TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER l: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.APPENDIX D INSTRUCTION MANUAL FOR THE BCHS COMMON REPORTING REQUIREMENTS



Section 635.APPENDIX D Instruction Manual for the BCHS Common Reporting Requirements

 

FORM APPROVED

OMB NO. 0915-0004

EXPIRES 12/31/82

 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

Bureau of Community Health Services

Division of Monitoring and Analysis

5600 Fishers Lane

Rockville, Maryland 20857

(301)443-2376

BUREAU OF COMMUNITY HEALTH SERVICES

COMMON REPORTING REQUIREMENTS

FACE SHEET

1) BCRR Reporting No.

2) Check one:

 

Initial Submission

Revision

3) REPORT FOR PERIOD (Check One & Complete Date)

 

January 198__ through June 198___

 

January 198__ through December 198___

 

_____ 198___ through _____ 198___

4) Sponsor/Grantee Name

5) Project Name and Address

7) Program(s)*

Grant Number

 

 

 

 

 

 

(a)

 

 

(b)

 

6) Project Name/Address Change

(c)

 

since last report?

Yes No

(d)

 

8) Name of Person Preparing Report

(e)

 

 

(f)

 

 

(g)

 

9) Area Code and Business Telephone Number of Person Preparing Report

10) Director (name)

Signature & Date

11)

Check those tables not submitted with this report because they are totally inapplicable for the reason listed: (do not submit blank tables)

 

2-A

Only applies to projects serving migratory and seasonal agricultural workers.

4

Only applies to primary care projects/grantees.

 

2-B

Only applies to CH, FP, MH and other projects designed by the Regional Office.

5

Only applies to projects affected by the Primary Care Effectiveness activity.

*Grantees receiving support from one or more BCHS program will report the identifying code for each program included and the grant number relating to each program (except in free-standing NHSC sites). The codes are as follows:

CH

- Community Health Center (includes RHI,

HC

- National Health Service Corps (BHPDS)

 

- UHI & Hospital-Affiliated).

MH

- Migrant Health

FP

- Title X Family Planning

 

 

1.

Submit:

 

 

a.

3 copies to:

the Data Manager

 

 

 

REGIONAL OFFICE

 

 

(unless the Regional Office specifies otherwise)

 

NOTE:

Grantees are in violation of Public Health Service policy if they fail to submit reports that are complete, timely, accurate and valid. Grantees are ineligible to receive continuation support if they have failed to comply with the submission requirements of the BCRR as established by the Regional Office.

2.

Direct questions to the Regional Data Manager.

3.

Check the appropriate reporting period and enter the terminal digit for the year in space 3 on the FACE SHEET and the upper right corner of each table.

4.

Attach an explanation to any table for which:

 

a.

sampling is used or estimates have been made; and/or

 

b.

the data is entered inconsistent with the definitions/instructions used in the BCRR Instruction Manual. Contact the Regional Data Manager if non-standard definitions are used.

5.

When submitting revisions of tables that have already been sent to the Regional Office or submitting for the first time a table which was omitted from a previous submission:

 

a.

Submit only those tables which are being revised (changed) or being submitted for the first time.

 

b.

Indicate the reporting period for the revised information on both the FACE SHEET and the table(s).

NOTE: The reporting period for the revised information should match the reporting period indicated on the FACE SHEET. Do not include tables with different due dates under one FACE SHEET;

 

c.

Check the appropriate box (Initial Submission or Revision) on the FACE SHEET and each table revised;

 

d.

Where a small number of cells are being revised they should be circled to avoid a re-keying of the entire table;

 

e.

Follow the distribution schedule in 1 above.

(REV. 1/82)


 

BCRR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

TABLE 1: NUMBER OF USERS BY TYPE OF PROVIDER,

AGE AND SEX FOR THIS REPORTING PERIOD

 

AGE AND SEX

USERS* BY TYPE OF PROVIDER

MEDICAL

(a)

DENTAL

(b)

Female:

 

 

 

1)

0-4

 

 

2)

5-9

 

 

3)

10-14

 

 

4)

15-19

 

 

5)

20-34

 

 

6)

35-44

 

 

7)

45-64

 

 

8)

65 and over

 

 

9)

SUBTOTAL

 

 

 

(LINES 1 through 8)

 

 

Male:

 

 

 

10)

0-4

 

 

11)

5-9

 

 

12)

10-14

 

 

13)

15-19

 

 

14)

20-34

 

 

15)

35-44

 

 

16)

45-64

 

 

17)

65 and over

 

 

18)

SUBTOTAL

 

 

 

(LINES 10 through 17)

 

 

19)

TOTAL

 

 

 

(LINES 9 + 18)

 

 

 

*A user is an individual who has had one or more encounters during the reporting period covered by this table (January - June or January - December).

 

 

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31).


 

BCRR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

TABLE 2-A: UTILIZATION OF SPECIAL POPULATION GROUPS

FOR THIS REPORTING PERIOD

 

NOTE: This table applies to any grantee servicing migratory and/or seasonal agricultural workers and their family members.

 

 

 

 

 

 

 

 

 

 

TYPE OF USER

MEDICAL

USERS*

(a)

DENTAL

USERS*

(b)

1)

Migratory Agricultural Workers and Family Members

 

 

2)

Seasonal Agricultural Workers and Family Members

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*A user is an individual who has had one or more encounters during the reporting period covered by this table (January - June or January - December).

 

 

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31).


 

BCCR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

FP/FS Delegate?

Yes

No

 

TABLE 2-B: NUMBER OF FAMILY PLANNING USERS BY TYPE OF USER AND AGE FOR THIS REPORTING PERIOD

 

NOTE: This table applies only to CH, FP, MH, and all other projects required by the Regional Office to report this table. Grantees which are required to submit this table but do no receive Title X funding should report all female Family Planning Users, regardless of income, on LINE 1.

 

TYPE OF FAMILY PLANNING USER

FAMILY PLANNING USERS*

(a)

1)

Women at or below 150% of Poverty Level

 

2)

Women above 150% of Poverty Level

 

3)

Men

4)

TOTAL (LINES 1+2)

 

Female Adolescent Users of Family Planning Services (Subset of LINE 4)

 

5)

Under 20 years old

 

6)

15-19 Year Olds

 

 

*A Family Planning user is an individual who has had one or more Family Planning Encounters (Medical or Other Health) during the reporting period covered by this table (January - June or January - December).

 

 

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31).


 

 

BCCR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

HCFA I.D. NO.

 

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

TABLE 3: PERSONNEL BY FUNCTIONAL COST CENTER AND ENCOUNTERS BY TYPE OF PROVIDER FOR THIS REPORTING PERIOD

 

 

PERSONNEL BY FUNCTIONAL COST CENTER*

STAFF* PERSONNEL EQUIVALENTS

ENCOUNTERS

Onsite With Staff Providers

All Other (Including Offsite

and Nonstaff)

(a)**

(b)***

(c)

(d)

MEDICAL SERVICES

(A)

1) Primary Care Physicians

 

 

 

 

2) Psychiatrists

 

 

 

 

3) Other Medical/Surgical Specialists

 

 

 

 

4) Midlevel Practitioners

 

 

 

 

5) Nurses − Medical

 

 

 

 

6) Medical Support

 

 

 

 

ANCIL-

LARY

SERVICES

(B)

7) Laboratory-Medical

 

 

 

 

(C)

 

8) X-Ray-Medical

 

 

 

 

(D)

 

9) Pharmacy-Medical & Dental

 

 

 

 

DENTAL SERVICES

 

10) Dentists

 

 

 

 

(E)

11) Dental Hygienists/

Oral Therapists

 

 

 

 

 

12) Dental Support

 

 

 

 

OTHER

HEALTH

SERVICES

(G)

13) Education/Social Service

 

 

 

 

14) Other Health

 

 

 

 

15)

 

 

 

 

16) Other Health Support

 

 

 

 

SUPPORT

SERVICES

(H)

17) Community Service

 

 

 

 

(I)

18) Environmental Health

 

 

 

 

(J)

19) Patient Transportation

 

 

 

 

 

20) Patient Records

 

 

 

 

CLINIC

OVER-

HEAD

(K)

21) Administration

 

 

 

 

(L)

22) Facility

 

 

 

 

 

23) TOTAL (LINES 1 through 22)

 

 

 

 

*

Assign staff time by function performed, not title. See instructions for this table.

**

Include only NHSC personnel in Column (a).

***

Include salaried personnel, as well as the personnel equivalents of any non-salaried personnel (contractual or donated) who work for the grantee on a scheduled time basis. (See definition of "Staff.") Include WIC, VISTA and volunteer staff, where appropriate.

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31).


 


BCRR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

 

TABLE 4: HOSPITAL INPATIENT CARE BY TYPE OF

ENCOUNTER FOR THIS REPORTING PERIOD

 

 

NOTE: To be completed by all primary care grantees/projects. Primary care grantees/projects include: CH, HC, and MH.

 

 

 

TYPE OF SERVICE

PATIENT ADMISSIONS BY PROJECT STAFF

(a)

HOSPITAL INPATIENT ENCOUNTERS

BY PROJECT STAFF*

(b)

1)

Pediatrics

 

 

2)

Internal Medicine

 

 

3)

Obstetrics

 

 

 

 

 

 

4)

Other (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Project staff include salaried, contracted or donated medical personnel, i.e., physicians and midlevel practitioners.

 

 

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31).


 


BCRR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

 

TABLE 5: SELECTED CLINICAL SERVICES FOR THIS REPORTING PERIOD

 

 

NOTE: Only applies to projects affected by Primary Care Effectiveness activity, as follows: CH, FP, HC and MH.

 

 

Clinical

User Category

Records Sampled

(a)

Records in Compliance

(b)

 

1)

 

Immunization

24-27 months

 

 

 

2)

 

Immunization

6 year olds

 

 

 

3)

 

Adolescent Family Planning

Counseling (under 20 years)

 

 

 

4)

 

Pap Smear Follow-up

 

 

 

5)

 

Hypertension Follow-up

(10 years and over)

 

 

 

6)

 

Anemia Screening

24-27 months

 

 

 

 

FREQUENCY OF REPORTING: Semi-annually (January 1 - June 30, July 1 - December 31)






BCRR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

HCFA I.D. NO.

 

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

TABLE 6: COSTS BEFORE AND AFTER DISTRIBUTION BY FUNCTIONAL COST CENTER FOR THIS REPORTING PERIOD

 

NOTE: Grantees should complete this table as follows:

 

Annual: The entire table (LINES 1 through 13, COLS. a through g).

 

First six months (unless instructed by the Regional Office to report quarterly for the first three quarters): Complete all of LINE 13, and the applicable cells of COLS. (f) and (g).

 

 

FUNCTIONAL

COST CENTER

SALARIED PERSONNEL* (WORKSHEET A, COL. h)

 

OTHER (INCLUDING CONSULTANT AND CONTRACT SERVICES)

VALUE OF DONATED MATERIAL & SERVICE**

TOTAL BEFORE DISTRIBUTION (COLS.

a + b + c + d)

TOTAL AFTER DISTRIBUTION OF FACILITY COSTS *** (WORKSHEET B, COL. e)

TOTAL AFTER FINAL DIST. OF CLINIC OVERHEAD COSTS (WORKSHEET B, COL. h)

(a)

(c)

(d)

(e)

(f)

(g)

HEALTH CARE FUNCTIONS

 

 

 

 

 

 

 

1)

Medical (A)

 

 

 

 

 

 

 

2)

Laboratory-Medical (B)

 

 

 

 

 

 

 

3)

X-Ray Medical (C)

 

 

 

 

 

 

 

4)

Pharmacy-Medical & Dental (D)

 

 

 

 

 

 

 

5)

Dental (inc. Lab & X-Ray) (E)

 

 

 

 

 

 

 

6)

Inpatient (F)

 

 

 

 

 

 

 

7)

Other Health (G)

 

 

 

 

 

 

 

8)

Community Service (H)

 

 

 

 

 

 

 

9)

Environment (I)

 

 

 

 

 

 

 

10)

Patient Transportation (J)

 

 

 

 

 

 

 

CLINIC OVERHEAD FUNCTIONS

 

 

 

 

 

 

 

11)

Administration (K)

 

 

 

 

 

 

- 0 -

12)

Facility (L)

 

 

 

 

 

- 0 -

- 0 -

13)

TOTAL (LINES 1 though 12)

 

 

 

 

 

 

 

 

*Include the costs of salaried personnel, including the costs of fringe benefits paid to employees (see TABLE 6 Worksheet A).

**Include the costs associated with donated personnel, including NHSC assignees. For NHSC personnel, include the reimbursable cost of the assignee(s), not the amount actually reimbursed to the Corps.

***Only the cells not shaded should be completed with the data transferred from Worksheet B.

 

NOTE: The distribution of PERSONNEL COSTS across from the functional areas should correspond to the distribution of STAFF PERSONNEL EQUIVALENTS shown in TABLE 3. For any individual whose time is split among two or more functions in TABLE 3, the same percentage split should be applied to personnel and consultant costs in this table.

 

All amounts should be rounded off to the nearest dollar.

 

CONSISTENCY CHECK:

LINE 13, COL. (e) = LINE 13, COL. (g)

 

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31).


 

TABLE 6 WORKSHEET A: DISTRIBUTION OF PATIENT RECORDS COSTS

AND FRINGE BENEFITS ACROSS FUNCTIONAL COST CENTERS

 

NOTE: If this Worksheet is used, it must be retained by the grantee.

It should not be submitted with TABLE 6.

 

 

 

 

DISTRIBUTION OF PATIENT RECORDS COSTS

DISTRIBUTION OF FRINGE

BENEFITS COSTS

Other Costs

Value of

Donated Mat.

& Svcs.

Total Before

Distribution

FUNCTIONAL

COST CENTERS

Number of Encounters

% of Total Encounters

Amount of Personnel Distrb. to Functions

Amount of Other Distrb. to Functions

Salaried Personnel Costs (inc. Col. C)

% of Total Salaries

Amount of Fringe Benefits Distrb. to Functions

Total Salaried Personnel Costs

 

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

HEALTH CARE FUNCTIONS

 

 

 

 

 

 

 

 

 

 

 

1)

Medical (A)

 

 

 

 

 

 

 

 

 

 

 

2)

Laboratory-Medical (B)

 

 

 

 

 

 

 

 

 

 

 

3)

X-Ray - Medical (C)

 

 

 

 

 

 

 

 

 

 

 

4)

Pharmacy-Medical & Dental (D)

 

 

 

 

 

 

 

 

 

 

 

5)

Dental (Lab & X-Ray) (E)

 

 

 

 

 

 

 

 

 

 

 

6)

Inpatient (F)

 

 

 

 

 

 

 

 

 

 

 

7)

Other Health (G)

 

 

 

 

 

 

 

 

 

 

 

8)

Community Service (H)

 

 

 

 

 

 

 

 

 

 

 

9)

Environmental (I)

 

 

 

 

 

 

 

 

 

 

 

10)

Patient Transportation (J)

 

 

 

 

 

 

 

 

 

 

 

11)

Patient Records

 

 

( )

( )

 

 

 

 

 

 

 

CLINIC OVERHEAD FUNCTIONS:

 

 

 

 

 

 

 

 

 

 

 

12)

Administration (K)

13)

Facility (L)

 

 

 

 

 

 

 

 

 

 

 

14)

Fringe Benefits

 

 

 

 

 

 

( )

 

 

 

 

15)

TOTAL (LINES 1 though 14)

 

100%

-0-

-0-

 

100%

-0-

 

 

 

 

 


TABLE 6 WORKSHEET B:

DISTRIBUTION OF CLINIC OVERHEAD COSTS ACROSS HEALTH CARE COST CENTERS

 

NOTE: If this Worksheet is used, it must be retained by the grantee. It should not be

submitted with TABLE 6.

 

 

Total before Distribution

Worksheet A, Col (k)

DISTRIBUTION OF FACILITY COSTS

Total after Distrb. of Facility Costs

(a + d)

DISTRIBUTION OF ADMINISTRATION COSTS

Total after Final Distrb.

of Clinic Overhead Costs

(e + g)

FUNCTIONAL COST CENTERS

Square Feet

of Space Used

% of Square

Footage

Amount of Facility Distrb. to Functions

% of Health Care Cost Subtotal

Amount of Admin. Distrb. to Functions

 

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

HEALTH CARE FUNCTIONS

 

 

 

 

 

 

 

 

1)

Medical (A)

 

 

 

 

 

 

 

 

2)

Laboratory -- Medical (B)

 

 

 

 

 

 

 

 

3)

X-Ray -- Medical (C)

 

 

 

 

 

 

 

 

4)

Pharmacy-Medical & Dental (D)

 

 

 

 

 

 

 

 

5)

Dental (Lab & X-Ray) (E)

 

 

 

 

 

 

 

 

6)

Inpatient (F)

 

 

 

 

 

 

 

 

7)

Other Health (G)

 

 

 

 

 

 

 

 

8)

Community Service (H)

 

 

 

 

 

 

 

 

9)

Environmental (I)

 

 

 

 

 

 

 

 

10)

Patient Transportation (J)

 

 

 

 

 

 

 

 

11)

SUBTOTAL (LINES 1 through 10)

 

 

 

 

 

100%

 

 

CLINIC OVERHEAD FUNCTIONS:

 

 

 

 

 

 

( )

-0-

12)

Administration (K)

13)

Facility (L)

 

 

 

( )

-0-

 

 

-0-

14)

SUBTOTAL (LINES 12 + 13)

 

 

 

 

 

 

 

 

15)

GRAND TOTAL

 

 

100%

-0-

 

 

-0-

 

 

CONSISTENCY CHECKS:

 

1. COL. (a) equals TABLE 6: COL. (e)

2. COL. (e) equals TABLE 6: COL. (f)

3. COL. (h) equals TABLE 6: COL. (g)

4. LINE 15, COL. (a), COL. (e), COL. (h) should all be equal.

 


 

BCRR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

TABLE 7: ACCOUNTS RECEIVABLE, CHARGES AND COLLECTIONS

BY SOURCE OF FUNDS FOR THIS REPORTING PERIOD

 

SOURCE OF FUNDS

ACCOUNTS RECEIVABLE AT BEGINNING OF THIS PERIOD

FULL CHARGES AND PREMIUMS DURING THIS PERIOD*

AMOUNT COLLECTED DURING THIS PERIOD

ADJUSTMENTS (identify below)**

ACCOUNTS RECEIVABLE AT END OF THIS PERIOD

 

(a)

(b)

(c)

(d)

(e)

1) Medicare

(Title XVIII)

 

 

 

 

 

2) Medicaid

(Title XIX)

 

 

 

 

 

3) Title XX

 

 

 

 

 

4) Other Third Parties

 

 

 

 

 

5) Patient Fees/Premiums

 

 

 

 

 

6) TOTAL (LINES

1+2+3+4+5)

 

 

 

 

 

*Charges or premiums prior to adjustments for patients' ability to pay, third party disallowances, etc. If Full Charges/Premiums are based upon a negotiated or contractual arrangement with a third party payor, and are not generally reflective of the costs of operation, footnote and explain below (name of third party, per unit, service, or capitation reimbursement rate or dollar limit).

 

**Breakdown of Adjustments by Type

DESCRIPTION

AMOUNT

 

7) Disallowances and Reductions (Contractual Allowances)

$

 

 

 

8) Sliding Payment Scale Adjustments

$

 

 

 

9) Bad Debt Write Off

$

 

 

 

10) Other (Specify)

 

$

 

 

 

CONSISTENCY CHECKS:

 

1. COL. (e) should equal COL. (a) + COL. (b) COL. (c) COL. (d)

 

2. The amount entered in COL. (a) should equal the amount entered in COL. (e) of the TABLE 7 for the preceding calendar year.

 

When TABLE 7 is completed for the same reporting period as TABLE 8, then:

 

3. LINE 6, COL. (c) should equal TABLE 8: LINE 16 COL. (a).

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period.

 


 


BCCR REPORTING NO.

 

REPORT FOR PERIOD (Check One & Complete Date)

 

 

January 198__ through June 198___

 

 

January 198__ through December 198___

 

 

_____ 198___ through _____ 198___

 

Initial Submission

Revision

 

TABLE 8: SUMMARY OF RECEIPTS AND EXPENDITURES

FOR THIS REPORTING PERIOD

 

NOTE: This table applies to grantee receipts and expenditures associated with services or activities in the approved application for BCHS funds, including those associated with delegate agency operations.

 

Grantees should complete this table as follows:

Annual: The entire table (LINES 1 through 23, COL. a).

First Six Months (unless instructed by the Regional Office to report quarterly for the first three quarters):

LINES 10, 16, 20 and 21 through 23, COL. (a).

 

 

Summary of Receipts and Expenditures

Actual for Reporting Period

(a)

Federal Grants

1)

Section 329 (Migrant Health)

 

2)

Section 330 (Community Health Center)

 

3)

MCH Block Grants*

 

4)

Title X (Family Planning)**

 

5)

Section 340 (Primary Care R & D)

 

6)

Appalachian Health

 

7)

Black Lung Clinic Program

 

8)

WIC***

 

9)

Other (Specify)****_____________

 

10)

SUBTOTAL (LINES 1 through 9)

 

Payment for

Services

11)

Title XVIII (Medicare)

 

12)

Title XIX (Medicaid)

 

13)

Title XX

 

14)

Other Third Parties

 

15)

Patient Collections

 

16)

SUBTOTAL (LINES 11 through 15)

 

Other

Sources

17)

State

 

18)

Local

 

19)

Other (Specify)**** _____________

 

20)

SUBTOTAL (LINES 17 through 19)

 

Expendi-

tures

21)

Capital Expenditures

 

22)

Non-Capital Expenditures*****

 

23)

SUBTOTAL (LINES 21 + 22)

 

*

Any form of State assistance through MCH Block

**

Indicate Title X funds received directly from the Federal government or indirectly through a delegate agency type relationship on LINE 4. Indicate other Federal grants received directly or indirectly on LINE 9.

***

Only include monies received for administration and operation of the WIC program, not the monies received for food. Do not include money spent on food on LINE 22.

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Enter NHSC loans on LINE 19.

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Include all actual expenditures by the grantee and its delegates on LINE 22. Payments made to the Federal government during the reporting period for the cost of NHSC assignees are entered on LINE 22.

FREQUENCY OF REPORTING: Semi-annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31).

 

(Source: Added at 14 Ill. Reg. 20783, effective January 1, 1991)