| Federally Qualified Health Clinic (FQHC) |
Line
No. | Federally Qualified Health Clinics | (1) |
|---|
| 2. | Indicate clinic type, if applicable: | Neither |
|
|
| Rural Health Clinic |
Line
No. | Rural Health Clinic | (1) |
|---|
| 3. | Is this a 95-210 Rural Health Clinic? | No |
|
|
Table 2.1 - Community Services Check one or more boxes for each service provided. | Line
No. | Community Services | (1)
Offered |
|---|
| 10. | Adult Day Care | No | | 11. | Child Care | No | | 12. | Community Education | No | | 13. | Community Nutrition | No | | 14. | Disaster Relief | No | | 15. | Environmental Health | No | | 16. | Homeless | No | | 17. | Legal | No | | 18. | Outreach | No | | 19. | Social Services | No | | 20. | Substance Abuse | No | | 21. | Transportation | No | | 22. | Vocational Training Placement | No | | 23. | Other | Yes |
| | Table 2.2 - Languages Spoken By Staff and Patients Check the staff box if one or more of your staff members speak a 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. | Arabic | No | No | | 31. | Armenian | No | No | | 32. | Cambodian | No | No | | 33. | Chinese | No | No | | 34. | Hindustani | No | No | | 35. | Hmong | No | No | | 36. | Japanese | No | No | | 37. | Korean | No | No | | 38. | Laotian | No | No | | 39. | Portugese | No | No | | 40. | Punjabi | No | No | | 41. | Russian | No | No | | 42. | Sign Language | No | No | | 43. | Spanish | Yes | Yes | | 44. | Tagalog | No | No | | 45. | Vietnamese | No | No |
|
|
| | Language Summary | Line
No. | Language Summary | (1) |
|---|
| 55. | Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent): | 5% | | 56. | Primary non-English language spoken by patients (from list above): | Spanish |
|
|
|
| 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. | Physicians | 6.00 | 0.00 | 0.00 | 6.00 | 11,647 | | 61. | Physician Assistants | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 62. | Family Nurse Practitioners | 1.00 | 0.00 | 0.00 | 1.00 | 1,714 | | 63. | Certified Nurse Midwives | 1.00 | 0.00 | 0.00 | 1.00 | 1,439 | | 64. | Visiting Nurses | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 65. | Dentists | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 66. | Registered Dental Hygienists (Alternative Practice) | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 67. | Psychiatrists | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 68. | Clinical Psychologists | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 69. | Licensed Clinical Social Workers (LCSW) | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 70. | Other Providers billable to Medi-Cal** | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 74. | Other Certified CPSP providers not listed above*** | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 75. | Subtotal | 8.00 | 0.00 | 0.00 | 8.00 | 14,800 |
|
| ** 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) | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 81. | Registered Dental Assistants | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 82. | Dental Assistants - Not licensed | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 83. | Marriage and Family Therapists (MFT) | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 84. | Registered Nurses | 1.00 | 0.00 | 0.00 | 1.00 | 1,084 | | 85. | Licensed Vocational Nurses | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 86. | Medical Assistants - Not licensed (1) | 6.50 | 0.00 | 0.00 | 6.50 | 14,800 | | 87. | Non-Licensed Patient Education Staff | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 88. | Substance Abuse Counselors (2) | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 89. | Billing Staff (3) | 0.00 | 0.00 | 0.00 | 0.00 | | | 90. | Other Administrative Staff (4) | 8.00 | 0.00 | 0.00 | 8.00 | | | 94. | Other Providers not listed above | 0.00 | 0.00 | 0.00 | 0.00 | | | 95. | Subtotal | 15.50 | 0.00 | 0.00 | 15.50 | 15,884 |
|
| (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 |
|
| Race |
Line
No. | Race | (1)
# of
Patients |
|---|
| 1. | White (include Hispanic) | 1,865 | | 2. | Black | 16 | | 3. | Native American / Alaskan Native | 32 | | 4. | Asian / Pacific Islander | 48 | | 5. | More than one race | 122 | | 9. | Other / Unknown | 140 | | 10. | Total Patients * | 2,223 |
|
|
| Ethnicity |
Line
No. | Ethnicity | (1)
# of
Patients |
|---|
| 11. | Hispanic | 318 | | 12. | Non-Hispanic | 1,188 | | 13. | Unknown | 717 | | 15. | Total Patients * | 2,223 |
|
| Federal Poverty Level |
Line
No. | Federal Poverty Level | (1)
# of
Patients |
|---|
| 20. | Under 100% | 691 | | 21. | 100 - 200% | 444 | | 22. | Above 200% | 365 | | 23. | Unknown | 723 | | 24. | Total Patients * | 2,223 |
|
|
Seasonal Agricultural And Migratory Workers Line
No. | Seasonal Agricultural and Migratory Workers | (1)
Number |
|---|
| 30. | Total Patients | 15 | | 31. | Total Encounters | 112 |
|
|
| Age Category |
Line
No. | Age Category | (1)
Males | (2)
Females |
|---|
| 40. | Under 1 year | 90 | 109 | | 41. | 1 - 4 years | 53 | 89 | | 42. | 5 - 12 years | 109 | 115 | | 43. | 13 - 14 years | 26 | 38 | | 44. | 15 - 19 years | 39 | 77 | | 45. | 20 - 34 years | 54 | 534 | | 46. | 35 - 44 years | 69 | 205 | | 47. | 45 - 64 years | 92 | 294 | | 48. | 65 and over | 72 | 158 | | 55. | Total Patients * | 604 | 1,619 |
|
|
| Patient Coverage |
Line
No. | Patient Coverage | (1)
# of
Patients |
|---|
| 60. | Medicare | 299 | | 61. | Medicare - Managed Care | 0 | | 62. | Medi-Cal | 787 | | 63. | Medi-Cal - Managed Care | 0 | | 64. | County Indigent / CMSP / MISP | 58 | | 65. | Healthy Families | 57 | | 66. | Private Insurance | 502 | | 67. | Alameda Alliance for Health | 0 | | 68. | LA Co. Public Private Partnership | 0 | | 69. | PACE Program | 0 | | 70. | Self-Pay / Sliding Fee | 21 | | 71. | Free | 90 | | 74. | All Other Payers | 409 | | 75. | Total Patients * | 2,223 |
|
|
| Episodic Programs |
Line
No. | Episodic Programs | (1)
# of
Patients |
|---|
| 80. | BCCCP | 0 | | 81. | CHDP | 0 | | 82. | EAPC | | | 83. | Family PACT | 18 | | 84. | Other County Programs | 0 | | 85. | Childrens Treatment Program | 0 | | 89. | Other Payer - covered by a grant | 0 | | 90. | Total Episodic Patients (duplicated) | 18 |
|
|
| Child Health And Disability Prevention (CHDP) |
Line
No. | Child Health And Disability Prevention (CHDP) | (1)
# of
Assessments |
|---|
| 95. | CHDP Assessments | 0 |
|
|
| * Totals for these tables must agree. |
|
|
|
| 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 Diseases | 001 - 139 | 353 | | 2. | Neoplasms | 140 - 239 | 236 | | 3. | Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders | 240 - 279 | 1,482 | | 4. | Blood and Blood Forming Disorders | 280 - 289 | 159 | | 5. | Mental Disorders | 290 - 319 | 955 | | 6. | Nervous System and Sense Organs Diseases | 320 - 389 | 790 | | 7. | Circulatory System Diseases | 390 - 459 | 1,013 | | 8. | Respiratory System Diseases | 460 - 519 | 1,087 | | 9. | Digestive System Diseases, excluding dental diagnosis | 530 - 579 | 387 | | 10. | Genitourinary System Diseases | 580 - 629 | 1,420 | | 11. | Pregnancy, Childbirth & the Puerperium | 630 - 679 | 476 | | 12. | Skin and Subcutaneous Tissue Diseases | 680 - 709 | 109 | | 13. | Musculoskeletal System and Connective Tissue Diseases | 710 - 739 | 685 | | 14. | Congenital Anomalies | 740 - 759 | 192 | | 15. | Certain Conditions Originating in the Perinatal Period | 760 - 779 | 129 | | 16. | Symptoms, Signs, and Ill-defined Conditions | 780 - 799 | 2,145 | | 17. | Injury and Poisoning | 800 - 999 | 151 | | 18. | Factors Influencing Health Status and Contact with Health Services | V01 - V91 | 2,944 | | 19. | Dental Diagnosis | 520-529 | 57 | | 20. | Family Planning S-Codes | | 30 | | 21. | Other | All other codes not in lines 1-20 | 0 | | 25. | Total | | 14,800 |
|
|
| 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. | Principal Services | CPT Codes - 2011 | (1)
# of
Encounters |
|---|
| 1. | Evaluation and Management (new patient) | 99201 - 99205 | 1,367 | | 2. | Evaluation and Management (established patient) | 99211 - 99215 | 7,498 | | 3. | Hospital Related Services | 99217 – 99226,
99231 - 99239,
99477 | 748 | | 4. | Consultations | 99241 - 99245,
99441 - 99444 | 185 | | 5. | Other Evaluation and Management Services | 99291 - 99292,
99354 - 99360,
99450, 99455 - 99456, 99499 | 737 | | 6. | Nursing Facility Related Services | 99304 - 99318 | 0 | | 7. | Case Management Services | 99363 - 99364,
99366 - 99368 | 0 | | 8. | Preventive Medicine (infant, child, adolescent) | 99381 - 99384,
99391 - 99394,
99461 | 58 | | 9. | Preventive Medicine (adult) | 99385 - 99387,
99395 - 99397 | 469 | | 10. | Counseling | 99401 - 99404,
99406 - 99409
99411 - 99412
99420 - 99429
99605 - 99607 | 0 | | All Other Services | | | | 11. | Anesthesia | 00100 – 01999,
99100,
99116,
99135,
99140,
99143 - 99150 | 0 | | 12. | Integumentary System | 10021 - 19499 | 291 | | 13. | Musculoskeletal System | 20005 - 29999 | 69 | | 14. | Respiratory System | 30000 - 32999 | 0 | | 15. | Cardiovascular System | 33010 - 37799 | 251 | | 16. | Hemic and Lymphatic System | 38100 - 38999 | 0 | | 17. | Mediastinum and Diaphragm System | 39000 - 39599 | 0 | | 18. | Digestive System | 40490 - 49999 | 22 | | 19. | Urinary System | 50010 - 53899 | 75 | | 20. | Male Genital System | 54000 - 55920 | 102 | | 21. | Intersex Surgery | 55970, 55980 | 0 | | 22. | Female Genital System | 56405 - 58999 | 603 | | 23. | Maternal Care and Delivery | 59000 - 59899 | 462 | | 24. | Endocrine System | 60000 - 60699 | 0 | | 25. | Nervous System | 61000 - 64999 | 4 | | 26. | Eye and Ocular Adnexa System | 65091 - 68899 | 0 | | 27. | Auditory System | 69000 - 69979 | 18 | | 28. | Radiology | 70010 - 79999 | 89 | | 29. | Pathology / Laboratory | 80047 – 89356, 89398 | 301 | | 30. | Medicine - Special Services | 90281 – 99091,
99170 – 99199 | 369 | | 31. | Family Planning "Z" Codes | "Z" codes | 32 | | 32. | Dental Encounters (CDT codes) | D0100-D0999 | 0 | | 33. | CPT Category III Codes | 0001T - 9999T | 0 | | 44. | Other | All other codes not in lines 1-33 | 1,050 | | 45. | Total | | 14,800 |
|
|
| 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 Services | CPT Codes - 2011 | (1)
# of
Procedures |
|---|
| 50. | Mammogram | 77051 – 77059 | 0 | | 51. | HIV Testing | 86689,
86701 - 86703,
87390 - 87391 | 0 | | 52. | Pap Smear | 88141 - 88155,
88164 - 88167,
88174 - 88175 | 0 | | 53. | Contraceptive Management | 11975 - 11977, 55250,
55300, 55400, 55450, 57170,
58300 - 58301, 58600
58605, 58611, 58670 - 58671 | 376 | | Vaccinations | | | | 60. | DTap, DTP, Diphtheria and Tetanus | 90389, 90696, 90698,
90700 – 90703, 90714, 90715,
90718 - 90721, 90723 | 1,010 | | 61. | Hemophilus Influenza B (Hib) | 90371, 90645 - 90648 | 226 | | 62. | Hepatitis A | 90632 – 90634,
90636 | 400 | | 63. | Hepatitis B | 90740, 90743 - 90744, 90746, 90747 | 603 | | 64. | HepB and Hib | 90748 | 59 | | 65. | Influenza Virus Vaccine | 90654 – 90658,
90660 - 90668 | 969 | | 66. | Measles, Mumps and Rubella (MMR) and Varicella (MMRV) | 90704 - 90708, 90710 | 348 | | 67. | Pneumococcal | 90669, 90670, 90732 | 125 | | 68. | Poliovirus | 90712 - 90713 | 308 | | 69. | Varicella | 90396, 90716 | 180 |
|
|
| Revenue and Utilization by Payment Source |
| (Do not put any "$" signs, commas or decimals, round up to whole dollar) |
Line
No. | | (1)
Medicare | (2)
Medicare
Managed | (3)
Medi-Cal | (4)
Medi-Cal
Managed | (5)
County/
CMSP/MISP | (6)
Healthy
Families |
|---|
| 1. | Encounters | 1,019 | 0 | 7,580 | 0 | 89 | 88 |  | | 2. | Gross Revenue
(Charges at 100% Rate) | $367,593 | $0 | $2,632,508 | $0 | $103,469 | $50,355 | | 3. | Sliding Fee Scale
Write-offs | $0 | $0 | | | | $0 | | 4. | Free/Complimentary
Write-offs | | | | | | | | 5. | Contractual Adjustments | $202,019 | $0 | $2,073,064 | $0 | $72,428 | $35,248 | | 6. | Bad Debts | $5,675 | $0 | | | | $0 | | 7. | Grants (see Section 7) | | | | | | | | 8. | Other Adjustments | $0 | $0 | $0 | $0 | $0 | $0 | | 9. | Reconciliation | $0 | $0 | $0 | $0 | $0 | | | 10. | Total Write-offs &
Adjustments
(sum lines 3 through 9) | $207,694 | $0 | $2,073,064 | $0 | $72,428 | $35,248 | | 15. | Net Patient Revenue (collected)
(line 2 – line 10) | $159,899 | $0 | $559,444 | $0 | $31,041 | $15,107 |
|
|
Line
No. | | (7)
Private
Insurance | (8)
Self-Pay/
Sliding Fee | (9)
Free | (10)
Breast
Cancer* | (11)
CHDP | (12)
EAPC |
|---|
| 1. | Encounters | 5,192 | 32 | 140 | 0 | 0 | | | | 2. | Gross Revenue
(Charges at 100% Rate) | $1,873,986 | $171,273 | $80,111 | $0 | $0 | | | 3. | Sliding Fee Scale
Write-offs | $0 | $153,172 | | | | | | 4. | Free/Complimentary
Write-offs | | | $80,111 | | | | | 5. | Contractual Adjustments | $1,003,710 | | | $0 | $0 | | | 6. | Bad Debts | $98,256 | $0 | | | | | | 7. | Grants (see Section 7) | | | | | | | | 8. | Other Adjustments | $0 | $0 | | $0 | $0 | | | 9. | Reconciliation | | | | | | | | 10. | Total Write-offs &
Adjustments
(sum lines 3 through 9) | $1,101,966 | $153,172 | $80,111 | $0 | $0 | | | 15. | Net Patient Revenue (collected)
(line 2 – line 10) | $772,020 | $18,101 | $0 | $0 | $0 | |
|
* These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program |
|
|
| ** Report number of patients on Line 1 for the PACE Program |
|
|
Line
No. | | (19)
Grand Totals |
|---|
| 1. | Encounters | 14,800 | | | 2. | Gross Revenue
(Charges at 100% Rate) | $5,341,700 | | 3. | Sliding Fee Scale Write-offs | $153,172 | | 4. | Free/Complimentary Write-offs | $80,111 | | 5. | Contractual Adjustments | $3,430,152 | | 6. | Bad Debts | $105,295 | | 7. | Grants (see Section 7) | | | 8. | Other Adjustments | $0 | | 9. | Reconciliation | $0 | | 10. | Total Write-offs & Adjustments
(sum lines 3 through 9) | $3,768,730 | | 15. | Net Patient Revenue (collected)
(line 2 – line 10) | $1,572,970 |
|
|
| Income Statement |
| (Do not input any "$" signs, commas or decimals, round up to whole dollar.) |
Line
No. | Revenue | (1) |
|---|
| 1. | Gross Patient Revenue (from Sec 6, line 2, column 19) | $5,341,700 | | 2. | Total Write-offs and Adjustments (from Sec 6, line 10, column 19) | $3,768,730 | | 3. | Net Patient Revenue (from Sec 6, line 15, column 19) | $1,572,970 | | Other Operating Revenue | | 4. | Federal Funds - Grants - all others (e.g. 330 funds) | $0 | | 400. | Federal Stimulus Grants - American Recovery and Reinvestment Act (ARRA) | | | 401. | Federal Funds - New Access Point (NAP) | $0 | | 402. | Federal Funds - Increased Demand for Services (IDS) | $0 | | 403. | Federal Funds - Capital Improvement Project (CIP) | | | 5. | State Funds - EAPC | | | 6. | State Funds - Other | $0 | | 7. | County Funds - LA County Public Private Partnership | $0 | | 10. | County Funds - Other County Grant Programs | $0 | | 11. | Local (City or District) Funds | $0 | | 12. | Private | $0 | | 13. | Donations/Contributions | $0 | | 19. | Other | $0 | | 20. | Total Other Operating Revenue (Sum lines 4 through 19) | $0 | | 25. | Total Operating Revenue (line 3 + line 20) | $1,572,970 | | Operating Expenses | | 30. | Salaries, Wages, and Emplyee Benefits | $2,886,371 | | 31. | Contract Services - Professional | $322,888 | | 32. | Supplies - Medical and Dental | $180,143 | | 33. | Supplies - Office | $42,257 | | 34. | Outside Patient Care Services | $0 | | 35. | Rent / Depreciation / Mortgage Interest | $11,408 | | 36. | Utilities | $6,897 | | 37. | Professional Liability Insurance | $137,837 | | 38. | Other Insurance | $0 | | 39. | Continuing Education | $21,500 | | 40. | Information Technology (including EHR) | $20,353 | | 44. | All Other Expenses | $1,394 | | 45. | Total Operating Expenses (Sum lines 30 through 44) | $3,631,048 | | 50. | Net from Operations (line 25 - line 45) | -$2,058,078 |
|
|
|
|
| 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 |
Line
No. | | (1) |
|---|
| 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.) | No |
|
|
| 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)." |
Line
No. | | (1) |
|---|
| 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.) | No |
|
|
| 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 | $0 | | 41. | Current Year Contribution | $0 | | 42. | Current Year Interest Earnings | $0 | | 43. | Current Year Expenditures | $0 | | 44. | Ending Fund Balance
(line 40 + line 41 + line 42 - line 43) | $0 |
|
|