| OMB No. 0915-0193 |
| Expiration: XX/XX/20XX |
| The 2018 UDS template list all tables and data entry points for the UDS Performance Report. To complete the template, you must enter all applicable data in the template. The Organization's BHCMIS ID and template version number will be displayed in the file name, please verify the BHCMIS ID before working on the downloaded template. For a full description of the module, visit the following page:https://bphc.hrsa.gov/datareporting/reporting/index.html. Step-by-step instructions on downloading, uploading and publishing the template, visit the following EHBs Help Page: https://help.hrsa.gov/x/SwCNAw. Contact UDS-Support@Reisystems.com if you have any questions. |
| 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 xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. 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 14N136B, Rockville, Maryland, 20857. |
| ZIP Code (a) | None/Uninsured (b) | Medicaid/Chip/OtherPublic (c) | Medicare (d) | Private (e) | Total Patients (f) |
| 22033 |
| ZIP Code (a) | None/Uninsured (b) | Medicaid/Chip/OtherPublic (c) | Medicare (d) | Private (e) | Total Patients (f) |
| Other ZIP Codes | |||||
| Unknown Residence | |||||
| Total (Zip Codes + Other Zip Codes) | |||||
| Comments |
| S.No | 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 | ||
| Subtotal Patients(Sum lines 1-18) | |||
| 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 | ||
| Subtotal Patients(Sum lines 19-33) | |||
| 34. | Ages 65-69 | ||
| 35. | Ages 70-74 | ||
| 36. | Ages 75-79 | ||
| 37. | Ages 80-84 | ||
| 38. | Ages 85 and over | ||
| Subtotal Patients(Sum lines 34-38) | |||
| 39. | Total Patients(Sum Lines 1-38) | ||
| Comments |
| S.No | 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 | ||||
| 2a. | Native Hawaiian | ||||
| 2b. | Other Pacific Islander | ||||
| 2. | Total Native 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) | ||||
| S.No | Patients by Linguistic Barriers to Care | Number (a) | |||
| 12. | Patients Best Served in a Language Other Than English | ||||
| S.No | Patients by Sexual Orientation | Number (a) | |||
| 13. | Lesbian or Gay | ||||
| 14. | Straight (not lesbian or gay) | ||||
| 15. | Bisexual | ||||
| 16. | Something else | ||||
| 17. | Don't know | ||||
| 18. | Chose not to disclose | ||||
| 19. | Total Patients (Sum Lines 13 to 18) | ||||
| S.No | Patients by Gender Identity | Number (a) | |||
| 20. | Male | ||||
| 21. | Female | ||||
| 22. | Transgender Male/ Female-to-Male | ||||
| 23. | Transgender Female/ Male-to-Female | ||||
| 24. | Other | ||||
| 25. | Chose not to disclose | ||||
| 26. | Total Patients (Sum Lines 20 to 25) | ||||
| Comments |
| S.No | Characteristic | Number of Patients (a) | ||||
| 1. | 100% and below | |||||
| 2. | 101 - 150% | |||||
| 3. | 151 - 200% | |||||
| 4. | Over 200% | |||||
| 5. | Unknown | |||||
| 6. | Total (Sum lines 1-5) | |||||
| S.No | Principal Third Party Medical Insurance Source | Specify | 0-17 Years Old (a) | 18 and Older (b) | ||
| 7. | None/Uninsured | |||||
| 8a. | Medicaid (Title XIX) | |||||
| 8b. | CHIP Medicaid | |||||
| 8. | Total Medicaid (Sum lines 8a+8b) | |||||
| 9a. | Dually eligible (Medicare and Medicaid) | |||||
| 9. | Medicare (Inclusive of dually eligible and other Title XVIII beneficiaries) | |||||
| 10a. | Other Public Insurance (Non-CHIP) (specify) | |||||
| 10b. | Other Public Insurance CHIP | |||||
| 10. | Total Public Insurance (Sum lines 10a+10b) | |||||
| 11. | Private Insurance | |||||
| 12. | Total (Sum lines 7+8+9+10+11) | |||||
| S.No | Managed Care Utilization | 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 (Sum lines 13a+13b) | |||||
| S.No | Special Populations | Number of Patients (a) | ||||
| 16. | Total Agricultural Workers or Dependents (All health centers report this line) | |||||
| 23. | Total Homeless (All health centers report this line) | |||||
| 24. | Total School Based Health Center Patients (All health centers report this line) | |||||
| 25. | Total Veterans (All health centers report this line) | |||||
| 26. | Total Patients Served at a Health Center Located In or Immediately Accessible to a Public Housing Site (All health centers report this line) | |||||
| Comments |
| S.No | Personnel by Major Service Category | Specify | FTEs (a) | Clinic Visits (b) | Patients (c) |
| Medical Care Services | |||||
| 1. | Family Physicians | ||||
| 2. | General Practitioners | ||||
| 3. | Internists | ||||
| 4. | Obstetrician/Gynecologists | ||||
| 5. | Pediatricians | ||||
| 7. | Other Specialty Physicians | ||||
| 8. | Total Physicians (Sum lines 1-7) | ||||
| 9a. | Nurse Practitioners | ||||
| 9b. | Physician Assistants | ||||
| 10. | Certified Nurse Midwives | ||||
| 10a. | Total NP, PA, and CNMs (Sum lines 9a - 10) | ||||
| 11. | Nurses | ||||
| 12. | Other Medical Personnel | ||||
| 13. | Laboratory Personnel | ||||
| 14. | X-Ray Personnel | ||||
| 15. | Total Medical (Sum lines 8+10a through 14) | ||||
| Dental Services | |||||
| 16. | Dentist | ||||
| 17. | Dental Hygienists | ||||
| 17a. | Dental Therapists | ||||
| 18. | Other Dental Personnel | ||||
| 19. | Total Dental Services (Sum lines 16-18) | ||||
| Mental Health Services | |||||
| 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 (Sum lines 20a-20c) | ||||
| Substance Use Disorder Services | |||||
| 21. | Substance Use Disorder Services | ||||
| Other Professional Services | |||||
| 22. | Other Professional Services Specify | ||||
| Vision Services | |||||
| 22a. | Ophthalmologists | ||||
| 22b. | Optometrists | ||||
| 22c. | Other Vision Care Staff | ||||
| 22d. | Total Vision Services (Sum lines 22a-22c) | ||||
| Pharmacy Personnel | |||||
| 23. | Pharmacy Personnel | ||||
| Enabling Services | |||||
| 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 (Sum lines 24-28) | ||||
| Other Programs/Services | |||||
| 29a. | Other Programs/Services Specify: | ||||
| 29b. | Quality Improvement Staff | ||||
| Administration and Facility | |||||
| 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) | ||||
| Grand Total | |||||
| 34. | Grand Total (Lines 15+19+20+21+22+22d+23+29+29a+29b+33) | ||||
| Comments |
| S.No | Health Center Staff | Persons (a) Full and Part Time | Total Months (b) Full and Part Time | Persons (c) Locum, On-Call, etc | Total Months (d) Locum, On-Call, etc |
| 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 | ||||
| 17a. | Dental Therapists | ||||
| 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 | ||||
| Comments |
| S.No | 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 Diseases | ||||
| 1-2. | Symptomatic / Asymptomatic HIV | B20, B97.35, O98.7-, Z21 | ||
| 3. | Tuberculosis | A15- through A19-, O98.01 | ||
| 4. | Sexually transmitted infections | A50- through A64- (exclude A63.0) | ||
| 4a. | Hepatitis B | B16.0-B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, O98.4- | ||
| 4b. | Hepatitis C | B17.10, B17.11, B18.2, B19.20, B19.21 | ||
| Selected Diseases of the Respiratory System | ||||
| 5. | Asthma | J45- | ||
| 6. | Chronic lower respiratory diseases | J40- through J44-, J47- | ||
| 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-, D49.3-, N60-, N63-, R92- | ||
| 8. | Abnormal cervical findings | C53-, C79.82, D06-, R87.61-, R87.629, R87.810, R87.820 | ||
| 9. | Diabetes mellitus | E08- through E13-, O24-(exclude O24.41-) | ||
| 10. | Heart disease (selected) | I01-, I02- (exclude I02.9), I20- through I25-, I27-, I28-, I30- through I52- |
||
| 11. | Hypertension | I10- through I16- | ||
| 12. | Contact dermatitis and other eczema | L23- through L25-, L30- (exclude L30.1, L30.3, L30.4, L30.5), L58- | ||
| 13. | Dehydration | E86- | ||
| 14. | Exposure to heat or cold | T33-, T34-, T67-, T68-, T69- |
||
| 14a. | Overweight and obesity | E66-, Z68- (exclude Z68.1, Z68.20 through Z68.24, Z68.51. Z68.52) | ||
| Selected Childhood Conditions (limited to ages 0 through 17) |
||||
| 15. | Otitis media and Eustachian tube disorders | H65- through H69- | ||
| 16. | Selected perinatal medical conditions | A33-, P19-, P22-through P29- (exclude P29.3), P35- through P96- (exclude P54-, P91.6-, P92-, P96.81), R78.81, R78.89 |
||
| 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 |
||
| Selected Mental Health and Substance Use Disorder Conditions |
||||
| 18. | Alcohol related disorders | F10-, G62.1 | ||
| 19. | Other substance related disorders (excluding tobacco use disorders) | F11- through F19- (exclude F17-), G62.0, O99.32- | ||
| 19a. | Tobacco use disorder | F17-, O99.33 | ||
| 20a. | Depression and other mood disorders | F30- through F39- | ||
| 20b. | Anxiety disorders including PTSD | F06.4, F40- through F42-, F43.0, F43.1-, F93.0 |
||
| 20c. | Attention deficit and disruptive behavior disorders | F90- through F91- | ||
| 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 F99- (exclude F55-, F84.2, F90-, F91-, F93.0, F98-), O99.34, R45.1, R45.2, 45.5, R45.6, R45.7, R45.81, R45.82, R48.0 | ||
| S.No | 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 |
||||
| 21. | HIV test | <b>CPT-4:</b> 86689, 86701 through 86703, 87389 through 87391, 87534 through 87539, 87806 | ||
| 21a. | Hepatitis B test | <b>CPT-4:</b> 86704 through 86707, 87340, 87341, 87350 | ||
| 21b. | Hepatitis C test | CPT-4: 86803, 86804, 87520 through 87522 | ||
| 22. | Mammogram | CPT-4: 77052, 77057, 77065, 77066, 77067 OR ICD-10: Z12.31 | ||
| 23. | Pap test | <b>CPT-4:</b> 88141 through 88153, 88155, 88164 through 88167, 88174, 88175 OR <b>ICD-10:</b> Z01.41-, Z01.42, Z12.4 (exclude Z01.411 and Z01.419) | ||
| 24. | Selected immunizations: hepatitis A; haemophilus influenzae B (HiB); pneumococcal; diphtheria; tetanus; pertussis (DTaP) (DTP) (DT); mumps; measles; rubella (MMR); poliovirus; varicella; hepatitis B |
<b>CPT-4:</b> 90632, 90633, 90634, 90636, 90643, 90644, 90645, 90646, 90647, 90648, 90669, 90670, 90696, 90697, 90698, 90700, 90701, 90702, 90703, 90704, 90705, 90706, 90707, 90708, 90710, 90712, 90713, 90714, 90715, 90716, 90718, 90720, 90721, 90723, 90730, 90731, 90732, 90740, 90743, 90744, 90745, 90746, 90747, 90748 | ||
| 24a. | Seasonal flu vaccine | <b>CPT-4:</b> 90630, 90653 through 90657, 90661, 90662, 90672, 90673, 90674, 90682, 90685 through 90688, 90749, 90756 | ||
| 25. | Contraceptive management | ICD-10: Z30- | ||
| 26. | Health supervision of infant or child (ages 0 through 11) | CPT-4: 99381 through 99383, 99391 through 99393 | ||
| 26a. | Childhood lead test screening (9 to 72 months) | <b>ICD-10:</b> Z13.88 <b>CPT-4:</b> 83655 | ||
| 26b. | Screening, Brief Intervention, and Referral to Treatment (SBIRT) | CPT-4: 99408, 99409 HCPCS: G0396, G0397, H0050 |
||
| 26c. | Smoke and tobacco use cessation counseling | <b>CPT-4:</b> 99406, 99407 OR <b>HCPCS:</b> S9075 OR <b>CPT-II:</b> 4000F, 4001F, 4004F | ||
| 26d. | Comprehensive and intermediate eye exams | CPT-4: 92002, 92004, 92012, 92014 | ||
| S.No | Service Category | Applicable ADA Code | Number of Visits (a) | Number of Patients (b) |
| Selected Dental Services | ||||
| 27. | Emergency Services | <b>ADA:</b> D9110 | ||
| 28. | Oral Exams | <b>ADA:</b> D0120, D0140, D0145, D0150, D0160, D0170, D0171, D0180 | ||
| 29. | Prophylaxis - adult or child | ADA: D1110, D1120 | ||
| 30. | Sealants | ADA: D1351 | ||
| 31. | Fluoride treatment - adult or child | <b>ADA:</b> D1206, D1208 <b>CPT-4:</b>99188 | ||
| 32. | Restorative services | ADA: D21xx through D29xx | ||
| 33. | Oral surgery (extractions and other surgical procedures) | <b>ADA:</b>D7xxx | ||
| 34. | Rehabilitative services (Endo, Perio, Prostho, Ortho) | ADA: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx | ||
| Sources of Codes: | ||||
| International Classification of Diseases, 2017, (ICD-10-CM). National Center for Health Statistics (NCHS). |
||||
| Current Procedural Terminology (CPT), 2017. American Medical Association (AMA). |
||||
| Current Dental Terminology (CDT), 2017 - 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. |
||||
| Comments |
| Prenatal Care Provided by Referral Only (Yes or No) | ||||
| S.No | Age | Number of Patients (a) | ||
| 1. | Less than 15 years | |||
| 2. | Ages 15-19 | |||
| 3. | Ages 20-24 | |||
| 4. | Ages 20-24 | |||
| 5. | Ages 45 and over | |||
| 6. | Total Patients (Sum lines 1-5) | |||
| S.No | Early Entry into Prenatal Care | 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 | |||
| S.No | 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 |
|||
| S.No | 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 | |||
| S.No | 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 |
|||
| S.No | 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 |
|||
| S.No | 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 (2) if identified to be a tobacco user received cessation counseling intervention |
|||
| S.No | Use of Appropriate Medications for Asthma | Total Patients Aged 5 through 64 years of age 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 |
|||
| S.No | Coronary Artery Disease (CAD): 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: Percentage of patients 18 years of age and older with a diagnosis of CAD who were prescribed a lipid-lowering therapy |
|||
| S.No | 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 Antiplatelet 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 |
|||
| S.No | 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 |
|||
| S.No | 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 |
|||
| S.No | 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 |
|||
| S.No | 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 |
|||
| Comments |
| S.No | Prenatal Services | Patients (a) | |||
| 0 | HIV-Positive Pregnant Women | 23 | |||
| 2 | Deliveries Performed by Health Center's Providers | 23 | |||
| S.No | 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 Race and Ethnicity | |||||
| h. | Unreported/Refused to Report Race and Ethnicity | ||||
| i. | Total | ||||
| Comments |
| S.No | Race and Ethnicity | Total Patients 18 through 85 Years of Age with Hypertension (2a) | Charts Sampled or EHR Total (2b) | Patients with Hypertension 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 Race and Ethnicity | ||||
| h. | Unreported/Refused to Report Race and Ethnicity | |||
| i. | Total |
| S.No | 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) |
| 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 Race and Ethnicity | ||||
| h. | Unreported/Refused to Report Race and Ethnicity | |||
| i. | Total |
| S.No | Cost Center | Specify | Accrued Cost (a) $ | Allocation Of Facility and Non-Clinical Support Services (b) $ | Total Cost After Allocation of Facility and Non-Clinical Support Services (c) $ |
| * Column c is equal to the sum of column a and column b. | |||||
| Financial Costs for Medical Care | |||||
| 1. | Medical Staff | ||||
| 2. | Lab and X-ray | ||||
| 3. | Medical/Other Direct | ||||
| 4. | Total Medical Care Services (Sum lines 1-3) | ||||
| Financial Costs for Other Clinical Services | |||||
| 5. | Dental | ||||
| 6. | Mental Health | ||||
| 7. | Substance Use Disorder | ||||
| 8a. | Pharmacy not including pharmaceuticals | ||||
| 8b. | Pharmaceuticals | ||||
| 9. | Other Professional Specify | ||||
| 9a. | Vision | ||||
| 10. | Total Other Clinical Services (Sum lines 5-9a) | ||||
| Financial Costs Of Enabling And Other Services | |||||
| 11a. | Case Management | ||||
| 11b. | Transportation | ||||
| 11c. | Outreach | ||||
| 11d. | Patient and Community Education | ||||
| 11e. | Eligibility Assistance | ||||
| 11f. | Interpretation Services | ||||
| 11g. | Other Enabling Services Specify | ||||
| 11h. | Community Health Workers | ||||
| 11. | Total Enabling Services Cost (Sum lines 11a-11h) | 201926 | |||
| 12. | Other Professional Specify | 195806 | |||
| 12a. | Quality Improvement | 10 | |||
| 13. | Total Enabling and Other Services (Sum Lines 11, 12, and 12a) | ||||
| 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 | 122294 | |||
| 19. | Total with Donations (Sum lines 17 and 18) | 14331402 | |||
| Comments |
| S.No | 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 Year (c2) $ | Collection of Other Payments: P4P, Risk Pools, etc. (c3) $ | Penalty/Payback (c4) $ | Allowances (d) $ | Sliding Fee Discounts (e) $ | Bad Debt Write Off (f) $ |
| 1. | Medicaid Non-Managed Care | |||||||||
| 2a. | Medicaid Managed Care (capitated) | |||||||||
| 2b. | Medicaid Managed Care (fee-for-service) | |||||||||
| 3. | Total Medicaid (Sum lines 1+2a+2b) | |||||||||
| 4. | Medicare Non-Managed Care | |||||||||
| 5a. | Medicare Managed Care (capitated) | |||||||||
| 5b. | Medicare Managed Care (fee-for-service) | |||||||||
| 6. | Total Medicare (Sum lines 4+5a+5b) | |||||||||
| 7. | Other Public including Non-Medicaid CHIP (Non Managed Care) | |||||||||
| 8a. | Other Public including Non-Medicaid CHIP (Managed Care capitated) | |||||||||
| 8b. | Other Public including Non-Medicaid CHIP (Managed Care fee-for-service) | |||||||||
| 9. | Total Other Public (Sum lines 7+8a+8b) | |||||||||
| 10. | Private Non-Managed Care | |||||||||
| 11a. | Private Managed Care (capitated) | |||||||||
| 11b. | Private Managed Care (fee-for-service) | |||||||||
| 12. | Total Private (Sum lines 10+11a+11b) | |||||||||
| 13. | Self pay | |||||||||
| 14. | Total (Sum lines 3+6+9+12+13) | |||||||||
| Comments |
| S.No | Source | Specify | 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 | ||
| 1k. | 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 | ||
| 5. | Total Other Federal Grants (Sum lines 2-3a) | ||
| 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 (Sum lines 1+5+9+10) | ||
| Comments |
| Other Data Elements | Answers |
| 1. Medication-Assisted Treatment (MAT) for Opioid Use Disorder | |
| 1a. How many physicians, certified nurse practitioners and physician assistants, 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? |
|
| 1b. 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? |
|
| 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. Enter number of assists |
|
| Comments |
| File Type | application/vnd.ms-office |
| File Title | HRSA |
| Subject | HRSA |
| Author | HRSA |
| Last Modified By | OPAE |
| File Modified | 2019-12-17 |
| File Created | 2018-10-25 |