1 UDS Tables

Bureau of Primary Health Care

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UNIFORM DATA SYSTEM (UDS)

Calendar Year 2015

UDS Tables

For help contact: 866-837-4357 (866-UDS-HELP) or udshelp330@bphcdata.net

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 0915-0193.  Public reporting burden for this collection of information is estimated to average 170 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information + 22 hours per individual grant report. 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 10C-03I, Rockville, Maryland, 20857.

Reporting Period: January 1, 2015 through December 31, 2015

PATIENTS BY ZIP CODE

ZIP Code (a)	None/ Uninsured (b)	Medicaid/ S-CHIP/ Other Public (c)	Medicare (d)	Private (e)
Other ZIP Codes
Unknown Residence
TOTAL

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 3A – PATIENTS BY AGE AND GENDER

Age Groups		Male Patients (a)	Female Patients (b)
1	Under age 1
2	Age 1
3	Age 2
4	Age 3
5	Age 4
6	Age 5
7	Age 6
8	Age 7
9	Age 8
10	Age 9
11	Age 10
12	Age 11
13	Age 12
14	Age 13
15	Age 14
16	Age 15
17	Age 16
18	Age 17
19	Age 18
20	Age 19
21	Age 20
22	Age 21
23	Age 22
24	Age 23
25	Age 24
26	Ages 25 – 29
27	Ages 30 – 34
28	Ages 35 – 39
29	Ages 40 – 44
30	Ages 45 – 49
31	Ages 50 – 54
32	Ages 55 – 59
33	Ages 60 – 64
34	Ages 65 – 69
35	Ages 70 – 74
36	Ages 75 – 79
37	Ages 80 – 84
38	Age 85 and over
39	Total Patients (Sum Lines 1-38)

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 3B – PATIENTS BY HISPANIC OR LATINO ETHNICITY/RACE/LANGUAGE

		Patients by Hispanic OR Latino Ethnicity
Patients by race		HISPANIC/ LATINO (a)	NOT HISPANIC/ LATINO (b)	UNREPORTED/REFUSED TO REPORT ETHNICITY (c)	TOTAL (d) (Sum Columns a+b+c)
1.	Asian
2a.	Native Hawaiian
2b.	Other Pacific Islander
2.	Total Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b)
3.	Black/African American
4.	American Indian/Alaska Native
5.	White
6.	More than one race
7.	Unreported/Refused to report race
8.	Total Patients (Sum Lines 1+2 + 3 to 7)

PATIENTS by Language		Number (a)
12.	Patients Best Served in a Language Other Than English

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 4 – SELECTED PATIENT CHARACTERISTICS

Characteristic								Number Of Patients ( a )
Income As Percent of Poverty Level
1.			100% and below
2.			101 – 150%
3.			151 – 200%
4.			Over 200%
5.			Unknown
6.			Total (Sum Lines 1 – 5)
Principal Third Party Medical Insurance Source						0-17 years old (a)			18 and older ( b )
7.			None/ Uninsured
8a.			Regular Medicaid (Title XIX)
8b.			CHIP Medicaid
8.			Total Medicaid (Line 8a + 8b)
9.			Medicare (Title XVIII)
9a.			Dually eligible (Medicare + Medicaid) (This is a subset of line 9)
10a.			Other Public Insurance Non-CHIP (specify:)
10b.			Other Public Insurance CHIP
10.			Total Public Insurance (Line 10a + 10b)
11.			Private Insurance
12.			Total (Sum Lines 7 + 8 + 9 +10 +11)
	Managed Care Utilization
	Payor Category			Medicaid ( a )	Medicare ( b )		Other Public Including Non-Medicaid CHIP ( c )			Private ( d )	Total ( e )
	13a.	Capitated Member months
	13b.	Fee-for-service Member months
	13c.	Total Member months ( 13a + 13b)
Characteristics – Special Populations								Number of Patients -- (a)
14.			Migratory (330g grantees only)
15.			Seasonal (330g grantees only)
16.			Total Agricultural Workers or Dependents (All Grantees Report This Line)
17.			Homeless Shelter (330h grantees only)
18.			Transitional (330h grantees only)
19.			Doubling Up (330h grantees only)
20.			Street (330h grantees only)
21.			Other (330h grantees only)
22.			Unknown (330h grantees only)
23.			Total Homeless (All Grantees Report This Line)
24.			Total School Based Health Center Patients (All Grantees Report This Line)
25.			Total Veterans (All grantees report this line)
26.			Total Public Housing Patients (All Health Centers Report This Line)

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 5 – STAFFING AND UTILIZATION

Personnel by Major Service Category		FTEs ( a )	Clinic Visits ( b )	Patients ( c )
1	Family Physicians
2	General Practitioners
3	Internists
4	Obstetrician/Gynecologists
5	Pediatricians
6
7	Other Specialty Physicians
8	Total Physicians (Lines 1 - 7)
9a	Nurse Practitioners
9b	Physician Assistants
10	Certified Nurse Midwives
10a	Total NP, PA, and CNMs (Lines 9a - 10)
11	Nurses
12	Other Medical personnel
13	Laboratory personnel
14	X-ray personnel
15	Total Medical (Lines 8 + 10a through 14)
16	Dentists
17	Dental Hygienists
18	Dental Assistants, Aides, Techs
19	Total Dental Services (Lines 16 - 18)
20a	Psychiatrists
20a1	Licensed Clinical Psychologists
20a2	Licensed Clinical Social Workers
20b	Other Licensed Mental Health Providers
20c	Other Mental Health Staff
20	Total Mental Health (Lines 20a-c)
21	Substance Abuse Services
22	Other Professional Services (specify___)
22a	Ophthalmologist
22b	Optometrist
22c	Other Vision Care Staff
22d	Total Vision Services (Lines 22a-c)
23	Pharmacy Personnel
24	Case Managers
25	Patient/Community Education Specialists
26	Outreach Workers
27	Transportation Staff
27a	Eligibility Assistance Workers
27b	Interpretation Staff
28	Other Enabling Services (specify___)
29	Total Enabling Services (Lines 24 - 28)
29a	Other Programs/Services (specify___)
30a	Management and Support Staff
30b	Fiscal and Billing Staff
30c	IT Staff
31	Facility Staff
32	Patient Support Staff
33	Total Facility and Non-Clinical Support Staff (Lines 30a - 32)
34	Grand Total Lines 15+19+20+21+22+22d+23+29+29a+33

Reporting Period: January 1, 2015 through December 31, 2015

Table 5A – Tenure for Health Center Staff

Health Center Staff		Full and part time			Locum, On-call, etc.
		Persons (a)		Total months (b)	Persons (c)	Total months (d)
1	Family Physicians
2	General Practitioners
3	Internists
4	Obstetrician/Gynecologists
5	Pediatricians
7	Other Specialty Physicians
9a	Nurse Practitioners
9b	Physician Assistants
10	Certified Nurse Midwives
11	Nurses
16	Dentists
17	Dental Hygienists
20a	Psychiatrists
20a1	Licensed Clinical Psychologists
20a2	Licensed Clinical Social Workers
20b	Other Licensed Mental Health Providers
22a	Ophthalmologist
22b	Optometrist
30a1	Chief Executive Officer
30a2	Chief Medical Officer
30a3	Chief Financial Officer
30a4	Chief Information Officer

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 6A – SELECTED DIAGNOSES AND SERVICES RENDERED

Diagnostic Category		Applicable ICD-9-CM Code	Number of Visits by Diagnosis regardless of primacy (A)	Number of Patients with Diagnosis regardless of primacy (B)
Selected Infectious and Parasitic Diseases
1-2.	Symptomatic HIV , Asymptomatic HIV	042 , 079.53, V08
1-2a.	Newly diagnosed HIV	(see instructions)
3.	Tuberculosis	010.xx – 018.xx
4.	Syphilis and other sexually transmitted infections	090.xx – 099.xx
4a.	Hepatitis B	070.20, 070.22, 070.30, 070.32
4b.	Hepatitis C	070.41, 070.44, 070.51, 070.54, 070.70, 070.71
Selected Diseases of the Respiratory System
5.	Asthma	493.xx
6.	Chronic bronchitis and emphysema	490.xx – 492.xx
Selected Other Medical Conditions
7.	Abnormal breast findings, female	174.xx; 198.81; 233.0x; 238.3 793.8x
8.	Abnormal cervical findings	180.xx; 198.82; 233.1x; 795.0x
9.	Diabetes mellitus	250.xx; 648.0x; 775.1x
10.	Heart disease (selected)	391.xx – 392.0x 410.xx – 429.xx
11.	Hypertension	401.xx – 405.xx;
12.	Contact dermatitis and other eczema	692.xx
13.	Dehydration	276.5x
14.	Exposure to heat or cold	991.xx – 992.xx
14a.	Overweight and obesity	ICD-9 : 278.0 – 278.02 or V85.xx excluding V85.0, V85.1, V85.51 V85.52
Selected Childhood Conditions
15.	Otitis media and eustachian tube disorders	381.xx – 382.xx
16.	Selected perinatal medical conditions	770.xx; 771.xx; 773.xx; 774.xx – 779.xx (excluding 779.3x)
17.	Lack of expected normal physiological development (such as delayed milestone; failure to gain weight; failure to thrive); Does not Include Sexual or Mental Development; Nutritional deficiencies	260.xx – 269.xx; 779.3x; 783.3x – 783.4x;

TABLE 6A – SELECTED DIAGNOSES AND SERVICES RENDERED

Diagnostic Category			Applicable ICD-9-CM Code	Number of Visits by Diagnosis regardless of primacy (A)	Number of Patients with Diagnosis regardless of primacy (B)
Selected Mental Health and Substance Abuse Conditions
18.	Alcohol related disorders	291.xx, 303.xx; 305.0x 357.5x
19.	Other substance related disorders (excluding tobacco use disorders)	292.1x – 292.8x 304.xx, 305.2x – 305.9x 357.6x, 648.3x
19a.	Tobacco use disorder	305.1
20a.	Depression and other mood disorders	296.xx, 300.4 301.13, 311.xx
20b.	Anxiety disorders including PTSD	300.0x, 300.2x, 300.3, 308.3, 309.81
20c.	Attention deficit and disruptive behavior disorders	312.8x, 312.9x, 313.81, 314.xx
20d.	Other mental disorders, excluding drug or alcohol dependence (includes mental retardation)	290.xx 293.xx – 302.xx (excluding 296.xx, 300.0x, 300.2x, 300.3, 300.4, 301.13);  306.xx - 319.xx (excluding 308.3, 309.81, 311.xx, 312.8x, 312.9x,313.81,314.xx)

TABLE 6A – SELECTED SERVICES RENDERED      

Service Category		Applicable ICD-9-CM or CPT-4 Code	Number of Visits (A)	Number of Patients (B)
Selected Diagnostic Tests/Screening/Preventive Services
21.	HIV test	CPT-4: 86689; 86701-86703; 87390-87391
21a.	Hepatitis B test	CPT-4: 86704, 86706, 87515-17
21b.	Hepatitis C test	CPT-4: 86803-04, 87520-22
22.	Mammogram	CPT-4: 77052, 77057 OR ICD-9: V76.11; V76.12
23.	Pap test	CPT-4: 88141-88155; 88164-88167, 88174-88175 OR ICD-9: V72.3; V72.31; V76.2
24.	Selected Immunizations: Hepatitis A, Hemophilus Influenza B (HiB), Pneumococcal, Diptheria, Tetanus, Pertussis (DTaP) (DTP) (DT), Mumps, Measles, Rubella, Poliovirus, Varicella, Hepatitis B Child)	CPT-4: 90633-90634, 90645 – 90648; 90670; 90696 – 90702; 90704 – 90716; 90718 - 90723; 90743 – 90744; 90748
24a.	Seasonal Flu vaccine	CPT-4: 90655 - 90662
25.	Contraceptive management	ICD-9: V25.xx
26.	Health supervision of infant or child (ages 0 through 11)	CPT-4: 99391-99393; 99381-99383;
26a.	Childhood lead test screening (9 to 72 months)	CPT-4: 83655
26b.	Screening, Brief Intervention, and Referral to Treatment (SBIRT)	CPT-4: 99408-99409
26c.	Smoke and tobacco use cessation counseling	CPT-4:  99406 and 99407; S9075
26d.	Comprehensive and intermediate eye exams	CPT-4: 92002, 92004, 92012, 92014
Service Category		Applicable ADA Code	Number of Visits (A)	Number of Patients (B)
Selected Dental Services
27.	I. Emergency Services	ADA : D9110
28.	II. Oral Exams	ADA : D0120, D0140, DO145, D0150, D0160, D0170, D0180
29.	Prophylaxis – adult or child	ADA : D1110, D1120,
30.	Sealants	ADA : D1351
31.	Fluoride treatment – adult or child	ADA : D1203, D1204, D1206
32.	III. Restorative Services	ADA : D21xx – D29xx
33.	IV. Oral Surgery (extractions and other surgical procedures)	ADA : D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7260, D7261, D7270, D7272, D7280
34.	V. Rehabilitative services (Endo, Perio, Prostho, Ortho)	ADA : D3xxx, D4xxx, D5xxx , D6xxx, D8xxx

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 6B – QUALITY OF CARE MEASURES

	Section A: Age Categories for Prenatal Patients
	DEMOGRAPHIC CHARACTERISTICS OF PRENATAL CARE PATIENTS
	AGE				NUMBER OF PATIENTS ( a )
	1		Less than 15 years
	2		Ages 15-19
	3		Ages 20-24
	4		Ages 25-44
	5		Ages 45 and Over
	6		Total Patients (Sum lines 1 – 5)
Section B – Trimester of Entry Into Prenatal Care
Trimester of First Known Visit for Women Receiving Prenatal Care During Reporting Year				Women Having First Visit with Health Center ( a )			Women Having First Visit with Another Provider ( b )
7		First Trimester
8		Second Trimester
9		Third Trimester
Section C – Childhood Immunization
Childhood Immunization				Total Number of patients with 3rd birthday during measurement year ( a )		Number Charts Sampled or EHR total ( b )		Number of Patients Immunized ( c )
10		MEASURE: Children who have received age appropriate vaccines prior to their 3rd birthday during measurement year (on or prior to December 31)
Section D – Cervical Cancer Screening
Pap Tests				Total number of Female Patients 24-64 years of Age ( a )		Number Charts Sampled or EHR total ( b )		Number of Patients Tested ( c )
11		MEASURE: Female patients aged 24-64 who received one or more Pap tests to screen for cervical cancer

Section E – Weight Assessment and Counseling for Children and Adolescents
Child and Adolescent Weight Assessment and Counseling		Total patients aged 3 – 17 on December 31 ( a )	Number Charts Sampled or EHR Total ( b )	Number of patients with counseling and BMI documented ( c )
12	MEASURE: Children and adolescents aged 3 until 17 during measurement year (on or prior to 31 December) with a BMI percentile, and counseling on nutrition and physical activity documented for the current year
Section F – Adult Weight Screening and Follow-up
Adult Weight Screening and Follow-up		Total patients aged 18 and older ( a )	Number Charts sampled or EHR total ( b )	Number of patients with BMI charted and follow-up plan documented as appropriate ( c )
13	MEASURE: Patients aged 18 and older with (1)_BMI charted and (2) follow-up plan documented if patients are overweight or underweight
Section G – Tobacco Use Screening and Cessation Intervention
Tobacco Use Screening and Cessation Intervention		Total patients aged 18 and older ( a )	Number Charts sampled or EHR total ( b )	Number of patients assessed for tobacco use And provided Intervention if a Tobacco User ( c )
14a	MEASURE: Patients aged 18 and older who (1) were screened for tobacco use one or more times in the measurement year or the prior year AND (2) for those found to be a tobacco user, received cessation counseling intervention or medication

Section H – Asthma Pharmacological Therapy
Asthma Treatment Plan		Total Patients aged 5 - 40 with persistent asthma ( a )	Number Charts Sampled or EHR Total ( b )	Number of Patients with Acceptable Plan ( c )
16	MEASURE: Patients aged 5 through 40 diagnosed with persistent asthma who have an acceptable pharmacological treatment plan
Section I – Coronary Artery Disease (CAD): Lipid Therapy
Lipid Therapy		Total Patients aged 18 And Older With CAD Diagnosis ( a )	Number Charts Sampled or EHR Total ( b )	Number of Patients Prescribed A Lipid Lowering Therapy ( c )
17	MEASURE: Patients aged 18 and older with a diagnosis of CAD who were prescribed a lipid lowering therapy
Section J – Ischemic Vascular Disease (IVD): Aspirin or Antithrombotic Therapy
Aspirin or Other Antithrombotic Therapy		Total Patients 18 And Older With IVD Diagnosis or AMI, CABG, or PTCA Procedure ( a )	Charts Sampled or EHR Total ( b )	Number of Patients With Aspirin or Other Antithrombotic Therapy ( c )
18	MEASURE: Patients aged 18 and older with a diagnosis of IVD or AMI,CABG, or PTCA procedure with aspirin or another antithrombotic therapy
Section K – Colorectal Cancer Screening
Colorectal Cancer Screening		Total Patients 51 through 74 Years of age ( a )	Charts Sampled or EHR Total ( b )	Number of Patients With Appropriate Screening For Colorectal Cancer ( c )
19	MEASURE: Patients age 51 through 74 years of age during measurement year (on or prior to 31 December) with appropriate screening for colorectal cancer

Section L – Newly Identified HIV Cases and Follow-up
New HIV Cases with Timely Follow-up		Total Patients First Diagnosed with HIV ( a )	Charts Sampled or EHR Total ( b )	Number of Patients Seen Within 90 Days of First Diagnosis of HIV ( c )
20	MEASURE: Patients whose first ever HIV diagnosis was made by health center staff between October 1 of the prior year and September 30 of the measurement year and who were seen for follow-up treatment within 90 days of that first ever diagnosis
Section M – Patients Screened for Depression and Follow-up
Patients Screened for Depression and Follow-up		Total Patients Aged 12 and Older ( a )	Charts Sampled or EHR Total ( b )	Number of patients Screened for Depression and Follow-Up Plan Documented as appropriate ( c )
21	MEASURE: Patients aged 12 and older who were (1) screened for depression with a standardized tool and if screening was positive (2) had a follow-up plan documented
Section N – Sealants to First Molars
Sealants to First Molars		Total Patients Aged 6 Through 9 ( a )	Charts Sampled or EHR Total ( b )	Number of patients with Sealants to First Molars ( c )
22	MEASURE: Children age 6-9 years at “elevated” risk who received a sealant on a permanent first molar tooth

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES

Section A: Deliveries and Birth Weight by Race and Hispanic/Latino Ethnicity

0	HIV Positive Pregnant Women
2	Deliveries Performed by Grantee’s Providers
Line #	Race and Ethnicity	Prenatal Care Patients Who Delivered During the Year (1a)	Live Births: <1500 grams (1b)	Live Births: 1500-2499 grams (1c)	Live Births: =>2500 grams (1d)
Hispanic/Latino
1a	Asian
1b1	Native Hawaiian
1b2	Other Pacific Islander
1c	Black/African American
1d	American Indian/Alaska Native
1e	White
1f	More than One Race
1g	Unreported/Refused to Report Race
	Subtotal Hispanic/Latino
Non-Hispanic/Latino
2a	Asian
2b1	Native Hawaiian
2b2	Other Pacific Islander
2c	Black/African American
2d	American Indian/Alaska Native
2e	White
2f	More than One Race
2g	Unreported/Refused to Report Race
	Subtotal Non-Hispanic/Latino
Unreported/Refused to Report Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES

Section B: Hypertension by Race and Hispanic/Latino Ethnicity

#	Race and Ethnicity	Total Hypertensive Patients (2a)	Charts Sampled or EHR Total (2b)	Patients with HTN Controlled (2c)
Hispanic/Latino
1a	Asian
1b1	Native Hawaiian
1b2	Other Pacific Islander
1c	Black/African American
1d	American Indian/Alaska Native
1e	White
1f	More than One Race
1g	Unreported/Refused to Report Race
	Subtotal Hispanic/Latino
Non-Hispanic/Latino
2a	Asian
2b1	Native Hawaiian
2b2	Other Pacific Islander
2c	Black/African American
2d	American Indian/Alaska Native
2e	White
2f	More than One Race
2g	Unreported/Refused to Report Race
	Subtotal Non-Hispanic/Latino
Unreported/Refused to Report Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES

Section C: Diabetes by Race and Hispanic/Latino Ethnicity

#	Race and Ethnicity	Total Patients with Diabetes (3a)	Charts Sampled or EHR Total (3b)	Patients with Hba1c <8% (3d1)	Patients with Hba1c >9% Or No Test During Year (3f)
Hispanic/Latino
1a	Asian
1b1	Native Hawaiian
1b2	Other Pacific Islander
1c	Black/African American
1d	American Indian/Alaska Native
1e	White
1f	More than One Race
1g	Unreported/Refused to Report Race
	Subtotal Hispanic/Latino
Non-Hispanic/Latino
2a	Asian
2b1	Native Hawaiian
2b2	Other Pacific Islander
2c	Black/African American
2d	American Indian/Alaska Native
2e	White
2f	More than One Race
2g	Unreported/Refused to Report Race
	Subtotal Non-Hispanic/Latino
Unreported/Refused to Report Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 8A – FINANCIAL COSTS

		Accrued Cost ( a )	Allocation of Facility and Non-Clinical Support Services ( b )	Total Cost After Allocation of Facility and Non-Clinical Support Services ( c )
Financial Costs for Medical Care
1.	Medical Staff			[Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document. Use the Drawing Tools tab to change the formatting of the pull quote text box.]
2.	Lab and X-ray
3.	Medical/Other Direct
4.	TOTAL MEDICAL CARE SERVICES (Sum Lines 1 Through 3)
Financial Costs for Other Clinical Services
5.	Dental
6.	Mental Health
7.	Substance Abuse
8a.	Pharmacy not including pharmaceuticals
8b.	Pharmaceuticals
9.	Other Professional (Specify ___________)
9a.	Vision
10.	TOTAL OTHER CLINICAL SERVICES (Sum Lines 5 through 9a)
Financial Costs of Enabling and Other Program Related Services
11a.	Case Management
11b.	Transportation
11c.	Outreach
11d.	Patient and Community Education
11e.	Eligibility Assistance
11f.	Interpretation Services
11g.	Other Enabling Services (specify: ___________)
11.	Total Enabling Services Cost (Sum Lines 11a through 11g)
12.	Other Related Services (specify:________________)
13.	TOTAL ENABLING AND OTHER SERVICES (Sum Lines 11 and 12)
Facility and Non-Clinical Support Services and Totals
14.	Facility
15.	Non Clinical Support Services
16.	TOTAL Facility and Non Clinical Support Services (Sum lines 14 and 15)
17.	TOTAL ACCRUED COSTS (Sum Lines 4 + 10 + 13 + 16)
18.	Value of Donated Facilities, Services, and Supplies (specify: _________________________)
19.	TOTAL WITH DONATIONS (Sum Lines 17 and 18)

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 9D (Part I of II) – PATIENT RELATED REVENUE (Scope of Project Only)

Payor Category		Full Charges This Period (a)	Amount Collected This Period (b)	Retroactive Settlements, Receipts, and Paybacks (c)				Allowances (d)	Sliding Discounts (e)	Bad Debt Write Off (f)
				Collection of reconciliation/wrap around Current Year (c1)	Collection of Reconciliation/wrap around Previous Years (c2)	Collection of other retroactive payments including risk pool/ incentive/ withhold (c3)	Penalty/ Payback (c4)
1.	Medicaid Non-Managed Care
2a.	Medicaid Managed Care (capitated)
2b.	Medicaid Managed Care (fee-for-service)
3.	Total Medicaid (Lines 1+ 2a + 2b)
4.	Medicare Non-Managed Care
5a.	Medicare Managed Care (capitated)
5b.	Medicare Managed Care (fee-for-service)
6.	Total Medicare (Lines 4 + 5a+ 5b)
7.	Other Public including Non-Medicaid CHIP (Non Managed Care)
8a.	Other Public including Non-Medicaid CHIP (Managed Care Capitated)

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 9D (Part II of II) – PATIENT RELATED REVENUE (Scope of Project Only)

Payor Category		Full Charges This Period (a)	Amount Collected This Period (b)	Retroactive Settlements, Receipts, and Paybacks (c)				Allowances (d)	Sliding Discounts (e)	Bad Debt Write Off (f)
				Collection of reconciliation/wrap around Current Year (c1)	Collection of Reconciliation/wrap around Previous Years (c2)	Collection of other retroactive payments including risk pool/ incentive/ withhold (c3)	Penalty/ Payback (c4)
8b.	Other Public including Non-Medicaid CHIP (Managed Care fee-for-service)
9.	Total Other Public (Lines 7+ 8a +8b)
10.	Private Non-Managed Care
11a.	Private Managed Care (capitated)
11b.	Private Managed Care (fee-for-service)
12.	Total Private (Lines 10 + 11a + 11b)
13.	Self Pay
14.	TOTAL (Lines 3 + 6 + 9 + 12 + 13)

Reporting Period: January 1, 2015 through December 31, 2015

TABLE 9E – OTHER REVENUES

Source		Amount (a)
BPHC Grants (Enter Amount Drawn Down – Consistent with PMS-272)
1a.	Migrant Health Center
1b.	Community Health Center
1c.	Health Care for the Homeless
1e.	Public Housing Primary Care
1g.	Total Health Center (Sum Lines 1a through 1e)
1j.	Capital Improvement Program Grants (excluding ARRA)
1k.	Affordable Care Act (ACA) Capital Development Grants, including School Based Health Center Capital Grants
1.	Total BPHC Grants (Sum Lines 1g + 1j + 1k)
Other Federal Grants
2.	Ryan White Part C HIV Early Intervention
3.	Other Federal Grants (specify:________________)
3a.	Medicare and Medicaid EHR Incentive Payments for Eligible Providers
4a.	American Recovery and Reinvestment Act (ARRA) Capital Improvement Project (CIP) and Facility Investment Program (FIP)
5.	Total Other Federal Grants (Sum Lines 2 – 4a)
Non-Federal Grants or Contracts
6.	State Government Grants and Contracts (specify:______________)
6a.	State/Local Indigent Care Programs (specify:________________)
7.	Local Government Grants and Contracts (specify:_______________)
8.	Foundation/Private Grants and Contracts (specify: ______________)
9.	Total Non-Federal Grants and Contracts (Sum Lines 6 +6A + 7+8)
10.	Other Revenue (Non-patient related revenue not reported elsewhere) (specify:________________)
11.	Total Revenue (Lines 1+5+9+10)

OMB Number: 0915-0193, Expiration Date: xx/xx/201x