SERVICES OFFERED AND DELIVERY METHOD
| Service Type Note: Not all Centers will provide all services |
Delivery Method Mark (X) if Applicable (More than one method may apply for a given service.) |
|||
| Provided by Grantee (a) |
By Referral/ Grantee Pays (b) |
By Referral/ Grantee Doesn't Pay (b) |
||
| Primary Medical Care Services | ||||
| 1. | General Primary Medical Care (other than that listed below) | |||
| 2. | Diagnostic Laboratory (technical component) | |||
| 3. | Diagnostic X-Ray Procedures (technical component) | |||
| 4. | Diagnostic Tests/Screenings (professional component) | |||
| 5. | Emergency Medical Services | |||
| 6. | Urgent Medical Care | |||
| 7. | 24-hour coverage | |||
| 8. | Family Planning | |||
| 9. | HIV Testing and Counseling | |||
| 10. | Testing for Blood Lead Levels | |||
| 11. | Immunizations | |||
| 12. | Following hospitalized patients | |||
| Obstetrical and Gynecological Care | ||||
| 13. | Gynecological Care | |||
| 14. | Prenatal Care | |||
| 15. | Antepartum Fetal Assessment | |||
| 16. | Ultrasound | |||
| 17. | Genetic Counseling and Testing | |||
| 18. | Amniocentesis | |||
| 19. | Labor and Delivery Professional Care | |||
| 20. | Postpartum Care | |||
| Service Type Note: Not all Centers will provide all services |
Delivery Method Mark (X) if Applicable (More than one method may apply for a given service.) |
|||
| Provided by Grantee (a) |
By Referral/ Grantee Pays (b) |
By Referral/ Grantee Doesn't Pay (b) |
||
| Specialty Medical Care | ||||
| 21. | Directly Observed TB Therapy | |||
| 22. | Respite Care | |||
| 23. | Other Specialty Care | |||
| Dental Care Services | ||||
| 24. | Dental Care - Preventive | |||
| 25. | Dental Care - Restorative | |||
| 26. | Dental Care - Emergency | |||
| 27. | Dental Care - Rehabilitative | |||
| Mental Health/Substance Services | ||||
| 28. | Mental Health Treatment/Counseling | |||
| 29. | Developmental Screening | |||
| 30. | 24-hour Crisis Intervention/Counseling | |||
| 31. | Other Mental Health Services | |||
| 32. | Substance Abuse Treatment/Counseling | |||
| 33. | Other Substance Abuse Services | |||
| Other Professional Services | ||||
| 34. | Hearing Screening | |||
| 35. | Nutrition Services Other than WIC | |||
| 36. | Occupational or Vocational Therapy | |||
| 37. | Physical Therapy | |||
| 38. | Pharmacy - Licensed Pharmacy staffed by Registered Pharmacist | |||
| 39. | Pharmacy - Provider Dispensing | |||
| 40. | Vision Screening | |||
| 41. | Podiatry | |||
| 42. | Optometry | |||
| Service Type Note: Not all Centers will provide all services |
Delivery Method Mark (X) if Applicable (More than one method may apply for a given service.) |
|||
| Provided by Grantee (a) |
By Referral/ Grantee Pays (b) |
By Referral/ Grantee Doesn't Pay (b) |
||
| Enabling Services | ||||
| 43. | Case Management | |||
| 44. | Child Care (during visit to center) | |||
| 45. | Discharge Planning | |||
| 46. | Eligibility Assistance | |||
| 47. | Environmental Health Risk Reduction (via detection and/or alleviation) | |||
| 48. | Health Education | |||
| 49. | Interpretation/Transition Services | |||
| 50. | Nursing Home and Assisted-Living Placement | |||
| 51. | Outreach | |||
| 52. | Transportation | |||
| 53. | Out Stationed Eligibility Workers | |||
| 54. | Home Visiting | |||
| 55. | Parenting Education | |||
| 56. | Special Education Program | |||
| 57. | Other (specify:_______________) | |||
| Preventive Services Related to Target Clinical Areas | ||||
| I. Cancer | ||||
| 58. | Pap Smear | |||
| 59. | Fecal Occult Blood Test | |||
| 60. | Sigmoidoscopy | |||
| 61. | Colonoscopy | |||
| 62. | Mammograms | |||
| 63. | Smoking Cessation Program | |||
| II. Diabetes | ||||
| 64. | Glycosylated hemoglobin measurement for people with diabetes | |||
| 65. | Urinary microalbumin measurement for people with diabetes | |||
| 66. | Foot exam for people with diabetes | |||
| 67. | Dilated eye exam for people with diabetes | |||
| III. Cardiovascular Disease | ||||
| 68. | Blood Pressure Monitoring | |||
| 69. | Weight Reduction Program | |||
| 70. | Blood Cholesterol Screening | |||
| Service Type Note: Not all Centers will provide all services |
Delivery Method Mark (X) if Applicable (More than one method may apply for a given service.) |
|||
| Provided by Grantee (a) |
By Referral/ Grantee Pays (b) |
By Referral/ Grantee Doesn't Pay (b) |
||
| IV. HIV/AIDS | ||||
| See line 9. HIV testing and counseling | ||||
| V. Infant Mortality | ||||
| 71. | Follow-up testing and related health care services for abnormal newborn bloodspot screening | |||
| See line 14. Prenatal Care | ||||
| VI. Immunizations | ||||
| See line 11. Immunizations | ||||
| Complementary/Alternative Therapies | ||||
| 72. | Acupuncture | |||
| 73. | Osteopathic Manipulation | |||
| 74. | Chiropractic | |||
| 75. | Massage Therapy | |||
| 76. | Other Manual Healing | |||
| 77. | Botanicals/Herbs | |||
| 78. | Homeopathy | |||
| 79. | Traditional Healing | |||
| 80. | Mind-body Techniques | |||
| Other Services | ||||
| 81. | WIC Services | |||
| 82. | Head Start Services | |||
| 83. | Food Banks/Delivered Meals | |||
| 84. | Employment/Educational Counseling | |||
| 85. | Assistance in obtaining housing | |||
*Source: BPHC UDS Manual, 2002 Revision.