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					                    Primary Care Access and Stabilization Grant

   MONTHLY REPORT SUBMISSION AUTHORIZATION

The authorized signature below certifies that the Monthly Report for the
organization indicated was submitted to the Louisiana Public Health Institute
(LPHI) at the time and day indicated on this form. Once you have completed the
Monthly Report and submitted it electronically to LPHI, complete this
authorization form. This authorization form may be mailed, faxed, or hand
delivered to LPHI. Both the Monthly Report and this authorization form must be
received at LPHI by 4:30pm EST on the 15th of the month.


Organization name:
Organization code:

File name of Monthly Report
submitted to LPHI:                                          .XLS

Included in the file:
  Number of Exhibit G
  (one per service delivery site):

 Number of Exhibit H
 (one for the organization):              1

Date of electronic submission:
Time of electronic submission:
Electronic submission by:




Authorized Signature:

Printed Name:

Title:

Date:
     EXHIBIT G: SERVICE DELIVERY SITE SUMMARY DATA FORM                                                                                                                                       Version   Creation Date
                                                                                                                                                                                                 3       10/10/2007
 1   Organization Code:                                               Site ID                                               Date of completion (MM/DD/YY):

 2   Service delivery site name:

 3   Name of individual completing this form:

                                                           Title:


     Under the Primary Care Access and Stabilization Grant, you are required to track and submit patient encounters, patient demographic information and staffing on a
     monthly basis for reporting. In order to demonstrate an increase in access to care, you are also responsible for reporting the cumulative unduplicated patient count and
     visit count by service delivery site from the starting month of the grant 9/07 through the end of the current month reported on this form.

 4   Data Reporting for the Month of:                                   Start Date (MM/DD/YY)                                             End Date (MM/DD/YY)

 5   Indicate the Total Number of Days the Service Delivery Site was Open (seeing patients) during this month's reporting period:
                                                             Total # of days
       Total # weekdays (e.g. 16    Total # weekend                               Total hours open
                                                              open (e.g.
                days ):            days (e.g. 2 days ) :                          (e.g. 160 hours ):
                                                            16+2=18 days ):
                                                                    0

6a   Indicate the Date of the Next Available Appointments to see a Primary Care Physician for the following Patient Types as of Today (same as Date of Completion ):
                                    1st available date     2nd available date     3rd available date     Not Applicable       Reason if NA:
     New Patient (non-Medicaid)
     New Medicaid Patient

6b   Indicate the Date (MM/DD/YY) of the Next Available Appointments to see a Psychiatrist for the following Patient Types as of Today (same as Date of Completion ):
                                    1st available date     2nd available date     3rd available date     Not Applicable       Reason if NA:
     New Patient (non-Medicaid)
     New Medicaid Patient

 7   Provide Data on the Number of Unique Users / Patients and Encounters by Provider Type Seen during this month's reporting period:
                                                               Physician's
                                                                                                                                                   Other Health Care
                                      Primary Care          Assistant / Nurse                              Specialist           Case Manager
                                                                                     RN / LPN                                                      Provider (describe   Dental Practitioner
                                       Phsyician           Practitioner / Nurse                        (described below):      (describe below):
                                                                                                                                                        below):
                                                                 Midwife
         PATIENT COUNT
     ENCOUNTER / VISIT COUNT


                                                                                                       Other Mental Health
                                         LCSW                 Psychologist           Psychiatrist
                                                                                                       Provider [Describe]:
         PATIENT COUNT
     ENCOUNTER / VISIT COUNT

     Specialisits:
     Case Manager:
     Other Health Care Provider:
                                                                              TOTALS
8a   CURRENT MONTH TOTALS                                                                         (New Patients Only)
                                                                                For BOTH Primary                                                If NOT TRACKING
                                    For Primary Care      For Mental Health
     UNIQUE USERS / PATIENTS                                                    and Mental Health           TOTAL                                 (Mark with an X
                                     Services ONLY         Services ONLY
                                                                                     Services                                                         below)
      UNDUPLICATED PATIENT
                                                                                                                        0
             COUNT
     ENCOUNTER / VISIT COUNT                                                                                            0

8b   CURRENT MONTH TOTALS                                                            (New + Established Patients)
                                                                            For BOTH Primary                                                    If NOT TRACKING
                                    For Primary Care      For Mental Health
     UNIQUE USERS / PATIENTS                                                and Mental Health               TOTAL                                 (Mark with an X
                                     Services ONLY         Services ONLY
                                                                                 Services                                                             below)
      UNDUPLICATED PATIENT
                                                                                                                        0
             COUNT
     ENCOUNTER / VISIT COUNT                                                                                            0

8c   CUMULATIVE TOTALS (9/1/07 - current)                                            (New + Established Patients)
                                                                                For BOTH Primary                                                If NOT TRACKING
                                    For Primary Care      For Mental Health
     UNIQUE USERS / PATIENTS                                                    and Mental Health           TOTAL                                 (Mark with an X
                                     Services ONLY         Services ONLY
                                                                                     Services                                                         below)
      UNDUPLICATED PATIENT
                                                                                                                        0
             COUNT
     ENCOUNTER / VISIT COUNT                                                                                            0



 9   Patient Demographics Based on UNDUPLICATED PATIENT COUNT at Service Delivery Site:

9a Gender                                 Male                 Female              Transgender             Unknown                               NOT TRACKING
   # of patients

9b Patient Age                            0-18                  19-65               66 or older            Unknown                               NOT TRACKING
   # of patients

                                                           Black or African
                                                                                                       American Indian or   Native Hawaiian /
9c Race                            White (non-Hispanic)    American (non-              Asian                                                        Multiracial     Other     Unknown      NOT TRACKING
                                                                                                        Alaskan Native       Pacific Islander
                                                              Hispanic)
     # of patients


9d Ethnicity                         Hispanic/Latino      Not Hispanic/Latino          Other               Unknown                               NOT TRACKING
     # of patients

9e Employment Status                    Employed            Not Employed             Disability            Unknown                               NOT TRACKING
   # of patients

 9f Language Best Served In:             English               Spanish          Other __________:          Unknown                               NOT TRACKING
    # of patients

     Income as a Percent of
9g                                     Below 100%          100-199 percent       200% and Above            Unknown                               NOT TRACKING
     Poverty Level
     # of patients

                                     Of those Below     Of those Below
9h                                 200%, how many are 300%, how many                                                                                                        NOT TRACKING
                                     also uninsured?  also have children?
     # of patients

     Primary Insurance / Payor                                                                                              Uninsured / Self-
10                                  Medicaid/LaCHIP            Medicare         Private / Commercial    Worker's Comp                               Unknown                 NOT TRACKING
     Source for Patients                                                                                                          Pay
     # of patients


                                                          HIVAIDS-Infected Persons with Serious          Persons with        Other: (Please
11 Special Populations                  Homeless                                                                                                    Unknown                 NOT TRACKING
                                                              Persons      Mental Health Illness       Substance Abuse          Specify)
     # of patients


     Parishes of Patients Served
12                                      Jefferson              Orleans             Plaquemines            St. Bernard       Outside Region 1        Unknown                 NOT TRACKING
     Based on LA-DHH Region 1
     # of patients

                                                                  Enrollment
     Medicaid Screening /                  Screened for                                 Referred to
13                                                                (completed                                     Unknown      Not Applicable       Reason if NA:                           NOT TRACKING
     Enrollment                              Eligibility                             Enrollment Center
                                                                 applications)
     # of patients

14   The data reported on this form are based on (mark X where appropriate):
                                      PMS/EMR system
                                      Other Microsoft Office system (Quickbooks, Excel, Access, etc)
                                      Paper-based system

15   NOTES / DISCLAIMERS about this month's data:


16   STAFFING PROFILE FOR SERVICE DELIVERY SITE*
                                                                  Number of           Total FTEs this
     PERSONNEL BY CATEGORY
                                                                  providers          reporting period*
     ADMINISTRATION                                                            0                   0.00
        Executive Director / CEO
        Finance Director (Fiscal Officer) / CFO
        Chief Operating Officer/ COO
        Chief Information Officer/ CIO
        Administrative Support Staff
     MEDICAL STAFF                                                             0                     0.00
        Medical/Clinical Director
        Family Practitioners
        General Practitioners
        Internists
        OB/GYNs
        Pediatricians
        Other Specialty Physicians (list below)
        Physician Assistants
        Nurse Practitioner
        Certified Nurse Midwives
        Nursing Care Manager
        Nurses (RNs, LPNs)
        Pharmacist, Pharmacy Support, Technicians
        Other Medical Personnel (list below)
        Laboratory Personnel (Lab Technicians)
        X-ray Personnel
        Clinical Support Staff (Medical Assistants, etc)
     DENTAL STAFF                                                              0                     0.00
        Dentists
        Dental Hygienists
        Dental Assistants, Aides, Technicians
     MENTAL HEALTH STAFF                                                       0                     0.00
        Psychiatrists
        Psychologists
        Licensed Clinical Social Workers
        Mental Health Specialists
        Alcohol and Substance Abuse Specialists
     ENABLING STAFF                                                            0                     0.00
        Patient Education Specialist (Health Educator)
        Case Managers
        Outreach (Outreach Staff)
        Other Enabling
     OTHER PROFESSIONAL STAFF
     OTHER STAFF
     * Should correspond to the period indicated for "Data reporting for the month of" at the top of this form

     Other Specialty Physicians:
     Other Medical Personnel:

17   NARRATIVE
     In the space below, provide a narrative explaining how this site, through use of PCASG funding, has been able to increase access to healthcare for residents of the Greater New Orleans area. This narrative should include,
     but is not limited to, a description of any change or increase in the hours of operation, the number of provider full time equivalents (FTEs), the types of services, outreach activities, and efficiency improvements.
Louisiana Public Health Institute
1515 Poydras Suite 1200
New Orleans LA 70112
(504) 301-9800

                                                                                                                                                              EXHIBIT H

                                            Exhibit H: PCASG Monthly Expenditure Report
Subawardee Name:______________________________________

Payment Award Description                     Base Payment

Award Amount
Cost Report for the Month of:

                    COLUMN A                        COLUMN B                 COLUMN C                  COLUMN D                    COLUMN E                     COLUMN F
                                                   APPROVED               GRANT                     GRANT                       GRANT
                                                     PCASG             EXPENDITURES              EXPENDITURES                EXPENDITURES                     REMAINING
                                                    BUDGET               THROUGH                       IN                         TO                           BALANCE
                                                    AMOUNT              LAST PERIOD               THIS MONTH                     DATE

PERSONNEL (Name, Title, FTE)
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
        TOTAL PERSONNEL                        $                   -   $                     -   $                       -   $                       -    $                     -
FRINGE BENEFITS
                                                                                                                                                          $                     -
        TOTAL FRINGE BENEFITS                  $                   -   $                     -   $                       -   $                       -    $                     -
TRAVEL

        TOTAL TRAVEL                                                                                                                                      $                     -
EQUIPMENT

        TOTAL EQUIPMENT                                                                                                                                   $                     -

SUPPLIES
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
        TOTAL SUPPLIES                         $                   -   $                     -   $                       -   $                       -    $                     -
CONTRACTS
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
                                                                                                                                                          $                     -
        TOTAL CONTRACTS                        $                   -   $                     -   $                       -   $                       -    $                     -
ALTERATION & RENOVATION

        TOTAL A&R                                                                                                                                         $                     -

OTHER COSTS
                                                                                                                                                          $                     -
        TOTAL OTHER COSTS                      $                   -   $                     -   $                       -   $                       -    $                     -

TOTALS                                         $                   -   $                    -    $                      -    $                      -     $                    -

Use only the Categories provided above. Do not add new categories.

If any of the above amounts are expended to benefit a related party or network provider,
please attach an explanation identifying the benefitted party and the expenditure category.
All amendments to budgeted amounts must be approved by LPHI prior to expenditure of funds.
Actual expenditures in excess of 10% of an approved budgeted category may be disallowed
under the terms of the Subawardee Agreement.


Interest Earned on PCASG Funds:
                                                     This period           Through Last Period       Total Interest Earned       Total Returned to LPHI       Balance due to LPHI




The subgrantee certifies that the information presented above is true, accurate and complete to the their knowledge.


Approval:


Date:

                                                                                                                                                          Version 2: 10/10/07
vernum     cre8date   orgcode       siteid       date         sdsname   respname resptitle
         3 10/10/2007           0            0       1/0/1900         0         0            0
stdate       enddate     c5_1       v5_2       v5_3       v5_4       v6a_1a       v6a_2a
    1/0/1900    1/0/1900        0          0          0          0            0            0
v6a_3a       v6a_4a       v6aspeca       v6a_1b       v6a_2b       v6a_3b       v6a_4b       v6aspecb
         0            0              0            0            0            0            0              0
v6b_1a       v6b_2a       v6b_3a       v6b_4a       v6bspeca       v6b_1b       v6b_2b       v6b_3b
         0            0            0            0              0            0            0            0
v6b_4b       v6bspecb       v7_1a       v7_2a       v7_3a       v7_4a       v7_5a       v7_6a
         0              0           0           0           0           0           0           0
v7_7a       v7_8a       v7_9a       v7_10a       v7_11a       v7_1b       v7_2b       v7_3b
        0           0           0            0            0           0           0           0
v7_4b       v7_5b       v7_6b       v7_7b       v7_8b       v7_9b       v7_10b       v7_11b
        0           0           0           0           0           0            0            0
v7_4spec       v7_5spec       v7_6spec       v8a_1a       v8a_2a       v8a_3a       v8a_4a       v8a_nta
           0              0              0            0            0            0            0             0
v8a_1b       v8a_2b       v8a_3b       v8a_4b       v8a_ntb       v8b_1a       v8b_2a       v8b_3a
         0            0            0            0             0            0            0            0
v8b_4a       v8b_nta       v8b_1b       v8b_2b       v8b_3b       v8b_4b       v8b_ntb       v8c_1a
         0             0            0            0            0            0             0            0
v8c_2a       v8c_3a       v8c_4a       v8c_nta       v8c_1b       v8c_2b       v8c_3b       v8c_4b
         0            0            0             0            0            0            0            0
v8c_ntb       v9a_1       v9a_2       v9a_3       v9a_4       v9a_nt       v9b_1       v9b_2
          0           0           0           0           0            0           0           0
v9b_3       v9b_4       v9b_nt       v9c_1       v9c_2       v9c_3       v9c_4       v9c_5
        0           0            0           0           0           0           0           0
v9c_6       v9c_7       v9c_8       v9c_nt       v9d_1       v9d_2       v9d_3       v9d_4
        0           0           0            0           0           0           0           0
v9d_nt       v9e_1       v9e_2       v9e_3       v9e_4       v9e_nt       v9f_1       v9f_2
         0           0           0           0           0            0           0           0
v9f_3       v9f_4       v9f_nt       v9g_1       v9g_2       v9g_3       v9g_4       v9g_nt
        0           0            0           0           0           0           0            0
v9h_1       v9h_2       v9h_nt       v10_1       v10_2       v10_3       v10_4       v10_5
        0           0            0           0           0           0           0           0
v10_6       v10_nt       v11_1       v11_2       v11_3       v11_4       v11_5       v11_6
        0            0           0           0           0           0           0           0
v11_nt       v12_1       v12_2       v12_3       v12_4       v12_5       v12_6       v12_nt
         0           0           0           0           0           0           0            0
v13_1       v13_2       v13_3       v13_4       v13_5       v13_6       v13_nt       v14_1a
        0           0           0           0           0           0            0            0
v14_1b       v14_1c       v15notes       v16adm_1a v16adm_1b v16adm_1c v16adm_1d v16adm_1e
         0            0              0            0         0         0         0         0
v16adm_1f v16adm_2a v16adm_2b v16adm_2c v16adm_2d v16adm_2e v16adm_2f v16med_1a
         0         0         0         0         0         0         0         0
v16med_1b v16med_1c v16med_1d v16med_1e v16med_1f v16med_1g v16med_1h v16med_1i
         0         0         0         0         0         0         0          0
v16med_1j       v16med_1k v16med_1l v16med_1m v16med_1n v16med_1o v16med_1p v16med_1q
            0            0         0        0          0         0         0         0
v16med_1r v16med_2a v16med_2b v16med_2c v16med_2d v16med_2e v16med_2f v16med_2g
         0         0         0         0         0         0         0         0
v16med_2h v16med_2i v16med_2j v16med_2k v16med_2l v16med_2m v16med_2n v16med_2o
         0         0         0         0         0        0          0         0
v16med_2p v16med_2q v16med_2r v16den_1a v16den_1b v16den_1c v16den_1d v16den_2a
         0         0         0         0         0         0         0          0
v16den_2b       v16den_2c       v16den_2d       v16men_1a v16men_1b v16men_1c v16men_1d v16men_1e
            0               0               0            0         0         0         0         0
v16men_1f v16men_2a v16men_2b v16men_2c v16men_2d v16men_2e v16men_2f v16ena_1a
         0         0         0         0         0         0         0          0
v16ena_1b       v16ena_1c       v16ena_1d       v16ena_1e       v16ena_2a       v16ena_2b       v16ena_2c       v16ena_2d
            0               0               0               0               0               0               0               0
v16ena_2e       v16ops_1       v16ops_2       v16os_1       v16os_2       v16ospspec v16ompspec
            0              0              0             0             0            0          0

				
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