CLINIC NAME AND ADDRESS

							                                                                                                                                                                                             ATTACHMENT 3
                                                                         RURAL HEALTH SERVICES DEVELOPMENT
                                                               SEASONAL AGRICULTURAL AND MIGRATORY WORKERS PROGRAM
                                                                                  FISCAL YEAR 2009-2012
CORPORATION NAME:
                                                                                            CLINIC SITE DATA SHEET

               CLINIC NAME AND ADDRESS                       COUNTY(IES) SERVED             RHSD            SAMW             OSHPD           NPI NUMBER         CLINIC          330            CLINIC       IDENTFY
                                                                                           FUNDING         FUNDING           9-DIGIT                           LICENSE         CLINIC      DESIGNATION      **NEW OR
                                                                                         REQUESTED       REQUESTED        COMMUNITY                            EXEMPT *       IDENTIFY       IDENTIFY:    CONTINUING
                                                                                          (AMOUNT)        (AMOUNT)       CLINIC LICENSE                        IDENTIFY        YES/NO       FQHC,RHC,       CLINIC:
                                                                                                                            NUMBER                            YES OR NO                         OR
                                                                                                                         OR INDICATE IF                                                     LOOKALIKE
                                                                                                                            EXEMPT
1.                                                                                      $               $


2.                                                                                      $               $


3.                                                                                      $               $


4.                                                                                      $               $


5.                                                                                      $               $


6.                                                                                      $               $


7.                                                                                      $               $


8.                                                                                      $               $


9                                                                                       $               $


10.                                                                                     $               $


                                                                 ANNUAL TOTAL           $               $




      Complete all columns for each clinic site requesting annual funds only. If you have more than 10 clinic sites submit a second page.
      *License Exemption: Health and Safety Code 1206 (c). “Any clinic conducted, maintained, or operated by a federally recognized Indian tribe or tribal organization, as defined in section 450 or 1601 or Title
      25 of the United States Code that is located on land recognized as tribal land by the federal government.”
      ** Continuing = Previously funded during FY 2008-2009. New = Not funded by RHSD or SAMW.