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Get City Of Los Angeles Claim Form 2021-2024

Please indicate the start and end dates of the twelve months for which the site is reporting. Scope Of Activity Reported The NHSC Site Data Tables are site specific one per physical address. Who Submits Site Data Tables Department of Health and Human Services to participate as an NHSC member site and which are not currently receiving grant support from the Health Resources and Services Administration s Bureau of Primary Health Care HRSA/BPHC. The NHSC Site Data Tables are to be completed prior to an NHSC Site Visit. All sites meeting the criteria above are to file a complete report except for Federal Bureau of Prison BOP nonfederal prison Indian Health Service IHS Section 638 and Immigration and Naturalization Service INS sites which are only to file the general site information Name of Site through Total Patient Visits and Table 4. Site Data Tables Name of Site Address of Site Date Prepared Prepared By 12 Month Reporting Period Total Annual Patients TABLE 1 PATIENTS OR VISITS BY PRIMARY INSURANCE TYPE Primary Insurance Complete data for Number of Patients OR Number of Patient Visits Number of Patients Percentage Patient Visits Visits 1 Medicare 2 Medicaid 3 Other Public Insurance 4 Private Insurance 5 Sliding Fee Schedule SFS 6 Self-Pay No Insurance and not on SFS 7 Total U.S. DEPARTMENT OF HEAlTH AND HUMAN SERVICES HEAlTH RESOURCES AND SERVICES ADMINISTRATION OF AND HUMAN SERVICES HEALTH RESOURCES AND SERVICES ADMINISTRATION Revised July 2013 Payment Source Full Charges a Amount Collected b 5 Self-Pay 6 Total lines 1-5 Self-Pay Adjustment Type Adjustments c 7 Self-Pay Sliding Fee Adjustments 8 Other Self-Pay Adjustments e.g. Self-Pay Bad Debt 9 Total Self-Pay Adjustments lines 7 and 8 TABLE 3 PATIENT APPLICATIONS FOR SLIDING FEE SCHEDULE SFS Patient Applications for the Sliding Fee Schedule Number of Applications 1 SFS Applications Approved 3 Total SFS Applications Received TABLE 4 SERVICE SITE STAFFING Personnel by Major Service Categories FTEs Medical Services 1 Family Practitioners 2 General Practitioners 3 Internists 4 Obstetrician/Gynecologists 5 Pediatricians 6 Psychiatrists 7 Other Physician Specialists 8 Total Physicians lines 1-7 9 Nurse Practitioners/Physician Assistants 10 Certified Nurse Midwives 11 Nurses 12 Other Medical Support Personnel 13 Total Medical Services lines 8-12 Ancillary Services 14 laboratory Services Personnel 15 X-Ray Services Personnel 16 Pharmacy Personnel 17 Total Ancillary Services lines 14-16 Dental Services 18 Dentists 19 Dental Hygienists 20 Dental Assistants Aides Technicians and Support 21 Total Dental Services lines 18-20 Mental Health and Behavioral Health Services 22 Mental Health Behavioral Health Specialists 24 Total MH BH Services lines 22-23 25 TOTAL lines 13 17 21 and 24 NOTES NHSC Site Data Tables General Instructions Reporting Period The reporting period is twelve continuous months. Activity at other sites owned or operated by the sponsoring organization is to be excluded* All related activity of all providers at the site is to be reported including activity of all NHSC and non-NHSC providers at the site.

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