OMB No.: 0915-0285. Expiration Date: 9/30/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR HRSA USE ONLY Health Resources and Services Administration Applicant Name Grant Number Application Tracking Number INCOME ANALYSIS FORM Part 1: Patient Service Revenue Program Income – Patients by Line Projected Prior FY Payer Category Primary Medical Billable Visits Income per Visit # Income Income:______ Insurance (a) (b) (c) (d) (e) 1 Medicaid 2 Medicare 3 Other Public 4 Private 5 Self-Pay 6 Total (Lines 1–5) Part 2: Other Income Other Federal, State, Local and Other Income – 7 Other Federal 8 State Government 9 Local Government Private Grants/ 10 Contracts 11 Contributions 12 Other Applicant (Retained 13 Earnings) 14 Total Other: (Lines 7–13) Total Non-Federal (Non-section 330) Income (Program Income Plus Other) Total Non-Federal (lines 15 6+14) Comments/Explanatory Notes (if applicable) 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 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour 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 10-29, Rockville, Maryland, 20857.
OMB No.: 0915-0285. Expiration Date: 9/30/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration INCOME ANALYSIS FORM FOR HRSA USE ONLY Applicant Name Grant Number Application Tracking Number Part 1: Patient Service Revenue – Program Income Line # Payer Category Patients by Primary Medical Insurance Billable Visits Income per Visit Projected Income Prior FY Income:______ (a) (b) (c) (d) (e) 1 Medicaid 2 Medicare 3 Other Public 4 Private 5 Self-Pay 6 Total (Lines 1–5) Part 2: Other Income – Other Federal, State, Local and Other Income 7 Other Federal 8 State Government 9 Local Government 10 Private Grants/ Contracts 11 Contributions 12 Other 13 Applicant (Retained Earnings) 14 Total Other: (Lines 7–13) Total Non-Federal (Non-section 330) Income (Program Income Plus Other) 15 Total Non-Federal (lines 6+14) Comments/Explanatory Notes (if applicable) 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 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour 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 10-29, Rockville, Maryland, 20857.
fy2015incomeanalysisform_.docx