 CFR 74.48 or 92.36(i) and other terms and conditions of the grant? These may be incorporated by reference where feasible – See the HHS Grants Policy Statement for more information on public policy requirements applicable to contractors at: http://www.hrsa.gov/grants/hhsgrantspolicy.pdf pages II-2 to II-6

Yes

No

List Page #(s):

The maximum amount of money for which the health center may become liable to the third party under the agreement?

Yes

No

List Page #(s):

Provisions consistent with the health center’s board approved procurement policies and procedures in accordance with 45CFR Part 74.41-48?

Yes

No

List Page #(s):

Assurances that no provisions will affect the health center’s overall responsibility for the direction of the site and services to be provided there and accountability to the Federal government by reserving sufficient rights and control to the health center to enable it to fulfill its responsibilities?

Yes

No

List Page #(s):

Requirements that the contractor maintain appropriate financial, program and property management systems and records and provides the health center, HHS and the U.S. Comptroller General with access to such records, including the submission of financial and programmatic reports to the health center if applicable and comply with any other applicable Federal procurement standards set forth in 45CFR Part 74 (including conflict of interest standards)?

Yes

No

List Page #(s):

Provision that such agreement is subject to termination (with administrative, contractual and legal remedies) in the event of breach by the contractor?

Yes

No

List Page #(s):

It is the responsibility of the health center to ensure that the contract does NOT inappropriately imply the conference of the benefits and/or privileges of the Health Center Program grantees or FQHC Look-Alikes such as 340B Drug Pricing or FQHC reimbursement, on the other party.

Attach the contract for the site (draft agreements are acceptable) here.

Contract for the site (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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5b. FOR SITES OPERATED BY SUBRECIPIENTS: If the proposed site is owned and/or operated by subrecipient on behalf of the health center through a written subrecipient agreement between the health center and the subrecipient organization to perform a substantive portion of the grant-supported program or project, respond to all of the following questions.

A subrecipient is an organization that “(ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant, and (II) meets the requirements to receive a grant under section 330 of such Act . . .” (§1861(aa)(4) and §1905(l)(2)(B) of the Social Security Act).

• Subrecipients must be compliant with all of the requirements of section 330 to be eligible to receive FQHC reimbursement from both Medicare and Medicaid.

• The subrecipient arrangement must be documented through a formal written agreement (Section 330(a)(1) of the PHS Act)

The health center (grantee of record) named on the NoA is the entity legally accountable to HRSA for performance of the project or program, the appropriate expenditure of funds by all parties including subrecipients, and other requirements placed on the health center (grantee of record), regardless of the involvement of others in conducting the project or program.

Has the health center’s key management staff confirmed that the subrecipient meets all applicable section 330 requirements and does the health center’s key management staff and its governing board have a plan in place to monitor the subrecipient's compliance over time?

Yes

No

Does the board-approved subrecipient agreement state, address or include the following elements necessary for meeting the programmatic, administrative, financial, and reporting requirements of the grant, including those necessary to ensure compliance with all applicable Federal regulations and policies:

Identification of the PI/PD and individuals responsible for the programmatic activity at the subrecipient organization along with their roles and responsibilities?

Yes

No

List Page #(s):

Procedures for directing and monitoring the programmatic effort?

Yes

No

List Page #(s):

Procedures to be followed in providing funding to the subrecipient, including dollar ceiling, method and schedule of payment, type of supporting documentation required, and procedures for review and approval of expenditures of grant funds?

Yes

No

List Page #(s):

If different from those of the recipient, a determination of policies to be followed in such areas as travel reimbursement and salaries and fringe benefits (the policies of the subrecipient may be used as long as they meet HHS requirements)?

Yes

No

List Page #(s):

Incorporation of applicable public policy requirements and provisions indicating the intent of the subrecipient to comply, including submission of applicable assurances and certifications? See the HHS Grants Policy Statement for more information on public policy requirements applicable to subrecipients at: http://www.hrsa.gov/grants/hhsgrantspolicy.pdf pages II-2 to II-6

Yes

No

List Page #(s):

Attach the subrecipient agreement documentation (draft documents are acceptable) here.

Subrecipient Agreement (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

Subrecipients are eligible to receive FQHC reimbursement as well as many of the other benefits and privileges of the Health Center Program grantees and Look-Alikes such as 340B Drug Pricing, FTCA coverage (section 330 grantees only).However, the health center AND subrecipient organization are reminded that such benefits are not automatically conferred and may require additional steps and updates (e.g. updating the FTCA deeming folder to ensure that the subrecipient is deemed via the grantee of record’s FTCA coverage).

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6. SERVICES:
Are all the services that will be offered at the proposed site already included within the approved scope of project as documented on your health center’s Form 5A

Yes

No, but a separate CIS Request will be submitted to add all new services to scope.

7. LIMITED SERVICE SITES

Is this a limited service sites that will not offer comprehensive primary care or will not be open to the entire health center patient population (e.g. sites that offer only oral or behavioral health services, sites that are only open to school-aged children, etc.):

How will patients seen at this proposed site be assured access to the full scope of existing required and additional services the health center provides? Please explain

Yes

No

If Yes, explain and address all of the following points as applicable.

• If the site is limited to a certain segment of the health center’s patient population (e.g. school-aged children), how will individuals who present for services at this site be referred to another appropriate health center site for services?

• If the site offers only limited services (e.g. dental-only), how will individuals seen at this site access the full scope of existing required and additional services the health center provides?

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

8. SLIDING FEE DISCOUNT PROGRAM:
Will the health center offer its current sliding fee discount program (sliding fee discount schedule, including any nominal fees and related implementing policies and procedures) at the proposed site to patients with incomes at or below 200 percent of the Federal Poverty Guidelines, and ensure that no patients will be denied access to the service due to inability to pay?

Yes

No

If No, briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

9. Financial Impact Analysis

Template Name	Template Description	Action
Financial Impact Analysis	Template for Financial Impact Analysis
Instructions	Instructions for Financial Impact Analysis

Attach Financial Impact Analysis Document here.

Financial Impact Analysis (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

9a. Explain how the addition of the proposed site to scope will be accomplished and sustained without additional section 330 Health Center Program funds. Specifically (referencing the attached Financial Impact Analysis, as necessary) describe how adequate revenue will be generated to cover all expenses as well as an appropriate share of overhead costs incurred by the health center in administering the new site.

The Financial Impact Analysis must at a minimum show a break-even scenario or the potential for generating additional revenue.

Additional revenue (program income) obtained through the addition of a new site must be invested in activities that further the objectives of the approved health center project, consistent with and not specifically prohibited by statute or regulations.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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9b. Is this change in scope dependent on any special grant, foundation or other funding that is time-limited, e.g., will only be available for 1 or 2 years?

Yes

No

If Yes, how will the new site be supported and sustained when these funds are no longer available? Describe a clear plan for sustaining the site.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)


All time-limited or special one-time funds should be clearly identified as such in the Financial Impact Analysis.

10. STAFFING:
Provide a clear and comprehensive description of the relevant staffing arrangements made to support the proposed new site and to ensure staffing is/will be sufficient to meet any projected patient/visit increases. The discussion of “staffing” should include non-health center employees if the site will be operated via contract or subrecipient arrangement. In addition, describe any potential impact on the overall organization’s staffing plan (reference the Financial Impact Analysis as applicable). Specifically describe any key management staff that will supervise/oversee site operations and who they will report to within the larger health center organizational structure (e.g. CMO, COO, etc.).

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

11. HEALTH CENTER STATUS: Discuss any major changes in the health center’s staffing, financial position, governance, and/or other operational areas, as well as any unresolved areas of non-compliance with Program Requirements (e.g. active Progressive Action conditions) in the past 12 months that might impact the health center’s ability to implement the proposed change in scope.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

12. CREDENTIALING AND PRIVILEGING:
How has the health center planned for the appropriate credentialing and privileging of all provider(s) that will staff the proposed site in accordance with PIN 2002-22?

In responding, consider the following:

• It is the responsibility of the health center to ensure that all credentialing and privileging of providers has been completed BEFORE providing services at the new site as part of their Federal scope of project. This includes services provided either Directly (Form 5A: Column I) OR via a (Form 5A: Column II) Formal Written Agreement (e.g. contract). For services provided via a Formal Written Referral Arrangement (Column III), the referral provider should be able to assure to the health center that all their providers are appropriately credentialed and privileged individually.

• The health center’s current board-approved policy must cover the required verification of credentials and establishment of privileges to perform any new activities and procedures expected of providers by the health center or be updated to do so (for services provided at the new site either Directly (Form 5A: Column I) OR via a (Form 5A: Column II) Formal Written Agreement.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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13. QUALITY IMPROVEMENT/ASSURANCE PLAN:
How will the proposed new site be integrated into and assessed via the health center’s quality improvement/assurance and risk management plans?

In responding, address the following:

• Will it be integrated into the current QI/QA plan?

• Are board-approved peer and chart review policies in place by which all provider(s) at the proposed site will be assessed?

• Are risk management plans in place to assure the new site has appropriate liability coverage (e.g. non-medical/dental professional liability coverage, general liability coverage, automobile and collision coverage, fire coverage, theft coverage, etc.).

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Additional Considerations for Adding a Site to Scope

While the following areas are not specific factors or criteria that will impact the CIS approval process, these are key elements that health centers should have considered or actively planned to address prior to adding a new site to scope.

A. Medical Malpractice Coverage: Your health center must develop plans for any providers that will provide services on behalf of the health center at the new site (e.g., extension of FTCA coverage, private malpractice coverage). Respond the following as applicable:

For grantees deemed under the FTCA, have you reviewed the FTCA Health Center Policy Manual or if appropriate, consulted with BPHC to assure the applicability of FTCA coverage?

The FTCA Health Center Policy Manual is available at:
http://www.bphc.hrsa.gov/policiesregulations/policies/pin201101.html For specific questions, contact the BPHC HelpLine at: 1-877-974-BPHC (2742) or Email: bphchelpline@hrsa.gov. Available Monday to Friday (excluding Federal holidays), from 8:30 AM – 5:30 PM (ET), with extra hours available during high volume periods.

Yes	Not Applicable, health center is not deemed or FTCA coverage does not apply.

If you selected "Not Applicable" respond to the question below.

For health centers not deemed under the FTCA or if FTCA coverage is not applicable to the site, have you developed a plan for medical malpractice coverage?

Yes

No

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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B. Section 340B Drug Pricing Program Participation: Health centers that participate in the 340B Drug Pricing Program are reminded that changes to the scope of project approved by BPHC do not automatically update within the 340B Program’s Database. Health centers should contact the HRSA Office of Pharmacy Affairs to determine whether any updates to the 340B Database are necessary by contacting Apexus Answers at 888-340-2787, or ApexusAnswers@340bpvp.com.

Will your health center complete all necessary 340B Program updates with the HRSA Office of Pharmacy Affairs?

Yes	Not Applicable, health center does not participate in the 340B program

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

C. Facility Requirements: Has your health center assured that any/all Federal, State and local standards/accreditation requirements of the facility where the new site will be established have been fully met (including those associated with CMS FQHC certification)?

Yes	Not Applicable

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

D. Reimbursement as a Federally Qualified Health Center (FQHC) under Medicare, Medicaid and CHIP:

Health centers are required to submit a separate Medicare enrollment application for each “permanent unit” at which they provide services. This includes units considered both “permanent sites” and “seasonal sites” under their HRSA scope of project, but not mobile vans. Health centers are also required to bill each service to Medicare using the unique Medicare Billing Number assigned to the site at which it was provided. Specifically, health centers must inform Medicare of the new site that has been added to scope by submitting a new Medicare Enrollment Application, Form 855A, to their Medicare Administrative Contractor. Form 855A is available at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads//cms855a.pdf. For further information on the Medicare enrollment application process, review Program Assistance Letter 2011-04: Process for Becoming Eligible for Medicare Reimbursement under the FQHC Benefit available at:http://www.bphc.hrsa.gov/policiesregulations/policies/pal201104.html.

In addition, many state Medicaid programs also require all permanent and seasonal sites to enroll individually and bill using a site-specific billing number. For further information about the requirements in a state, health centers should contact their Primary Care Association or State Medicaid Agency.

Will your health center submit a separate Medicare enrollment application for the new site to the appropriate Medicare Administrative Contractor as soon as possible after HRSA’s approval of the Change in Scope, and bill for services provided at this new site using that site’s unique Medicare Billing Number?

Yes	Not Applicable

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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Will your health center determine if a separate Medicaid enrollment application is required for your new site, and if so, submit it as soon as possible?

Yes	Not Applicable

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

E. National Health Service Corps Program Participation: Health centers that participate in the National Health Service Corps (NHSC) are reminded that all NHSC providers must continue to work ONLY at an approved site within the health center's scope of project. Note that there may be some sites within a health center’s scope of project that are not NHSC-eligible (see the Eligibility Requirements and Qualification Factors section of the NHSC Site Reference Guide at http://nhsc.hrsa.gov/downloads/sitereference.pdf for information on eligible and non-eligible NHSC sites).

NHSC sites and participants may contact the NHSC through the Customer Service Portal (https://programportal.hrsa.gov/extranet/landing.seam) or through the Customer Care Center by calling 1-800-221-9393.

In adding this site to your scope, has your health center assessed the impact on any NHSC participants that will be asked to work at this site and advised them that they will need to seek a site reassignment with the NHSC prior to beginning work at this new site?

Yes	Not Applicable, health center does not plan to place any NHSC participants at this site.

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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