UDS Tables (redlined)

Uniform Data System

Reporting Tables

Table Patients by ZIP Code

Reporting Period: January 1, 2019, through December 31, 2019

ZIP Code (a)	None/Uninsured (b)	Medicaid / CHIP / Other Public (c)	Medicare (d)	Private (e)	Total Patients (f)
[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration] [Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
Other ZIP Codes	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
Unknown Residence	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
Total	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]

Note: This is a representation of the form. The actual online input process looks significantly different, and the printed output from EHB may be modified

Table 3A: Patients by Age and by Sex Assigned at Birth

Reporting Period: January 1, 2019, through December 31, 2019

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

Table 3B: Demographic Characteristics

Reporting Period: January 1, 2019, through December 31, 2019

Patients by Hispanic or Latino Ethnicity

Line	Patients By Race	Hispanic/ Latino (a)	Non-Hispanic/ Latino (b)	Unreported/ Refused to Report Ethnicity (c)	Total (d) (Sum Columns a+b+c)
1.	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2a.	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b.	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2.	Total Native Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
3.	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
4.	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
5.	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
6.	More than one race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
7.	Unreported/Refused to report race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
8.	Total Patients (Sum Lines 1+2 + 3 to 7)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Line	Patients by Language	Number (a)
12.	Patients Best Served in a Language Other Than English	<blank for demonstration>

Line	Patients by Sexual Orientation	Number (a)		Line	Patients by Gender Identity	Number (a)
13.	Lesbian or Gay			20.	Male
14.	Straight (not lesbian or gay)			21.	Female
15.	Bisexual			22.	Transgender Male/ Female-to-Male
16.	Something else			23.	Transgender Female/ Male-to-Female
17.	Don’t know			24.	Other
18.	Chose not to disclose			25.	Chose not to disclose
19.	Total Patients (Sum Lines 13 to 18)			26.	Total Patients (Sum Lines 20 to 25)

Table 4: Selected Patient Characteristics

Reporting Period: January 1, 2019, through December 31, 2019

Line	Characteristic	Number of Patients
Line	Income as Percent of Poverty Guideline	Number of Patients (a)
1.	100% and below	<blank for demonstration>
2.	101–150%	<blank for demonstration>
3.	151–200%	<blank for demonstration>
4	Over 200%	<blank for demonstration>
5.	Unknown	<blank for demonstration>
6.	TOTAL (Sum Lines 1–5)	<blank for demonstration>

Line	Principal Third -Party Medical Insurance	0-17 years old (a)	18 and older (b)
7.	None/Uninsured	<blank for demonstration>	<blank for demonstration>
8a.	Regular Medicaid (Title XIX)	<blank for demonstration>	<blank for demonstration>
8b.	CHIP Medicaid	<blank for demonstration>	<blank for demonstration>
8.	Total Medicaid (Line 8a + 8b)	<blank for demonstration>	<blank for demonstration>
9a.	Dually Eligible (Medicare and Medicaid)
9.	Medicare (Inclusive of dually eligible and other Title XVIII beneficiaries)	<blank for demonstration>	<blank for demonstration>
10a.	Other Public Insurance Non-CHIP (specify:)	<blank for demonstration>	<b<blank for demonstration>lank for demonstration>
10b.	Other Public Insurance CHIP	<blank for demonstration>
10.	Total Public Insurance (Line 10a + 10b)	<blank for demonstration>	<blank for demonstration>
11.	Private Insurance	<blank for demonstration>	<blank for demonstration>
12.	TOTAL (Sum Lines 7 + 8 + 9 +10 +11)	<blank for demonstration>	<blank for demonstration>

Line	Managed Care Utilization Payer Category	Medicaid (a)	Medicare (b)	Other Public Including Non-Medicaid CHIP (c)	Private (d)	TOTAL (e)
13a.	Capitated Member months	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
13b.	Fee-for-service Member months	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
13c.	Total Member months (Sum Lines 13a + 13b)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Line	Special Populations	Number of Patients (a)
14.	Migratory (330g grantees only)	<blank for demonstration>
15.	Seasonal (330g grantees only)	<blank for demonstration>
16.	Total Agricultural Workers or Dependents (All Health Centers Report This Line)	<blank for demonstration>
17.	Homeless Shelter (330h grantees only)	<blank for demonstration>
18.	Transitional (330h grantees only)	<blank for demonstration>
19.	Doubling Up (330h grantees only)	<blank for demonstration>
20.	Street (330h grantees only)	<blank for demonstration>
21.	Other (330h grantees only)	<blank for demonstration>
22.	Unknown (330h grantees only)	<blank for demonstration>
23.	Total Homeless (All Health Centers Report This Line)	<blank for demonstration>
24.	Total School-Based Health Center Patients (All Health Centers Report This Line)	<blank for demonstration>
25.	Total Veterans (All Health Centers Report This Line)	<blank for demonstration>
26.	Total Patients Served at a Health Center Located In or Immediately Accessible to a Public Housing Site (All Health Centers Report This Line)	<blank for demonstration>

Table 5: Staffing and Utilization

Reporting Period: January 1, 2019, through December 31, 2019

Line	Personnel by Major Service Category	FTEs (a)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
1	Family Physicians
2	General Practitioners
3	Internists
4	Obstetrician/Gynecologists
5	Pediatricians
7	Other Specialty Physicians
8	Total Physicians (Lines 1–7)
9a	Nurse Practitioners
9b	Physician Assistants
10	Certified Nurse Midwives
10a	Total NPs, PAs, 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
17a	Dental Therapists
18	Other Dental Personnel
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	Total Substance Use Disorder Services
22	Other Professional Services (specify)
22a	Ophthalmologists
22b	Optometrists
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
27c	Community Health Workers
28	Other Enabling Services (specify)
29	Total Enabling Services (Lines 24–28)
29a	Other Programs/Services (specify)
29b	Quality Improvement Staff
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+29b+33)

Selected Service Detail
	Mental Health Service Detail	Personnel (a1)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
20a01	Physicians (other than psychiatrists)
20a02	Nurse Practitioners
20a03	Physician Assistants
20a04	Clinical Nurse Midwives
20a05	Clinical Nurse Specialists
	Substance Use Disorder Detail	Personnel (a1)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
21a	Psychiatrists
21b	Physicians (other than psychiatrists)
21c	Nurse Practitioners
21d	Physician Assistants
21e	Clinical Nurse Midwives
21f	Clinical Nurse Specialists
21g	Licensed Clinical Psychologists
21h	Licensed Clinical Social Worker

Table 6A: Selected Diagnoses and Services Rendered

Reporting Period: January 1, 2019, through December 31, 2019

Table 6A: Selected Diagnoses

Line	Diagnostic Category	Applicable ICD-10-CM Code	Number of Visits by Diagnosis Regardless of Primacy (a)	Number of Patients with Diagnosis (b)
Selected Infectious and Parasitic Disease	Selected Infectious and Parasitic Diseases	Selected Infectious and Parasitic Diseases	Selected Infectious and Parasitic Diseases	Selected Infectious and Parasitic Diseases
1-2.	Symptomatic / Asymptomatic HIV	B20, B97.35, O98.7-, Z21	<blank for demonstration>	<blank for demonstration>
3.	Tuberculosis	A15- through A19-	<blank for demonstration>	<blank for demonstration>
4.	Sexually transmitted infections	A50- through A64- (exclude A63.0), M02.3-	<blank for demonstration>	<blank for demonstration>
4a.	Hepatitis B	B16.0 through B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51	<blank for demonstration>	<blank for demonstration>
4b.	Hepatitis C	B17.10, B17.11, B18.2, B19.20, B19.21	<blank for demonstration>	<blank for demonstration>
Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System
5.	Asthma	J45-	<blank for demonstration>	<blank for demonstration>
6.	Chronic obstructive pulmonary diseases	J40- through J44-, J47-	<blank for demonstration>	<blank for demonstration>
Selected Other Medical Conditions	Selected Other Medical Conditions	Selected Other Medical Conditions	Selected Other Medical Conditions	Selected Other Medical Conditions
7.	Abnormal breast findings, female	C50.01-, C50.11-, C50.21-, C50.31-, C50.41-, C50.51-, C50.61-, C50.81-, C50.91-, C79.81, D05-, D48.6-, N63-, R92-	<blank for demonstration>	<blank for demonstration>
8.	Abnormal cervical findings	C53-, C79.82, D06-, R87.61-, R87.810, R87.820	<blank for demonstration>	<blank for demonstration>
9.	Diabetes mellitus	E08- through E13-, O24- (exclude O24.41-)	<blank for demonstration>	<blank for demonstration>
10.	Heart disease (selected)	I01-, I02- (exclude I02.9), I20- through I25-, I27-, I28-, I30- through I52-	<blank for demonstration>	<blank for demonstration>
11.	Hypertension	I10- through I16-	<blank for demonstration>	<blank for demonstration>
12.	Contact dermatitis and other eczema	L23- through L25-, L30- (exclude L30.1, L30.3, L30.4, L30.5), L55- through L59- (exclude L57.0 through L57.4)	<blank for demonstration>	<blank for demonstration>
13.	Dehydration	E86-	<blank for demonstration>	<blank for demonstration>
14.	Exposure to heat or cold	T33-, T34-, T67-, T68-, T69-	<blank for demonstration>	<blank for demonstration>
14a.	Overweight and obesity	E66-, Z68- (exclude Z68.1, Z68.20 through Z68.24, Z68.51. Z68.52)	<blank for demonstration>	<blank for demonstration>
Selected Childhood Conditions (limited to ages 0 thru 17)	Selected Childhood Conditions (limited to ages 0 through 17)	Selected Childhood Conditions (limited to ages 0 thru 17)	Selected Childhood Conditions (limited to ages 0 thru 17)	Selected Childhood Conditions (limited to ages 0 thru 17)
15.	Otitis media and Eustachian tube disorders	H65- through H69-	<blank for demonstration>	<blank for demonstration>
16.	Selected perinatal medical conditions	A33-, P22- through P29- (exclude P29.3), P35- through P96- (exclude P54-, P91.6-, P92-, P96.81), R78.81, R78.89	<blank for demonstration>	<blank for demonstration>
17.	Lack of expected normal physiological development (such as delayed milestone; failure to gain weight; failure to thrive); Nutritional deficiencies in children only. Does not include sexual or mental development.	E40- through E46-, E50- through E63-, P92-, R62- (exclude R62.7), R63.2, R63.3	<blank for demonstration>	<blank for demonstration>
Selected Mental Health and Substance Abuse Conditions	Selected Mental Health and Substance Abuse Conditions	Selected Mental Health and Substance Abuse Conditions	Selected Mental Health and Substance Abuse Conditions	Selected Mental Health and Substance Abuse Conditions
18.	Alcohol related disorders	F10-, G62.1	<blank for demonstration>	<blank for demonstration>
19.	Other substance related disorders (excluding tobacco use disorders)	F11- through F19- (exclude F17-), G62.0, O99.32-	<blank for demonstration>	<blank for demonstration>
19a.	Tobacco use disorder	F17-	<blank for demonstration>	<blank for demonstration>
20a.	Depression and other mood disorders	F30- through F39-	<blank for demonstration>	<blank for demonstration>
20b.	Anxiety disorders including PTSD	F06.4, F40- through F42-, F43.0, F43.1-, F93.0	<blank for demonstration>	<blank for demonstration>
20c.	Attention deficit and disruptive behavior disorders	F90- through F91-	<blank for demonstration>	<blank for demonstration>
20d.	Other mental disorders, excluding drug or alcohol dependence	F01- through F09- (exclude F06.4), F20- through F29-, F43- through F48- (exclude F43.0- and F43.1-), F50- through F59- (exclude F55-), F60- through F99- (exclude F84.2, F90-, F91-, F98-), R45.1, R45.2, R45.5, R45.6, R45.7, R45.81, R45.82, R48.0	<blank for demonstration>	<blank for demonstration>

Table 6A: Selected Services Rendered

Line	Service Category	Applicable ICD-10-CM Code or CPT-4/II Code	Number of Visits (a)	Number of Patients (b)
Selected Diagnostic Tests/Screening/Preventive Services	Selected Diagnostic Tests/ Screening/Preventive Services	Selected Diagnostic Tests/Screening/Preventive Services	Selected Diagnostic Tests/Screening/Preventive Services	Selected Diagnostic Tests/Screening/Preventive Services
21.	HIV test	CPT-4: 86689; 86701 through 86703; 87389 through 87391	<blank for demonstration>	<blank for demonstration>
21a.	Hepatitis B test	CPT-4: 86704, 86706, 87515 through 87517	<blank for demonstration>	<blank for demonstration>
21b.	Hepatitis C test	CPT-4: 86803, 86804, 87520 through 87522	<blank for demonstration>	<blank for demonstration>
22.	Mammogram	CPT-4: 77052, 77057, 77065, 77066, 77067 OR ICD-10: Z12.31	<blank for demonstration>	<blank for demonstration>
23.	Pap test	CPT-4: 88141 through 88155, 88164 through 88167, 88174, 88175 OR ICD-10: Z01.41-, Z01.42, Z12.4 (exclude Z01.411 and Z01.419)	<blank for demonstration>	<blank for demonstration>
24.	Selected Immunizations: Hepatitis A, Hemophilus Influenza B (HiB), Pneumococcal, Diphtheria, Tetanus, Pertussis (DTaP) (DTP) (DT), Mumps, Measles, Rubella, Poliovirus, Varicella, Hepatitis B Child)	CPT-4: 90633, 90634, 90645 through 90648, 90670, 90696 through 90702, 90704 through 90716, 90718 through 90723, 90743, 90744, 90748	<blank for demonstration>	<blank for demonstration>
24a.	Seasonal Flu vaccine	CPT-4: 90654 through 90662, 90672, 90673, 90685 through 90688	<blank for demonstration>	<blank for demonstration>
25.	Contraceptive management	ICD-10: Z30-	<blank for demonstration>	<blank for demonstration>
26.	Health supervision of infant or child (ages 0 through 11)	CPT-4: 99381 through 99383, 99391 through 99393	<blank for demonstration>	<blank for demonstration>
26a.	Childhood lead test screening (9 to 72 months)	CPT-4: 83655	<blank for demonstration>	<blank for demonstration>
26b.	Screening, Brief Intervention, and Referral to Treatment (SBIRT)	CPT-4: 99408, 99409 HCPCS: G0396, G0397, H0050	<blank for demonstration>	<blank for demonstration>
26c.	Smoke and tobacco use cessation counseling	CPT-4:  99406, 99407 OR HCPCS: S9075 OR CPT-II: 4000F, 4001F	<blank for demonstration>	<blank for demonstration>
26d.	Comprehensive and intermediate eye exams	CPT-4: 92002, 92004, 92012, 92014	<blank for demonstration>	<blank for demonstration>

Line	Service Category	Applicable ADA Code	Number of Visits (a)	Number of Patients (b)
Selected Dental Services	Selected Dental Services	Selected Dental Services	Selected Dental Services	Selected Dental Services
27.	I. Emergency Services	ADA: D9110	<blank for demonstration>	<blank for demonstration>
28.	II. Oral Exams	ADA: D0120, D0140, DO145, D0150, D0160, D0170, D0171, D0180	<blank for demonstration>	<blank for demonstration>
29.	Prophylaxis – adult or child	ADA: D1110, D1120	<blank for demonstration>	<blank for demonstration>
30.	Sealants	ADA: D1351	<blank for demonstration>	<blank for demonstration>
31.	Fluoride treatment – adult or child	ADA: D1206, D1208	<blank for demonstration>	<blank for demonstration>
32.	III. Restorative Services	ADA: D21xx through D29xx	<blank for demonstration>	<blank for demonstration>
33.	IV. Oral Surgery (extractions and other surgical procedures)	ADA: D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, D7260, D7261, D7270, D7272, D7280, D7290 through D7294	<blank for demonstration>	<blank for demonstration>
34.	V. Rehabilitative services (Endo, Perio, Prostho, Ortho)	ADA: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx	<blank for demonstration>	<blank for demonstration>

Sources of Codes:

• International Classification of Diseases, 2019, (ICD-10-CM). National Center for Health Statistics (NCHS).

• Current Procedural Terminology (CPT), 2019. American Medical Association (AMA).

• Current Dental Terminology (CDT), 2019 – Dental Procedure Codes. American Dental Association (ADA).

Note: “X” in a code denotes any number including the absence of a number in that place. “–” (Dashes) in a code indicate that additional characters are required.ICD-10-CM codes all have at least four digits. These codes are not intended to reflect if a code is billable or not. Instead they are used to point out that other codes in the series are to be considered.

Table 6B: Quality of Care Measures

Reporting Period: January 1, 2019, through December 31, 2019

0	Prenatal Care Provided by Referral Only (Check if Yes)

Section A – Age Categories for Prenatal Care Patients:

Demographic Characteristics of Prenatal Care Patients

Line	Age	Number of Patients (a)
1	Less than 15 years	[blank for demonstration]
2	Ages 15-19	[blank for demonstration]
3	Ages 20-24	[blank for demonstration]
4	Ages 25-44	[blank for demonstration]
5	Ages 45 and over	[blank for demonstration]
6	Total Patients (Sum lines 1-5)	[blank for demonstration]

Section B - Early Entry into Prenatal Care

Line	Early Entry into Prenatal Care	Women Having First Visit with Health Center (a)	Women Having First Visit with Another Provider (b)
7	First Trimester	[blank for demonstration]	[blank for demonstration]
8	Second Trimester	[blank for demonstration]	[blank for demonstration]
9	Third Trimester	[blank for demonstration]	[blank for demonstration]

Section C - Childhood Immunization Status

Line	Childhood Immunization Status	Total Patients with 2nd Birthday (a)	Number Charts Sampled or EHR total (b)	Number of Patients Immunized (c)
10	MEASURE: Percentage of children 2 years of age who received age appropriate vaccines by their 2nd birthday	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section D - Cervical Cancer Screening

Line	Cervical Cancer Screening	Total Female Patients Aged 23 through 64 (a)	Number Charts Sampled or EHR total (b)	Number of Patients Tested (c)
11	MEASURE: Percentage of women 23-64 years of age, who were screened for cervical cancer	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section E- Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents

Line	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents	Total Patients Aged 3 through 17 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Counseling and BMI Documented (c)
12	MEASURE: Percentage of patients 3-17 years of age with a BMI percentile, and counseling on nutrition and physical activity documented	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section F – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Line	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	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: Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section G – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Line	Preventive Care and Screening: 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: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months and if identified to be a tobacco user (2) received cessation counseling intervention	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section H – Use of Appropriate Medications for Asthma

Line	Use of Appropriate Medications for Asthma	Total Patients Aged 5 through 64 with Persistent Asthma (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Acceptable Plan (c)
16	MEASURE: Percentage of patients 5 through 64 years of age identified as having persistent asthma and were appropriately ordered medication	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section I - Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Line	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Total Patients Aged 21 and Older at Risk of Cardiovascular Events (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Prescribed, or on Statin Therapy (c)
17	MEASURE: Percentage of patients 21 years of age and older at high risk of cardiovascular events-who were prescribed or were actively using statin therapy

Section J - Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antitplatelet

Line	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	Total Patients Aged 18 And Older With IVD Diagnosis or AMI, CABG, or PCI Procedure (a)	Charts Sampled or EHR Total (b)	Number of Patients With Documentation of Aspirin or Other Anitplatelet Therapy (c)
18	MEASURE: Percentage of patients 18 years of age and older with a diagnosis of IVD or AMI,CABG, or PCI procedure with aspirin or another antiplatelet	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section K - Colorectal Cancer Screening

Line	Colorectal Cancer Screening	Total Patients Aged 50 through 75 (a)	Charts Sampled or EHR Total (b)	Number of Patients With Appropriate Screening For Colorectal Cancer (c)
19	MEASURE: Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section LL - HIV Linkage to Care

Line	HIV Linkage to Care	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: Percentage of 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	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section M – Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Line	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	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: Percentage of patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan documented	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section N – Dental Sealants for Children between 6-9 Years

6b Line	Dental Sealants for Children between 6-9 Years	Total Patients Aged 6 through 9 at Moderate to High Risk for Caries (a)	Charts Sampled or EHR Total (b)	Number of Patients with Sealants to First Molars (c)
22	MEASURE: Percentage of children 6 through 9 years of age, at moderate to high risk of caries who received a sealant on a first permanent molar	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section O – Closing the Referral Loop: Receipt of Specialist Report

Line	Closing the Referral Loop: Receipt of Specialist Report	Total Patients Referred by One Provider to Another Provider (a)	Charts Sampled or EHR Total (b)	Number of Patients with a Referral, for which the Referring Provider Received a Specialist Report (c)
23	MEASURE: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Table 7: Health Outcomes and Disparities

Reporting Period: January 1, 2019, through December 31, 2019

Section A: Deliveries and Birth Weight

Line	Description	Patients
0	HIV Positive Pregnant Women	<blank for demonstration>
2	Deliveries Performed by Health Center’s Providers	<blank for demonstration>

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)
<blank for demonstration>	Hispanic/Latino	<section divider cell>	<section divider cell>	<section divider cell>	<section divider cell>
1a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
<blank for demonstration>	Subtotal Hispanic/Latino	<cell not reported>	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Non-Hispanic/Latino	<section divider cell>	<section divider cell>	<section divider cell>	<section divider cell>
2a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
<blank for demonstration>	Subtotal Non-Hispanic/Latino	<cell not reported>	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Unreported/Refused to Report Ethnicity	<section divider cell>	<section divider cell>	<section divider cell>	<section divider cell>
h	Unreported/Refused to Report Race and Ethnicity	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
i	Total	<cell not reported>	<cell not reported>	<cell not reported>	<cell not reported>

Section B: Controlling High Blood Pressure

Line #	Race and Ethnicity	Total Patients 18 through 85 Years of Age with Hypertension (2a)	Charts Sampled or EHR Total (2b)	Patients with HTN Controlled (2c)
<blank for demonstration>	Hispanic/Latino	<section divider cell>	<section divider cell>	<section divider cell>
1a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
	Subtotal Hispanic/Latino	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Non-Hispanic/Latino	<section divider cell>	<section divider cell>	<section divider cell>
2a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
	Subtotal Non-Hispanic/Latino	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Unreported/Refused to Report Ethnicity	<section divider cell>	<section divider cell>	<section divider cell>
h	Unreported/Refused to Report Race and Ethnicity	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
i	Total

Section C: Diabetes: Hemoglobin A1c Poor Control

Line #	Race and Ethnicity	Total Patients 18 through 75 Years of Age with Diabetes (3a)	Charts Sampled or EHR Total (3b)	Patients with HbA1c >9% Or No Test During Year (3f)
<blank for demonstration>	Hispanic/Latino	<section divider cell>	<section divider cell>	<section divider cell>
1a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
Subtotal	Subtotal Hispanic/Latino	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Non-Hispanic/Latino	<section divider cell>	<section divider cell>	<section divider cell>
2a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
Subtotal	Subtotal Non-Hispanic/Latino	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Unreported/Refused to Report Ethnicity	<section divider cell>	<section divider cell>	<section divider cell>
h	Unreported/Refused to Report Race and Ethnicity	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
i	Total	<cell not reported>	<cell not reported>	<cell not reported>

Table 8A: Financial Costs

Reporting Period: January 1, 2019, through December 31, 2019

Line	Cost Center	Accrued Cost (a)	Allocation of Facility and Non-Clinical Support Services (b)	Total Cost After Allocation of Facility and Non-Clinical Support Services (c)
[blank for section divide]	Financial Costs of Medical Care	[blank for section divide]	[blank for section divide]	[blank for section divide]
1.	Medical Staff	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
2.	Lab and X-ray	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
3.	Medical/Other Direct	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
4.	Total Medical Care Services (Sum Lines 1- 3)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
[blank for section divide]	Financial Costs of Other Clinical Services	[blank for section divide]	[blank for section divide]	[blank for section divide]
5.	Dental	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
6.	Mental Health	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
7.	Substance Abuse	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
8a.	Pharmacy not including pharmaceuticals	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
8b.	Pharmaceuticals	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
9.	Other Professional (Specify: ______)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
9a.	Vision	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
10.	Total Other Clinical Services (Sum Lines 5 through 9a)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
[blank for section divide]	Financial Costs of Enabling and Other Services	[blank for section divide]	[blank for section divide]	[blank for section divide]
11a.	Case Management	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11b.	Transportation	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11c.	Outreach	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11d.	Patient and Community Education	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11e.	Eligibility Assistance	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11f.	Interpretation Services	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11g.	Other Enabling Services (Specify: _____)	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11h.	Community Health Workers
11.	Total Enabling Services Cost (Sum Lines 11a through 11h)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
12.	Other Related Services (Specify:_______)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
12a.	Quality Improvement
13.	Total Enabling and Other Services (Sum Lines 11, 12, and 12a)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
[blank for section divide]	Facility and Non-Clinical Support Services and Totals	[blank for section divide]	[blank for section divide]	[blank for section divide]
14.	Facility	[blank for demonstration]	[Cell not reported]	[Cell not reported]
15.	Non-Clinical Support Services	[blank for demonstration]	[Cell not reported]	[Cell not reported]
16.	Total Facility and Non-Clinical Support Services (Sum Lines 14 and 15)	[blank for demonstration]	[Cell not reported]	[Cell not reported]
17.	Total Accrued Costs (Sum Lines 4 + 10 + 13 + 16)	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
18.	Value of Donated Facilities, Services, and Supplies (specify: __________________)	[Cell not reported]	[Cell not reported]	[blank for demonstration]
19.	Total With Donations (Sum Lines 17 and 18)	[Cell not reported]	[Cell not reported]	[blank for demonstration]

Table 9D: Patient Related Revenue (Scope of Project Only)

Reporting Period: January 1, 2019, through December 31, 2019

blank	Blank	blank	Blank	Retroactive Settlements, Receipts, and Paybacks (c)				blank	blank	blank
Line	Payer Category	Full Charges This Period (a)	Amount Collected This Period (b)	Collection of Reconciliation/ Wrap-Around Current Year (c1)	Collection of Reconciliation/ Wrap-Around Previous Years (c2)	Collection of Other Payments: P4P, Risk Pools, Withholds, etc. (c3)	Penalty/ Payback (c4)	Allowances (d)	Sliding Discounts (e)	Bad Debt Write Off (f)
1.	Medicaid Non-Managed Care	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
2a.	Medicaid Managed Care (capitated)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
2b.	Medicaid Managed Care (fee-for-service)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
3.	Total Medicaid (Lines 1 + 2a + 2b)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
4.	Medicare Non-Managed Care	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
5a.	Medicare Managed Care (capitated)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
5b.	Medicare Managed Care (fee-for-service)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
6.	Total Medicare (Lines 4 + 5a + 5b)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
7.	Other Public, including Non-Medicaid CHIP (Non-Managed Care)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
8a.	Other Public, including Non-Medicaid CHIP (Managed Care Capitated)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
8b.	Other Public, including Non-Medicaid CHIP (Managed Care fee-for-service)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
9.	Total Other Public (Lines 7 + 8a + 8b)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
10.	Private Non-Managed Care	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]		[not reported]	[not reported]
11a.	Private Managed Care (capitated)	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
11b.	Private Managed Care (fee-for-service)	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
12.	Total Private (Lines 10 + 11a + 11b)	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
13.	Self-pay	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[not reported]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]
14.	TOTAL (Lines 3 + 6 + 9 + 12 + 13)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Table 9E: Other Revenues

Reporting Period: January 1, 2019, through December 31, 2019

Line	Source	Amount (a)
[blank]	BPHC Grants (Enter amount drawn down – Consistent with PMS 272)	[blank]
1a.	Migrant Health Center	[blank]
1b.	Community Health Center	[blank]
1c.	Health Care for the Homeless	[blank]
1e.	Public Housing Primary Care	[blank]
1g.	Total Health Center (Sum Lines 1a through 1e)	[blank]
1j.	Capital Improvement Program Grants	[blank]
1k.	Capital Development Grants, including School Based Health Center Capital Grants	[blank]
1.	Total BPHC Grants (Sum Lines 1g + 1j + 1k)	[blank]
[blank]	Other Federal Grants	[blank]
2.	Ryan White Part C HIV Early Intervention	[blank]
3.	Other Federal Grants (specify: _______)	[blank]
3a.	Medicare and Medicaid EHR Incentive Payments for Eligible Providers	[blank]
5.	Total Other Federal Grants (Sum Lines 2–3a)	[blank]
[blank]	Non-Federal Grants or Contracts	[blank]
6.	State Government Grants and Contracts (specify: _______)	[blank]
6a.	State/Local Indigent Care Programs (specify: _______)	[blank]
7.	Local Government Grants and Contracts (specify: _______)	[blank]
8.	Foundation/Private Grants and Contracts (specify: _______)	[blank]
9.	Total Non-Federal Grants and Contracts (Sum Lines 6 + 6A + 7+8)	[blank]
10.	Other Revenue (Non-patient related revenue not reported elsewhere) (specify: _______)	[blank]
11.	Total Revenue (Lines 1 + 5 + 9 + 10)	[blank]

Appendix A: Listing of Personnel

All line numbers in the following table refer to Table 5. Not all services delivered by a “provider” count as visits. Do not count interactions with “non-providers” as visits. Use the Provider definitions to classify personnel as a “provider” or “non-provider.”

Personnel by Major Service Category	Provider	Non-Provider
Physicians	<blank>	<blank>
Family Practitioners (Line 1)	X	<blank>
General Practitioners (Line 2)	X	<blank>
Internists (Line 3)	X	<blank>
Obstetricians/Gynecologists (Line 4)	X	<blank>
Pediatricians (Line 5)	X	<blank>
Licensed Medical Residents—line determined by specialty	X	<blank>
Other Specialist Physicians (Line 7)	<blank>	<blank>
Allergists	X	<blank>
Cardiologists	X	<blank>
Dermatologists	X	<blank>
Orthopedists	X	<blank>
Surgeons	X	<blank>
Urologists	X	<blank>
Other Specialists and Sub-Specialists	X	<blank>
Nurse Practitioners (Line 9a)	X	<blank>
Physician Assistants (Line 9b)	X	<blank>
Certified Nurse Midwives (Line 10)	X	<blank>
Nurses (Line 11)	<blank>	<blank>
Clinical Nurse Specialists	X	<blank>
Public Health Nurses	X	<blank>
Home Health Nurses	X	<blank>
Visiting Nurses	X	<blank>
Registered Nurses (RNs)	X	<blank>
Licensed Practical Nurses/Licensed Vocational Nurses	<blank>	X
Nurse emergency medical services (EMS)/Nurse emergency medical technicians (EMT)	X
Other Medical Personnel (Line 12)	<blank>	<blank>
Nurse Aides/Assistants (Certified and Uncertified)	<blank>	X
Clinic Aides/Medical Assistants (Certified and Uncertified Medical Technologists)	<blank>	X
Unlicensed Interns and Residents	<blank>	X
EMS/EMT Staff (not credentialed as a nurse)		X
Laboratory Personnel (Line 13)	<blank>	<blank>
Pathologists	<blank>	X
Medical Technologists	<blank>	X
Laboratory Technicians	<blank>	X
Laboratory Assistants	<blank>	X
Phlebotomists	<blank>	X
X-Ray Personnel (Line 14)	<blank>	<blank>
Radiologists	<blank>	X
X-Ray Technologists	<blank>	X
X-Ray Technicians	<blank>	X
Radiology Assistants	<blank>	X
Ultrasound Technicians		X
Dentists (Line 16)	<blank>	<blank>
General Practitioners	X	<blank>
Oral Surgeons	X	<blank>
Periodontists	X	<blank>
Endodontists	X	<blank>
Other Dental	<blank>	<blank>
Dental Hygienists (Line 17)	X	<blank>
Dental Therapists (Line 17a)	X
Dental Assistants, Advanced Practice Dental Assistants (Line 18)	<blank>	X
Dental Technicians (Line 18)	<blank>	X
Dental Aides (Line 18)	<blank>	X
Dental Students (including Hygienist Students) (Line 18)	<blank>	X
Mental Health (Line 20) and Substance Abuse (Line 21)	<blank>	<blank>
Psychiatrists (Line 20a)	X	<blank>
Psychologists (Line 20a1)	X	<blank>
Social Workers - Clinical (Line 20a2 or 21)	X	<blank>
Social Workers - Psychiatric (Line 20b or 21)	X	<blank>
Family Therapists (Line 20b or 21)	X	<blank>
Psychiatric Nurse Practitioners (Line 20b)	X	<blank>
Nurses - Psychiatric and Mental Health (Line 20b)	X	<blank>
Unlicensed Mental Health Providers, including trainees (interns or residents) and “Certified” staff (Line 20c)	X	<blank>
Alcohol and Drug Abuse Counselors (Line 21)	X	<blank>
RN Nurse Counselors (Line 20b or 21)	X	<blank>
All Other Professional Personnel (Line 22)		<blank>
Audiologists	X	<blank>
Acupuncturists	X	<blank>
Chiropractors	X	<blank>
Community Health Aides and Practitioners	X	<blank>
Herbalists	X	<blank>
Massage Therapists	X	<blank>
Naturopaths	X	<blank>
Registered Dietitians, including Nutritionists/Dietitians	X	<blank>
Occupational Therapists	X	<blank>
Podiatrists	X	<blank>
Physical Therapists	X	<blank>
Respiratory Therapists	X	<blank>
Speech Therapists/Pathologists	X	<blank>
Traditional Healers	X	<blank>
Vision Services Personnel (Line 22a-22d)	<blank>	<blank>
Ophthalmologists (Line 22a)	X	<blank>
Optometrists (Line 22b)	X	<blank>
Ophthalmologist/Optometric Assistants (Line 22c)	<blank>	X
Ophthalmologist/Optometric Aides (Line 22c)	<blank>	X
Ophthalmologist/Optometric Technicians (Line 22c)	<blank>	X
Pharmacy Personnel (Line 23)	<blank>	<blank>
Pharmacists, Clinical Pharmacists	<blank>	X
Pharmacy Technicians	<blank>	X
Pharmacist Assistants	<blank>	X
Pharmacy Clerks	<blank>	X
Enabling Services (Line 29)	<blank>	<blank>
Case Managers (Line 24)	<blank>	<blank>
Case Managers	X	<blank>
Care/Referral Coordinators	X	<blank>
Patient Advocates	X	<blank>
Social Workers	X	<blank>
Public Health Nurses	X	<blank>
Home Health Nurses	X	<blank>
Visiting Nurses	X	<blank>
Registered Nurses	X	<blank>
Licensed Practical Nurses/Licensed Vocational Nurses	X	<blank>
Health Educators (Line 25)	<blank>	<blank>
Family Planning Counselors	X	<blank>
Health Educators	X	<blank>
Social Workers	X	<blank>
Public Health Nurses	X	<blank>
Home Health Nurses	X	<blank>
Visiting Nurses	X	<blank>
Registered Nurses	X	<blank>
Licensed Practical Nurses /Licensed Vocational Nurses	X	<blank>
Outreach Workers (Line 26)	<blank>	X
Patient Transportation Workers (Line 27)	<blank>	<blank>
Patient Transportation Coordinators	<blank>	X
Drivers	<blank>	X
Eligibility Assistance Workers (Line 27a)	<blank>	<blank>
Benefits Assistance Workers	<blank>	X
Pharmacy Assistance Program Eligibility Workers	<blank>	X
Eligibility Workers	<blank>	X
Patient Navigators	<blank>	X
Patient Advocates	<blank>	X
Registration Clerks	<blank>	X
Certified Assisters		X
Interpretation (Line 27b)	<blank>	<blank>
Interpreters	<blank>	X
Translators	<blank>	X
Community Health Workers (Line 27c)
Community Health Workers		X
Community Health Advisors or Representatives		X
Lay Health Advocates		X
Promotoras		X
Other Enabling Services Personnel (Line 28)	<blank>	X
Other Program Related Services Staff (Line 29a)	<blank>	<blank>
WIC Workers	<blank>	X
Head Start Workers	<blank>	X
Housing Assistance Workers	<blank>	X
Childcare Workers	<blank>	X
Food Bank/Meal Delivery Workers	<blank>	X
Employment/Educational Counselors	<blank>	X
Exercise Trainers/Fitness Center staff	<blank>	X
Adult Day Health Care, Frail Elderly Support staff	<blank>	X
Quality Improvement Staff (QI) (Line 29b)
QI Nurses		X
QI Technicians		X
QI Data Specialists		X
Statisticians, Analysts		X
Quality Assurance/Quality Improvement and HIT/EHR Design and Operation Staff	<blank>	X
Management and Support Staff (Line 30a)	<blank>	<blank>
Project Directors	<blank>	X
Chief Executive Officer/Executive Directors	<blank>	X
Chief Financial Officers/Fiscal Officers)	<blank>	X
Chief Information Officers	<blank>	X
Chief Medical Officers	<blank>	X
Secretaries/Administrative Assistants	<blank>	X
Administrators	<blank>	X
Directors of Planning And Evaluation	<blank>	X
Clerk Typists	<blank>	X
Personnel Directors	<blank>	X
Receptionists	<blank>	X
Directors of Marketing	<blank>	X
Marketing Representatives	<blank>	X
Enrollment/Service Representatives	<blank>	X
Fiscal and Billing Staff (Line 30b)	<blank>	<blank>
Finance Directors	<blank>	X
Accountants	<blank>	X
Bookkeepers	<blank>	X
Billing Clerks	<blank>	X
Cashiers	<blank>	X
Data Entry Clerks	<blank>	X
IT Staff (Line 30c)	<blank>	<blank>
Directors of Data Processing	<blank>	X
Programmers	<blank>	X
IT Help Desk Technicians	<blank>	X
Data Entry Clerks	<blank>	X
Facility (Line 31)	<blank>	<blank>
Janitors/Custodians	<blank>	X
Security Guards	<blank>	X
Groundskeepers	<blank>	X
Equipment Maintenance Personnel	<blank>	X
Housekeeping Personnel	<blank>	X
Patient Services Support Staff (Line 32)	<blank>	<blank>
Medical and Dental Team Clerks	<blank>	X
Medical and Dental Team Secretaries	<blank>	X
Medical and Dental Appointment Clerks	<blank>	X
Medical and Dental Patient Records Clerks	<blank>	X
Patient Records Supervisors	<blank>	X
Patient Records Technicians	<blank>	X
Patient Records Clerks	<blank>	X
Patient Records Transcriptionists	<blank>	X
Registration Clerks	<blank>	X
Appointments Clerks	<blank>	X

Appendix D: Health Center Health Information Technology (HIT) Capabilities and Quality Recognition

Instructions

The Health Information Technology (HIT) Capabilities and Quality Recognition Form includes a series of questions on health information technology (HIT) capabilities, including electronic health record (EHR) interoperability and eligibility for Meaningful Use. The HIT and Quality Recognition Form must be completed and submitted as part of the UDS submission. The first part includes questions about the health center’s implementation of an EHR, certification of systems, how widely adopted the system is throughout the health center and its providers.

Questions

The following questions appear in the EHB. Complete them before you file the UDS Report. Instructions for the HIT questions are on screen in EHB as you are completing the form. Respond to each question based on your health center status as of December 31.

1. Does your center currently have an Electronic Health Record (EHR) system installed and in use?

   1. Yes, installed at all sites and used by all providers

   2. Yes, but only installed at some sites or used by some providers

If the health center installed it, indicate if it was in use by December 31, by:

1. Installed at all sites and used by all providers: For the purposes of this response, “providers” mean all medical providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives. Although some or all of the dental, mental health, or other providers may also be using the system, as may medical support staff, this is not required to choose response a. For the purposes of this response, “all sites” means all permanent sites where medical providers serve health center medical patients and does not include administrative-only locations, hospitals or nursing homes, mobile vans, or sites used on a seasonal or temporary basis. You may check this option even if a few, newly hired, untrained employees are the only ones not using the system.

2. Installed at some sites or used by some providers: Select option b if one or more permanent sites did not have the EHR installed, or in use (even if this is planned), or if one or more medical providers (as defined above) do not yet use the system. When determining if all providers have access to the system, the health center should also consider part-time and locum providers who serve clinic patients. Do not select this option if the only medical providers who did not have access were those who were newly hired and still being trained on the system.

3. No

Select “no” if no EHR was in use on December 31, even if you had the system installed and training had started.

This question seeks to determine whether the health center installed an EHR by December 31 and, if so, which product is in use, how broad is access to the system, and what features are available and in use. While they can often produce much of the UDS data, do not include practice management systems or other billing systems. If the health center purchased an EHR but had not yet placed it into use, answer “No.”

If a system is in use (i.e., if a or b has been selected above), indicate if your system has been certified by the Office of the National Coordinator - Authorized Testing and Certification Bodies (ONC-ATCB).

1a. Is your system certified by the Office of the National Coordinator for Health IT (ONC) Health IT Certification Program?

1. Yes

2. No

Health centers are to indicate in the blanks the vendor, product name, version number, and ONC-certified health IT product list number. (More information is available at ONC-ATCB at http://onc-chpl.force.com/ehrcert.) If you have more than one EHR (if, for example, you acquired another practice which has its own EHR), report the EHR that will be the successor system.

Vendor

Product Name

Version Number

ONC-certified Health IT Product List Number

2. Does your center send prescriptions to the pharmacy electronically? (Do not include faxing.)

   1. Yes

   2. No

   3. Not sure

3. Does your center use computerized, clinical decision support, such as alerts for drug allergies, checks for drug-drug interactions, reminders for preventive screening tests, or other similar functions?

   1. Yes

   2. No

   3. Not sure

4. Which of the following key providers/ health care settings does your center electronically exchange clinical information with? (Select all that apply)

• Hospitals/ Emergency Rooms

• Specialty Clinicians

• Other Primary Care Providers

• None of the Above

• Other (please describe)

5. Does your center engage patients through health IT in any of the following ways? (Select all that apply)

• Patient Portals

• Kiosks

• Secure Messaging

• Other (please describe)

• No, we do not engage patients using health IT

6. How do you collect data for UDS clinical reporting (Tables 6B and 7)?

   1. We use the EHR to extract automated reports

   2. We use the EHR but only to access individual patient charts

   3. We use the EHR in combination with another data analytic system

   4. We do not use the EHR

6. How does your health center utilize health IT and EHR data beyond direct patient care? (Select all that apply)

• Quality Improvement

• Population Health Management

• Program Evaluation

• Research

• Other (please describe)

• No, we do not utilize health IT or EHR data beyond direct patient care

6. Does your health center collect data on individual patients’ social risk factors, outside of the data reportable in the UDS?

1. Yes

2. No, but in planning stages to collect this information

3. No, not planning to collect this information

6. Which standardized screener(s) for social risk factors, if any, do you use? (Select all that apply)

• Accountable Health Communities Screening Tools

• Upstream Risks Screening Tool and Guide

• iHELP

• Recommended Social and Behavioral Domains for EHRs

• Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

• Well Child Care, Evaluation, Community Resources, Advocacy Referral, Education (WE CARE)

• WellRx

• Other: _______________________________________________________________

• Do not use a standardized screener

Appendix E: Other Data Elements

Instructions

Health centers are becoming increasingly diverse and comprehensive in the care and services provided. These questions capture the changing landscape of healthcare centers to include expanded services and delivery systems.

Questions

Report on these data elements as part of their UDS submission. Topics include medication-assisted treatment, telehealth, and outreach and enrollment assistance. Respond to each question based on your health center status as of December 31.

1. Medication-Assisted Treatment (MAT) for Opioid Use Disorder

   1. How many physicians, certified nurse practitioners and physician assistants ¹, on-site or with whom the health center has contracts, have obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat opioid use disorder with medications specifically approved by the U.S. Food and Drug Administration (FDA) for that indication?

   2. How many patients received medication-assisted treatment for opioid use disorder from a physician, certified nurse practitioner, or physician assistant, with a DATA waiver working on behalf of the health center?

2. Did your organization use telehealth in order to provide remote clinical care services?

(The term “telehealth” includes “telemedicine” services, but encompasses a broader scope of remote healthcare services. Telemedicine is specific to remote clinical services whereas telehealth may include remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.)

a. Yes

i. Who did you use telehealth to communicate with? (Select all that apply)

(1) Patients at remote locations from your organization (e.g., home telehealth, satellite locations)

(2) Specialists outside your organization (e.g., specialists at referral centers)

(3) Professional organizations for staff training (e.g., continuing medical education, administrative, mettings, etc)

ii. What telehealth technologies did you use? (Select all that apply)

(1) Real-time telehealth (e.g., video conference)

(2) Store-and-forward telehealth (e.g., secure email with photos or videos of patient examinations)

(3) Remote patient monitoring

(4) Mobile Health (mHealth)

iii. What primary telehealth services were used at your organization? (Select all that apply)

(1) Primary care

(2) Oral health

(3) Psychiatry

(4) Mental health

(5) Substance abuse

(6) Dermatology

(7) Chronic conditions

(8) Disaster management

(9) Consumer and professional health education

(10) Ophthalmology

(11) Other, please specify _______________________________________

b. If you did not have telehealth services, please comment why (Select all that apply)

i. Have not considered/unfamiliar with telehealth service options

ii. Lack of reimbursement for telehealth services

iii. Inadequate broadband/telecommunication service (Select all that apply)

(1) Cost of service

(2) Lack of infrastructure

(3) Other, please specify ___________________________________

iv. Lack of funding for telehealth equipment

v. Lack of training for telehealth services

vi. Not needed

vii. Other, please specify ____________________________

3. Provide the number of all assists provided during the past year by all trained assisters (e.g., certified application counselor or equivalent) working on behalf of the health center (employees, contractors, or volunteers), regardless of the funding source that is supporting the assisters’ activities. Outreach and enrollment assists are defined as customizable education sessions about affordable health insurance coverage options (one-on-one or small group) and any other assistance provided by a health center assister to facilitate enrollment through the Marketplace, Medicaid or CHIP.

Enter Number of Assists ________________

Note: Assists do not count as visits on the UDS tables.

APPENDIX F: Workforce

Instructions

It is important to understand the current state of health center workforce training and different staffing models to better support recruitment and retention of health center professionals. Appendix F includes a series of questions on health center workforce.

Questions

Respond to each question based on your health center’s status as of December 31.

1. Does your health center provide health professional education¹/training?

1. Yes

2. No

2. If yes, which category best describes your health center’s role in the health professional education/training process?

1. Sponsor²

2. Training Site Partner³

3. Other

3. Please indicate the range of health professional education/training offered at your health center and how many individuals you have trained in each category within the last year.

	Pre-Graduate/Certificate	Post Graduate Training
Medical
Physicians
Family Physicians
General Practitioners
Internists
Obstetrician/Gynecologists
Pediatricians
Other Specialty Physicians
Medical Assistants
Physician Assistants
Nurse Practitioners
Certified Nurse Midwives
Registered Nurses
Licensed Practical Nurses/Vocational Nurses
Dental
Dentists
Dental Therapists
Dental Hygienist
Vision
Ophthalmologists
Optometrists
Mental Health
Psychiatrists
Clinical Psychologists
Clinical Social Workers
Professional Counselors
Marriage and Family Therapists
Psychiatric Nurse Specialists
Mental Health Nurse Practitioners
Mental Health Physician Assistants
Substance Use Disorder Personnel
Other Professionals
Chiropractors
Dietitians/ Nutritionists
Pharmacists
Other (Specify)

3. Provide the number of health center staff serving as preceptors at your health center ___

3. Provide the number of health center staff (non-preceptors) supporting health center training programs ___

3. How often does your health center implement satisfaction surveys for providers?

1. Monthly

2. Quarterly

3. Annually

4. We do not currently conduct provider satisfaction surveys

5. Other, please specify

3. How often does your health center implement satisfaction surveys for general staff?

1. Monthly

2. Quarterly

3. Annually

4. We do not currently conduct staff satisfaction surveys

5. Other, please specify

¹ Health Professional Education/Training does not include continuing education units.

² A Sponsor hosts a comprehensive health profession education and/or training program, the implementation of which may require partnerships with other entities that deliver focused, time-limited education and/or training (e.g., a teaching health center with a family medicine residency program).

³A Training Site Partner delivers focused, time-limited education and/or training to learners in support of a comprehensive curriculum hosted by another health profession education provider (e.g., month-long primary care dentistry experience for dental students).

1 With the enactment of the Comprehensive Addiction and Recovery Act of 2016, Public Law 114-198, opioid treatment prescribing privileges have been extended beyond physicians to include certain qualifying nurse practitioners (NPs) and physicians’ assistants (PAs).

2