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					      Washington State Health Care Authority                                                  Part 3
      Community Health Services

      Application
           Dental, Medical, & Migrant
           For State Fiscal Year 2009 (July 1, 2008 through June 30, 2009)

      Part 3 - Institutional File
           Institutional File and Programmatic Assurance
           Dental and Medical Professionals' Licensure
           Agency Profile Forms

      Use Microsoft Excel to complete this form.
           (Do not use Microsoft Word)
      Instructions:
           This electronic form contains selected data from your previous year's application.
           Please edit, update, or enter current data in the fields highlighted in green.
           Please use the following keys to move through the form:
           TAB and the UP, Down, LEFT and RIGHT ARROWS.
           Please include information current as of the date of preparation.

           Please begin by typing the name of your organization.

      Agency Name:
           Use your mouse to click on the page tabs at the bottom of your screen
           to continue with the remaining pages.


           The deadline for submitting applications is 4:00 PM, PST, Friday, April 4, 2008.

           Please submit this Part 3 of the application along with Parts 1 and 2 as instructed
           on page 3 of the Application Instruction booklet.

           Please refer to the CHS Application Instruction booklet for additional details and instructions.

           For assistance in completing these forms you may contact us as follows:
           - Via e-mail:       chs107@hca.wa.gov
           - Via telephone:    (360) 923-2777

           Internet web address: www.chs.hca.wa.gov.




0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                      Cover
                                  Index


Form                                            Tab

Institutional File and Programmatic Assurance   T.3

Dental Professionals' Licensure                 T.4 & T.4.2 (continuation)

Medical Professionals' Licensure                T.5 & T.5.2 (continuation)

Profile Form: Delivery Sites                    T.6

Profile Form: Hours of Operation                T.7

Profile Form: After-Hours Coverage              T.8

Profile Form: Staffing Patterns in FTEs         T.9

Profile Form: Services                          T.10

Profile Form: Top 3 Diagnosis                   T.11

Profile Form: Hospital Arrangements             T.12




  0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                          Index
0

Institutional File and Programmatic Assurance
Instructions:
For each item listed with a red "XX", enter the date of the latest revision in the "Latest Revision Date" column.
PLEASE SUBMIT A COPY OF EACH ITEM INDICATED WITH A RED "XX" IN YOUR GRANT SUBMISSION.
We need to receive a complete set of the required documents under the CHS column.

                                                                                    Latest
                                                               Location of file    Revision
                                                              Contractor             Date
Required Components                                             Site      CHS      (MM/YY)                        Comments
I.    Health Services
   A. Patient confidentiality policy and/or procedures                       XX                                 Send Annually
   B. Patient grievance policy and/or procedures                  XX                                    At Contractor Site Do Not Send
   C. Quality Assurance (QA/CQI) plan                             XX                                    At Contractor Site Do Not Send
   D. Malpractice coverage and subcontracts                                  XX                                 Send Annually
II.       Management and Finance
       A. Organizational chart                                               XX                                 Send Annually
       B. Personnel policies and procedures                       XX                                    At Contractor Site Do Not Send
       C. Data collection and information system(s)               XX                                    At Contractor Site Do Not Send
       D. Accounting policies and/or procedures manual(s)         XX                                    At Contractor Site Do Not Send
       E. Agreements with Basic Health Plan(s)                               XX                 Send if a new applicant or if there was a change
       F. Agreements with Medicaid managed care plan(s)           XX                                    At Contractor Site Do Not Send
       G. Billing and collection policies and/or procedures       XX                                    At Contractor Site Do Not Send
       H. Independent Auditors' Report                                       XX                              Send every two years
        I. Sliding Fee Schedule                                              XX                                 Send Annually
       J. Sliding Fee Application                                           XX                                  Send Annually
III.      Governance
       A. Board Roster                                            XX                                    At Contractor Site Do Not Send
       B. Board by-laws                                                      XX                 Send if a new applicant or if there was a change
       C. Articles of Incorporation                                          XX                 Send if a new applicant or if there was a change
       D. IRS proof of not-for-profit status                                 XX                 Send if a new applicant or if there was a change



Certification:

I have submitted all updates and revisions to documents in the Institutional File held in the
Community Health Services (CHS) office, and I maintain up-to-date copies of the above listed
documents accessible on-site which are available for HCA review.



                      Contract Signature Authority                                   Date




             0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                                T.3
     0

     Dental Professionals' Licensure
    Instructions:
    To enter the table, use the TAB key or the Mouse.
    To move around the table, use the Arrow or Tab keys.
    Professional Designation (Prof. Des.): enter DDS, DMD, or RDH.
    Please include employees as well as contractors.
    NOTE: Licenses expiring April 30, 2008 or earlier should be updated.
    Verify status of license renewal at:       DOH - Online Credential Search (click)

                           Name                                                                CURRENT
                                                                                                License
                                                      Prof.    FTE                      St.    Expiration   Medicaid
                Last               First        MI    Des.    Value       License #     Lic.      Date      Billing #
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
    16
    17
    18
    19
    20
    21
    22
    23
    24
    25
    26
    27
    28
    29
    30
    31
    32
    33
    34
    35
    36
    37
    38
    39
    40
    41
    42
    43
    44
    45
    46
    47
    48
    49
    50

0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                                T.4.1
0

Dental Professionals' Licensure (continuation page)
Instructions:
To enter the table, use the TAB key or the Mouse.
To move around the table, use the Arrow or Tab keys.
Professional Designation (Prof. Des.): enter DDS, DMD, or RDH.
Please include employees as well as contractors.
NOTE: Licenses expiring April 30, 2008 or earlier should be updated.
Verify status of license renewal at:            DOH - Online Credential Search (click)

                           Name                                                                 CURRENT

                                                       Prof.      FTE                    St.    Expiration   Medicaid Billing
              Last                 First         MI    Des.      Value     License #     Lic.     Date              #
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100

0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                               T.4.2
    0
    Medical Professionals' Licensure
    Instructions:
    To enter the table, use the TAB key or the Mouse.
    To move around the table, use the Arrow or Tab keys.
    Professional Designation (Prof. Des.): enter MD, ARNP, or PA.
    Please include employees as well as contractors.
    NOTE: Licenses expiring April 30, 2008 or eariler should be updated.
    Verify status of license renewal at:               DOH - Online Credential Search (click)

                              Name                                                                     CURRENT
                                                                                                                    Medicare    Medicaid
                                                            Prof.     FTE                       St.    Expiration   Provider    Provider
                Last                  First           MI    Des.     Value       License #      Lic.     Date       Billing #   Billing #
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
    16
    17
    18
    19
    20
    21
    22
    23
    24
    25
    26
    27
    28
    29
    30
    31
    32
    33
    34
    35
    36
    37
    38
    39
    40
    41
    42
    43
    44
    45
    46
    47
    48
    49
    50
    51
    52
    53
    54
    55
    56
    57
    58
    59
    60



0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                                                    T.5.1
0
Medical Professionals' Licensure (continuation page)
Instructions:
To enter the table, use the TAB key or the Mouse.
To move around the table, use the Arrow or Tab keys.
Professional Designation (Prof. Des.): enter MD, ARNP, or PA.
Please include employees as well as contractors.
NOTE: Licenses expiring April 30, 2008 or eariler should be updated.
Verify status of license renewal at:                            DOH - Online Credential Search (click)

                                    Name                                                                        CURRENT
                                                                                                                             Medicare    Medicaid
                                                                       Prof.      FTE                    St.    Expiration   Provider    Provider
                     Last                          First         MI    Des.      Value       License #   Lic.     Date       Billing #   Billing #
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120



    0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                                                T.5.2
0

Profile Form: Delivery Sites (Dental and Medical Clinics only)
Site Name - self explanatory
Street Address - self explanatory
City, State, Zip - self explanatory
Clinic Manager - enter the name of the Clinic Manager
Clinic Mgr Phone - enter the Clinic Manager's telephone number
County - self explanatory
Type of Service - choose one of the following four types of services:
DENTAL or MEDICAL or DENTAL & MEDICAL or OTHER (if neither Dental or Medical please state service type)
Dental or Medical Clinic telephone numbers - enter the telephone numbers patients use to request appointments
Remarks - enter "MOBILE" if a mobile clinic, "SCHOOL" if located in a school, or other pertinent description
                                                                                                                         Type of   Dental Clinic   Medical Clinic
         Site Name            Street Address         City, State, Zip     Clinic Manager   Clinic Mgr Phone     County   Service     Phone            Phone         Remarks

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U


         0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                                                                      T.6
0

Profile Form: Hours of Operation

                                               SITES
    DAY          A             B           C     D     E   F   G
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday



                                               SITES
    DAY          H             I           J     K     L   M   N
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday



                                               SITES
    DAY          O             P           Q     R     S   T   U
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday


0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                           T.7
0

Profile Form: After-Hours Coverage

Instructions:
Mark with an "X" as applicable.

After Hours                                                                   SITES
Coverage Availability       A     B    C     D        E   F   G   H   I   J     K     L   M   N   O   P   Q   R   S         T   U

Clinic staff


Answering service routes
calls to clinic staff

Other
(Describe below in Brief
Comments)
No arrangements
(Describe below in Brief
Comments)



Brief Comments (indicate which site the comment refers to)




           0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                   T.8
0

Profile Form: Staffing Patterns in FTEs
Instructions:
Enter the FTE value for each type of staff by site.
Note: the table will round to 2 decimal places.
  For example, if you enter 1.155, the table will display 1.16

                                                                                 SITES
TYPE OF STAFF               A     B      C     D      E     F    G   H   I   J   K       L   M   N   O   P   Q   R   S   T     U

Primary MD, DO

ARNP, PA

CNM/LM

RN

LPN/LVN

Medical Assistants

Aides

Pharmacists

Lab. Technicians

Radiation Technicians

Dentists (DDS, DMD)

Dental Hygienists (RDH)

Dental Assistants

Administration
Other




         0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                        T.9
0

Profile Form: Services
This table is intended to distinguish the primary health care services that are provided directly by your health
clinic(s) onsite from those that are provided offsite through referrals to other providers/specialists including
facilities like mobile clinics, community centers, schools, senior centers, migrant camps, etc.


Please mark the Location column with either Onsite or Offsite and
enter the names of referrals in the green spaces.
Onsite - (onsite services)
Offsite - (offsite services or referrals)
Medical specialties or acute care referrals please enter the names of referrals in the green spaces below.

                            Primary Health Care Services                                         Location
 Preventative health services onsite or elsewhere
    Well child care
      Eye and ear examinations for children
      Periodic screening of children and adults
    Family planning services
    Perinatal services
    Maternity services
    Acute/episodic medical care
    Management of chronic disease
    Emergency medical services onsite or elsewhere
    Emergency/after-hours medical services
 Diagnostic services onsite or elsewhere
    Basic diagnostic lab
    Diagnostic x-ray
 Dental services onsite or elsewhere
    Preventive dental care
    Emergency dental services
    Diagnostic & restorative dental
 Supplemental Health Services
    Arrangements for transportation services
    Mental health
    Outreach
    Health education
    Pharmaceutical services, as appropriate, onsite or elsewhere

    Referrals to medical specialties (PLEASE LIST)




    Referrals to acute care (PLEASE LIST)




     0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                      T.10
      0


Profile Form: Top 3 Medical Diagnosis & 5 Dental Relative Value Unit (RVU) Categories
Instructions: Please input the top diagnosis or RVU category and the corresponding range of
ADA Dental codes.
This information is for statistical use.


                               Top 3 Diagnosis (Medical)                      ICD9 Code

  1

  2

  3

                    Programs Addressing Top 3 Medical Diagnosis




                             Top 5 Dental RVU Categories                      ADA Codes

  1

  2

  3

  4

  5




0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                  T.11
           0
           Profile Form: Hospital Arrangements
           Instructions:
           Enter the primary hospital arrangement made for each delivery site.
            (only one hospital per delivery site, please)
           Indicate whether or not the arrangement includes Admitting Privileges and/or Attending Responsibility
            by typing an "X" in either the "Yes" or the "No" columns.
                                                                                   Admitting            Attending
           SITE     Hospital                                                       Privileges          Responsibility
                    Street Address                                               Yes           No    Yes           No
                    City, State Zip
           A.


           B.


           C.


           D.


           E.


           F.


           G.


           H.


           I.


           J.


           K.


           L.


           M.


           N.


           O.


           P.


           Q.


           R.


           S.


           T.


           U.



0c5351e9-6b91-4648-8fee-5a64cdcf65e9.xls                                                                                T.12
                                                 Part 3 Instructions/Help
                                                                                                                            Return to T.3
The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative
Code chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.


T.3 - Institutional File and Programmatic Assurance
This form lists the documents each grantee is required to maintain. Copies of some of these documents are kept on file at the CHS office; the
other documents are maintained at the grantee’s site and made available for Community Health Services inspection. Contractors must update
the “Latest Revision Date” column (green cells) and send to CHS documents that have a double red-X (XX) in the column labeled
"CHS." The "Comments" column provides information regarding whether the form must be submitted "Annually", "Do Not Send", or
"New Applicant or if there was a Change"
                                                  Part 3 Instructions/Help
                                                                                                                              Return to T.4.1

The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.

T.4.1 & T.4.2 - Dental Professionals' Licensure
This form includes provider name, professional designation (Dr., DDS, RDH, etc…), full time equivalent (FTE) value (between .10 and 1.0),
license number, state licensed in, and license expiration date. Please update the dental professionals’ licensure with current information. A link
to the Department of Health (DOH) credential search web page has been provided on the form for your convenience.

New to this year’s grant application we have added Medicaid Billing # (input ID numbers assigned to clinic, delivery site, or provider as
applies). The Medicaid Billing # replaces the past requirement of sending on a separate sheet Medicaid Billing # for your dental clinics
or providers.
                                                 Part 3 Instructions/Help
                                                                                                                           Return to T.5.1
The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.


T.5 - Medical Professionals' Licensure
This form includes provider name, professional designation (Dr., RN, ARNP, PA, etc…), full time equivalent (FTE) value (between .10 and 1.0),
license number, state licensed in, and license expiration date. Please update the medical professionals’ licensure with current information. A
link to the Department of Health (DOH) credential search web page has been provided on the form for your convenience.

New to this year’s grant application we have added Medicare & Medicaid Billing # (input ID numbers assigned to clinic, delivery site, or
provider as applies). The Medicare & Medicaid Billing # replaces the past requirement of sending on a separate sheet Medicare &
Medicaid Billing # for your medical clinics or providers.
                                                   Part 3 Instructions/Help
                                                                                                                                                                  Return to T.6

The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code chapter 182-
20, Standards for Community Health Clinics. This information is required to be eligible for funding.

T.6 - Profile Form: Delivery Site (Dental and Medical Clinics only)
Include in this form the site name, street address, city/state/zip, clinic manager’s name and phone number, county located, type of service (medical, dental,
medical & dental, etc...), dental or medical phone numbers patients would call (as applies), and any remarks for each of your healthcare delivery sites. If you
have more sites than space on the form please contact CHS at chs107@hca.wa.gov .
                                                         Part 3 Instructions/Help
                                                                                                                            Return to T.7
The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.


T.7 - Profile Form: Hours of Operation
This form includes the hours of operation for each of the delivery sites listed in tab T.6. Please use the corresponding site letter from T.6 (delivery
site location list) when you fill out the hours of operation table in tab T.7. If this is a mobile unit please provide start and end hours if available (or
varies) on the days of the week as applicable


Pacific Rim Community Health

Profile Form: Hours of Operation

                                                             SITES
    DAY             A             B              C             D              E              F             G
Monday       7:15 - 6:00    7:15 - 6:00    6:45 - 5:30   6:45 - 5:30   8:00 - 6:00    8:00 - 8:00    8:00 - 8:00

Tuesday      7:15 - 6:00    7:15 - 6:00    6:45 - 5:30   6:45 - 5:30   8:00 - 6:00    8:00 - 8:00    8:00 - 8:00

Wednesday    7:15 - 6:00    7:15 - 6:00    6:45 - 5:30   6:45 - 5:30   10:00 - 6:00   10:30 - 8:00   10:30 - 8:00

Thursday     7:15 - 6:00    7:15 - 6:00    6:45 - 5:30   6:45 - 5:30   8:00 - 7:30    8:00 - 8:00    8:00 - 8:00

Friday       7:15 - 6:00    7:15 - 6:00    6:45 - 5:30   6:45 - 5:30   8:00 - 5:00    8:00 - 5:00    8:00 - 5:00

Saturday                                                               8:30 - 1:30    8:30 - 4:00    8:30 - 4:00

Sunday



                                                             SITES
    DAY             H              I              J            K              L             M              N
Monday       8:30 - 8:30    10:30 - 6:30

Tuesday      8:30 - 5:30    10:30 - 6:30

Wednesday    8:30 - 5:30    9:30 - 5:00

Thursday     8:30 - 5:30    10:30 - 6:30

Friday       8:30 - 5:30    8:30 - 5:00

Saturday     10:00 - 2:00

Sunday



                                                             SITES
    DAY            O               P             Q             R              S              T             U
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday
                                                   Part 3 Instructions/Help
                                                                                                                        Return to T.8

The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.

T.8 - Profile Form: After-Hours Coverage
Include on this form the after hours coverage availability by type (clinic staff, answering service, other, and none) for each of the delivery sites
listed in tab T.6. Fill out comments table for all delivery sites that after hours coverage is not by clinic staff with a brief comment about the
coverage. Please use the corresponding site letter from T.6 (delivery site location list) when you fill out the after hours coverage table in tab T.8.
                                                   Part 3 Instructions/Help
                                                                                                                       Return to T.9

The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.


T.9 - Profile Form: Staffing Patterns in FTEs
Provide the total Full Time Equivalent (FTE) hours by staff type (MD, RN, DDS, RDH, etc…) for each delivery site. For those working in an
administrative position use administration staff type and other for those positions not listed or not administrative. Please use the corresponding
site letter from T.6 (delivery site location list) when you fill out the staffing patterns in FTEs table in tab T.9.
                                                 Part 3 Instructions/Help
                                                                                                                    Return to T.10
The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.


T. 10- Profile Form: Services
This form is intended to distinguish the primary health care services that are provided directly by your health clinic(s) onsite from those
that are provided offsite through referrals to other providers/specialists including facilities like mobile clinics, community centers, schools,
senior centers, migrant camps, etc. Please mark the Location column with either Onsite or Offsite and enter the names of referrals in the
green spaces.
                                                Part 3 Instructions/Help
                                                                                                                Return to T.11
The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.


Profile Form: Top 3 Medical Diagnosis & 5 Dental Relative Value Unit (RVU) Categories
In the first section of this form provide the top 3 patient medical diagnoses and corresponding ICD9 codes from the past calendar year. In the
next section of the form list programs that are being implemented to address the top 3 medical diagnoses from the first section. In the
final section provide the top 5 patient dental RVU categories (not procedures) and their corresponding range of American Dental Association
(ADA) codes from the past calendar year. The categories and ADA range codes to select from are listed on the form.
                                                  Part 3 Instructions/Help
                                                                                                                     Return to T.12
The purpose of Part 3 is to ensure that your agency complies with the established requirements of the Washington Administrative Code
chapter 182-20, Standards for Community Health Clinics. This information is required to be eligible for funding.


T.12 - Profile Form: Hospital Arrangements
Provide the primary hospital arrangement (one per site) for each delivery site listed in tab T.6. Include the address and mark with an “X” in the
yes or no green boxes whether your providers have admitting privileges and or attending responsibilities at the hospital.

				
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Description: Sample Admitting Forms document sample