Annual Utilization Report of Primary Care Clinic
Facility Name:SECOND MOBILE UNIT
OSHPD ID:306124028Report Status:Revised
License Category:Community ClinicReport Year:2006
Table of Contents
Click on any of the links listed below to view the corresponding section.
Section 1 - General Information
Section 2 - Clinic Services
Section 3 - Patient Demographics
Section 4 - Encounters by Principal Diagnosis
Section 5 - Encounters by Principal Service
Section 6 - Revenue and Utilization by Payer
Section 7 - Income Statement
Section 8 - Capital Projects and Funds
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:SECOND MOBILE UNIT
2.OSHPD ID Number:306124028
3.Street Address:301 P STREET
4.City:EUREKA
5.Zip:95501
6.Facility Phone No.:(707) 443 - 4266 ext. 22
7.Administrator Name:Sally Hewitt
8.Administrator E-mail Address:shewitt@mobilemed.org
9.Was this clinic in operation at any time during the year?:No
10.Operation Open From:1/1/2006
11.Operation Open To:12/31/2006
12.Name of Parent Corporation:Mobile Medical Office
13.Corporate Business Address:301 P Street
14.City:Eureka
15.State:CA
16.Zip:95501 -
17.Person Completing Report:Unknown Report Preparer
18.Phone No.:707-443-4666x22
19.Fax No.:707-443-6123
20.E-mail Address:shewitt@mobilemed.org
30.Submitted by:mobilemed
31.Submitted Date and Time:2/15/2007 4:42:57 PM
32.Corrected by:tommychi
33.Corrected Date and Time:4/4/2007 4:12:39 PM
Section 2 - Clinic Services
1.License Category:Community Clinic
Federally Qualified Health Clinic (FQHC)
Line
No.		Federally Qualified Health Clinics and Rural Clinics(1)
2.Indicate clinic type, if applicable:Unspecified
Rural Health Clinic
Line
No.		Rural Health Clinic(1)
3.Is this a 95-210 Rural Health Clinic?
Table 2.1 - Community Services
Check one or more boxes for each service provided.
Line
No.		Community Services(1)
Offered
10.Adult Day CareNo
11.Child CareNo
12.Community EducationNo
13.Community NutritionNo
14.Disaster ReliefNo
15.Environmental HealthNo
16.HomelessNo
17.LegalNo
18.OutreachNo
19.Social ServicesNo
20.Substance AbuseNo
21.TransportationNo
22.Vocational Training PlacementNo
23.Other (See Survey)No
Table 2.2 - Languages Spoken By
Check the staff box if one or more staff members speaks the listed language. Check the patients box if 100 patients (or more than 1% of your patient population) are best served in a listed language. Estimates are acceptable if exact counts are not available.
Line
No.		Language Spoken By(1)
Staff		(2)
Patients
30.ArabicNoNo
31.ArmenianNoNo
32.CambodianNoNo
33.ChineseNoNo
34.HindustaniNoNo
35.HmongNoNo
36.JapaneseNoNo
37.KoreanNoNo
38.LaotianNoNo
39.PortugeseNoNo
40.PunjabiNoNo
41.RussianNoNo
42.Sign LanguageNoNo
43.SpanishNoNo
44.TagalogNoNo
45.VietnameseNoNo
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):0%
56.Primary non-English language spoken by patients (from list above):
FTE's and Encounters by Primary Care Provider
Line
No.		Primary Care Provider(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Encounters
60.Physicians0
61.Physician Assistants0
62.Family Nurse Practitioners0
63.Certified Nurse Midwives0
64.Visiting Nurses0
65.Dentists0
66.
67.Psychiatrists0
68.Clinical Psychologists0
69.Licensed Clinical Social Workers (LCSW)0
70.Other Providers billable to Medi-Cal**0
74.Other Certified CPSP providers not listed above***0
75.Subtotal0
** Other Providers billable to Medi-Cal - Included here are Chiropractors, Physical Therapists, Optometrists and any other professionals who are able to be reimbursed through the Medi-Cal program.
*** Comprehensive Perinatal Services Program - List all other professional not listed above that are certified by the CPSP program to render services and can be reimbursed.
FTE's and Contacts by Clinical Support Staff
Line
No.		Clinical Support Staff(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Contacts
80.Registered Dental Hygienists (not Alternative Practice)0
81.Registered Dental Assistants0
82.Dental Assistants - Not licensed0
83.Marriage and Family Therapists (MFT) - from above0
84.Registered Nurses0
85.Licensed Vocational Nurses0
86.Medical Assistants - Not licensed (1)0
87.Non-Licensed Patient Education Staff0
88.Substance Abuse Counselors (2)0
89.Billing Staff (3)
90.Other Administrative Staff (3)
94.Other Providers not listed above
95.Subtotal0
(1) Also includes Certified Medical Assistants
(2) Does not include substance abuse counseling performed by providers listed elsewhere
(3) Staff must spend 80% of time on billing
(4) Includes Executive Directors, CFO's, Medical & Dental Records staff, Medical & Dental Receptionists & other management staff
Section 3 - Patient Demographics
Race
Line
No.		Race(1)
# of
Patients
1.White (include Hispanic)0
2.Black0
3.Native American / Alaskan Native0
4.Asian / Pacific Islander0
9.Other / Unknown0
10.Total Patients *0
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic0
12.Non-Hispanic0
13.Unknown0
15.Total Patients *0

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%0
21.100 - 200%0
22.Above 200%0
23.Unknown0
24.Total Patients *0
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
#
30.Total Patients0
31.Total Encounters0
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year00
41.1 - 4 years00
42.5 - 12 years00
43.13 - 14 years00
44.15 - 19 years00
45.20 - 34 years00
46.35 - 44 years00
47.45 - 64 years00
48.65 and over00
55.Total Patients *00
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare0
61.Medicare - Managed Care0
62.Medi-Cal0
63.Medi-Cal - Managed Care0
64.County Indigent / CMSP / MISP0
65.Healthy Families0
66.Private Insurance0
67.Alameda Alliance for Health0
68.LA Co. Public Private Partnership0
69.San Diego Co. Medical Plan0
70.Self-Pay / Sliding Fee0
71.Free0
74.All Other Payers0
75.Total Patients *0
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCCP0
81.CHDP0
82.EAPC0
83.Family PACT0
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)0
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments0
Section 4 - Encounters By Principal Diagnosis
Encounters by Principal Diagnosis
Report the diagnosis (or symptom, condition, problem or complaint) as the main reason for the encounter. Do not report the secondary diagnosis(es). There should be only one principal diagnosis for each encounter.
Line
No.		Classification of Diseases and/or Injuries
for each Principal Diagnosis		ICD-9-CM Codes(1)
# of Encounters
1.Infectious and Parasitic Diseases001 - 1390
2.Neoplasms140 - 2390
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 2790
4.Blood and Blood Forming Disorders280 - 2890
5.Mental Disorders290 - 3190
6.Nervous System and Sense Organs Diseases320 - 3890
7.Circulatory System Diseases390 - 4590
8.Respiratory System Diseases460 - 5190
9.Digestive System Diseases, excluding dental diagnosis530 - 5790
10.Genitourinary System Diseases580 - 6290
11.Pregnancy, Childbirth & the Puerperium630 - 6770
12.Skin and Subcutaneous Tissue Diseases680 - 7090
13.Musculoskeletal System and Connective Tissue Diseases710 - 7390
14.Congenital Anomalies740 - 7590
15.Certain Conditions Originating in the Perinatal Period760 - 7790
16.Symptoms, Signs, and Ill-defined Conditions780 - 7990
17.Injury and Poisoning800 - 9990
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V850
19.Dental Diagnosis520-5290
20.Family Planning S-Codes0
21.Other0
25.Total0
Section 5 - Encounters By Principal Service
Encounters by Principal Service
Classify each encounter by the principal CPT code that was reported on the billing document for this encounter. Do not report secondary procedures. There should be one and only one procedure code reported for each encounter.
Line
No.		Evaluation and Management ServicesCPT Codes - 2006(1)
# of
Encounters
1.Evaluation and Management (new patient)99201 - 992050
2.Evaluation and Management (established patient)99211 - 992150
3.Hospital Related Services99217 – 99223
99231 - 99239		0
4.Consultations99241 - 992550
5.Other Evaluation and Management Services99281 - 99285
99354 - 99360
99420 - 99429
99450 - 99499		0
6.Nursing Facility Related Services99301 - 993160
7.Case Management Services99361 - 993730
8.Preventive Medicine (infant, child, adolescent)99381 - 99384
99391 - 99394
99431 - 99440		0
9.Preventive Medicine (adult)99385 - 99387
99395 - 99397		0
10.Counseling99401 - 994120
All Other Services
11.Anesthesia00100 – 01999
99100
99116
99135
99140
99143 - 99150		0
12.Integumentary System10021 - 194990
13.Musculoskeletal System20000 - 299990
14.Respiratory System30000 - 329990
15.Cardiovascular System33010 - 377990
16.Hemic and Lymphatic System38100 - 389990
17.Mediastinum and Diaphragm System39000 - 395990
18.Digestive System40490 - 499990
19.Urinary System50010 - 538990
20.Male Genital System54000 - 558990
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 589990
23.Maternal Care and Delivery59000 - 598990
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649990
26.Eye and Ocular Adnexa System65091 - 688990
27.Auditory System69000 - 699900
28.Radiology70010 - 799990
29.Pathology / Laboratory80048 – 893560
30.Medicine - Special Services90281 – 99091
99170 – 99199		0
31.Family Planning "Z" Codes"Z" codes0
32.Dental Encounters (CDT codes)D0100-D09990
33.CPT Category III Codes0003T - 0161T0
44.Any other encounters0
45.Total0
Selected Procedure Code
Report the number of procedures for each code (or range of codes) regardless of whether it is the principal or secondary procedure code.
Line
No.		Evaluation and Management ServicesCPT Codes - 2006(1)
# of
Procedures
50.Mammogram76082 – 76083
76090 - 76092		0
51.HIV Testing86689
86701 - 86703
87390 - 87391		0
52.Pap Smear88141 - 88155
88164 - 88167
88174 - 88175		0
53.Contraceptive Management11975 - 11977
55250, 55450, 57170,
58300 - 58301
58600 - 58611		0
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90698, 90700 – 90701,
90718		0
61.Hemophilus Influenza B (Hib)90645 - 906480
62.Hepatitis A90632 – 90634
90636		0
63.Hepatitis B90740, 90743, 90744, 90746 - 907470
64.HepB and Hib907480
65.Influenza Virus Vaccine90655 – 90658
90660		0
66.Measles, Mumps and Rubella (MMR) and Varicella (MMRV)90704 - 90708, 907100
67.Pneumococcal906690
68.Poliovirus90712 - 907130
69.Varicella907160
Section 6 - Revenue and Utilization by Payer
Line
No.		(1)
Medicare		(2)
Medicare
Managed		(3)
Medi-Cal		(4)
Medi-Cal
Managed		(5)
County/
CMSP/MISP		(6)
Healthy
Families
1.Encounters000000
2.Gross Revenue
(Charges at 100% Rate)
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments
6.Bad Debts
7.Grants
enter positive numbers
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)
15.Net Patient Revenue (collected)
(line 2 – Line 10)
Line
No.		(7)
Private
Insurance		(8)
Self-Pay/
Sliding Fee		(9)
Free		(10)
Breast
Cancer*		(11)
CHDP		(12)
EAPC
1.Encounters000000
2.Gross Revenue
(Charges at 100% Rate)
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments
6.Bad Debts
7.Grants
enter positive numbers
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)
15.Net Patient Revenue (collected)
(line 2 – Line 10)
*  These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program
Line
No.		(13)
Family
PACT		(14)
San Diego
Med Plan		(15)
LA - PPP		(16)
Alameda
Alliance		(17)
Other
County		(18)
All Other
Payers
1.Encounters000000
2.Gross Revenue
(Charges at 100% Rate)
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments
6.Bad Debts
7.Grants
enter positive numbers
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)
15.Net Patient Revenue (collected)
(line 2 – Line 10)
Line
No.		(19)
Grand Totals
1.Encounters0
2.Gross Revenue
(Charges at 100% Rate)
3.Sliding Fee Scale Write-offs
4.Free/Complimentary Write-offs
5.Contractual Adjustments
6.Bad Debts
7.Grants, enter positive numbers( )
8.Other Adjustments
9.Reconciliation
10.Total Write-offs & Adjustments
(sum lines 3 through 9)
15.Net Patient Revenue (collected)
(line 2 – Line 10)
Section 7 - Income Statement
Income Statement
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)
3.Net Patient Revenue (from Sec 6, line 15, column 19)
Other Operating Revenue
4.Federal Funds
State Funds
5.EAPC
6.Other
County Funds
7.LA County Public Private Partnership
9.San Diego County Medical Plan
10.Other County Grant Programs
11.Local (City or District) Funds
12.Private
13.Donations/Contributions
19.Other
20.Total Other Operating Revenue (Sum Lines 4 through 19)
25.Total Operating Revenue (Line 3 + Line 20)

Line
No.		Operating Expenses(1)
30.Salaries, Wages, and Emplyee Benefits
31.Contract Services - Professional
32.Supplies - Medical and Dental
33.Supplies - Office
34.Outside Patient Care Services
35.Rent / Depreciation / Mortgage Interest
36.Utilities
37.Professional Liability Insurance
38.Other Insurance
39.Continuing Education
44.All Other Expenses
45.Total Operating Expenses (Sum Lines 30 through 44)
50.Net from Operations (Line 25 - Line 45)
Section 8 - Major Capital Expenditures
Section 127285(3) of the Health and Safety Code requires each clinic to report "acquisitions of diagnostic or therapeutic equipment during the reporting period with a value in excess of five hundred thousand dollars ($500,000)."
Diagnostic and Therapeutic Equipment Acquired During The Report Period
1.Did your clinic acquire any diagnostic or therapeutic equipment that had a value in excess of $500,000?
(If 'Yes', fill out lines 2 through 11, as necessary, below.)
Diagnostic and Therapeutic Equipment Detail
Line
No.		(1)
Description of Equipment		(2)
Value		(3)
Date of Aquisition
MM/DD/YYYY		(4)
Means of Acquisition
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Building Projects Commenced During Report Period Costing Over $1,000,000
Section 127285(4) of the Health and Safety Code requires each clinic to report the "commencement of projects during the reporting period that require a capital expenditure for the facility or clinic in excess of one million dollars ($1,000,000)."
25.Did your clinic commence any building projects during the report period which will require an aggregate capital expenditure exceeding $1,000,000?
(If 'Yes', fill out lines 26 through 30, as necessary, below.)
Detail of Capital Expenditures
Line
No.		(1)
Description of Project		(2)
Projected Total Capital Expenditure		(3)
OSHPD Project No. (if applicable)
26.
27.
28.
29.
30.
Capital Fund
Line
No.		Capital Fund(1)
40.Beginning Fund Balance
41.Current Year Contribution
42.Current Year Interest Earnings
43.Current Year Expenditures
44.Ending Fund Balance
(Line 40 + Line 41 + Line 42 - Line 43)
General Comments:
Data for this facility is combined with our other report. OSHPD ID #306124014
Errors and Warnings