Medical Director E-Mail Address We have read the ☐ Yes ☐No What was the size of your Total Budget Total FTEs organization in 2014? What is your organizational Private Non Public Non State Other (describe) structure? Profit Agency Profit County Agency Agency Which most closely describes your Rural Frontier Urban Suburban Other service area? How many visits/encounters did your Number agency provide in 2014? How many unduplicated clients did Number your agency serve in 2014? Annually, what percent of clients are Percent Percent Percent children/youth, adults, or older Children/youth Adults Older Adults adults? 0-17 18-64 65+ What percent are non-English Percent speaking? What percent of clients are: White/Caucasian American Asian / African Hispanic Indian / Pacific American/ / Latino Alaska Native Islander Black Other significant information about your organization: Describe your existing integrated health services (use as much space as necessary): Are you partnering with non-FQHC organizations? YES (complete the next set of questions) NO (skip to Organizational Commitment section) Do you have a formal (e.g., written agreement, joint business plan) relationship for: Non-psychiatric medical care Yes No
Medical Director E-Mail Address We have read the ☐ Yes ☐No What was the size of your organization in 2014? Total Budget Total FTEs What is your organizational structure? Private Non Profit Agency Public Non Profit County Agency State Agency Other (describe) Which most closely describes your service area? Rural Frontier Urban Suburban Other How many visits/encounters did your agency provide in 2014? Number How many unduplicated clients did your agency serve in 2014? Number Annually, what percent of clients are children/youth, adults, or older adults? Percent Children/youth 0-17 Percent Adults 18-64 Percent Older Adults 65+ What percent are non-English speaking? Percent What percent of clients are: White/Caucasian American Indian / Alaska Native Asian / Pacific Islander African American/ Black Hispanic / Latino Other significant information about your organization: Describe your existing integrated health services (use as much space as necessary): Are you partnering with non-FQHC organizations? YES (complete the next set of questions) NO (skip to Organizational Commitment section) Do you have a formal (e.g., written agreement, joint business plan) relationship for: Non-psychiatric medical care Yes No
FQHC-Cohort-4-Application-Final-Draft.docx