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Site Development Manual: Chapter 9

Exhibit 9-5: FORM 1 - PART B, BPHC FUNDING REQUEST SUMMARY

  FEDERAL FUNDS REQUESTED
BASED ON A 12-MONTH BUDGET FOR YEAR 1, YEAR 2 OR YEAR 3
REQUESTED BPHC
FUNDING:		 TYPE OF HEALTH CENTER NEW START SATELLITE
Year 1 Year 2 Year 3 Year 1 Year 2 Year 3
Operational One-time (up
to $150,000)		 Operational Operational Operational One-time (up
to $150,000)		 Operational Operational
Community Health Center CHC - 330(e)                
Migrant Health Center MHC - 330(g)                
Health Care for the Homeless HCH - 330(h)                
School Based Health Centers SBHC - 330(e)                
Public Housing Primary Care PHPC - 330(i)                
TOTAL FEDERAL FUNDING REQUEST                
ESTIMATED FUNDING for New Start or Satellite Activity NOTE: New access point applicants may request funding for one or more types of health centers authorized under section 330. Funding listed above will constitute a request for funding for the specified types of health centers.

NOTE: The Federal support requested in Year 1, 2, 3 MAY NOT exceed the published cap of $650,000 established for new access point.
FUNDING PROGRAM: YEAR 1
TOTAL BUDGET		 YEAR 2
TOTAL BUDGET		 YEAR 3
TOTAL BUDGET
A. Federal $ $ $
B. Applicant $ $ $
C. State $ $ $
D. Local $ $ $
E. Other $ $ $
F. Program Income $ $ $
G. Total $ $ $

Sample Budget Narrative

This sample budget narrative is provided as a broad outline. Providing additional information and detail is recommended to fully describe your proposal. Any significant changes in the costs of each object class from year 1 to year 2 and year 2 to year 3 should be fully explained and justified in the budget narratives for years 1, 2, and 3. The impact on the Federal request should be discussed.

REVENUE: (From FORM 3 - Income Analysis) Year 1 Year 2 Year 3
PATIENT SERVICE INCOME
  (including Pharmacy)		 $5,770,180 $6,956,042 $7,537,506
LOCAL & STATE GRANTS
  (Break out by fund source)		 $1,253,500 $1,565,000 $1,700,000
LOCAL FUNDING $450,254 $550,000 $550,000
FEDERAL BPHC 330 GRANT $550,000 $439,699 $475,690
OTHER FEDERAL FUNDING
  (Break out by fund source)		 $0    
TOTAL: REVENUE $8,023,934 $9,510,741 $10,263,196
EXPENSES: Year 1 Year 2 Year 3
PERSONNEL: See Personnel by Position
& nbsp; and BPHC Program		 $4,587,223 $5,422,816 $5,500,000
FRINGE BENEFITS: Break out each
  portion of Fringe Benefits:
     FICA
     Retirement, etc.		 $951,849 $1,125,234 $1,130,000
TOTAL: PERSONNEL & FRINGE $5,539,072 $6,548,050 $6,730,000
TRAVEL:
Providers CME ($ per full-time equivalent (FTE)) $ $ $
Nursing CME ($ per FTE) $ $ $
Other Professional CME ($ per FTE) $ $ $
Travel to meetings ($ per attendees x # of trips)
      Executive Director (2 meetings)
      Board Chair (2 meetings)		 $ $ $
Management & Board $ $ $
State and National Meetings $ $ $
Other Board/Management Travel $ $ $
Local Travel (# of trips @ organization's mileage rate) $ $ $
  TOTAL: TRAVEL $ 25,432 $ 35,010 $ 45,690
EQUIPMENT:
  See attached Equipment Listing
  TOTAL: EQUIPMENT $118,000 $ 0 $ 0
SUPPLIES:
Office & Printing Supplies $X.XX per encounter $ $ $
Medical & Dental Records $X.XX per encounter $ $ $
Medical Supplies $X.XX per encounter $ $ $
Expenses Continued: Year 1 Year 2 Year 3
Pharmacy Supplies including Drugs
  Average per # of Prescriptions 		$ $ $
X-ray supplies Average per # of X-rays $ $ $
Laboratory supplies per average # of procedures $ $ $
Building and Maintenance Supplies per # of sites $ $ $
  TOTAL: SUPPLIES $1,452,940 $1,952,300 $2,430,000
CONTRACTUAL (Please describe with enough detail to justify the costs)
"Patient Care Contracts"
Outside Reference Lab
    XYZ Company for any tests that cannot be
    Performed in house (Avg. # of procedures
    X Avg. Cost)		 $ $ $
Outside Contract Pharmacies (describe)
    (Avg. # of prescriptions X Avg. Cost) 		$ $ $
GYN/OB Contract with ABC Company
    (Avg. # of Patients served X Avg. Cost)		 $ $ $
Ophthalmologist with RST Company
    (Avg. # of patients @ Avg. Cost)		 $ $ $
Temporary Nursing Coverage
    (Avg. # of days @ Avg. Costs)		 $ $ $
    Subtotal: Patient Care Contracts $ $ $
Temporary Nursing Coverage
    (Avg. # of days @ Avg. Costs)		 $ $ $
"Non-Patient Contracts"
Housekeeping Services with LMN Company
    for # of sites 		$ $ $
Security Services with DEF Company for
    # of hours per site 		$ $ $
Computer Maintenance Contract $ $ $
    Subtotal: Non-Patient Contracts $ $ $
  TOTAL: CONTRACTUAL $386,020 $395,100 $425,000
ALTERATION & RENOVATIONS: (describe if applicable)
  Alteration and renovation of unused building space for use as dental operatories
  TOTAL: A&R $32,000 $0 $0
OTHER:
Payroll Processing Services $ $ $
Audit Services with JKL Company $ $ $
Legal Fees with WXY Company fee per hour $ $ $
Association Dues $ $ $
Building Contents Insurance $ $ $
Telephone Service $ $ $
Answering Services $ $ $
Postage $ $ $
Utilities $ $ $
Rent (describe per site) $ $ $
Marketing/Outreach $ $ $
Any special taxes (describe) $ $ $
Technical Assistance $ $ $
   TOTAL: OTHER $530,470 $580,281 $632,506
TOTAL: ALL BUDGET $8,023,934 $9,510,741 $10,263,196
EQUIPMENT: Year 1 Year 2 Year 3
4 exam tables (4 @ $3,000) $ 12,000 $0 $0
1 Medical X-Ray (1 @ $17,800) $ 17,800 $0 $0
4 Dental Units (4 @ $ 4,500) $ 18,000 $0 $0
4 Dental Chairs (4 @ $4,000) $ 16,000 $0 $0
1 Dental X-Ray (1 @ $10,200) $ 10,200 $0 $0
8 Stools (8 @ $250) $ 2,000 $0 $0
20 Hand pieces (20 @ $600) $ 12,000 $0 $0
1 Developing Unit (1 @ $2,000) $ 2,000 $0 $0
8 PCs and related software (8 @ 3,500) $ 28,000 $0 $0
    TOTAL ALL EQUIPMENT $ 118,000 $0 $0

FORM 2 - PROPOSED STAFF PROFILE

YEAR   1 checkbox   YEAR 2 checkbox   YEAR 3 checkbox

PERSONNEL BY CATEGORY TOTAL FTEs PROPOSED
{ a }		 ANNUAL SALARY OF POSITION
{ b }		 TOTAL SALARY
{ a * b }
NEW STARTS
(All sites included in Exhibit B-2)		 SATELLITES
(New site(s) ONLY)
ADMINISTRATION        
  Executive Director        
  Finance Director        
  Chief Operating Officer        
  Administrative Support Staff        
MEDICAL STAFF        
  Medical Director        
  Family Practitioners        
  General Practitioners        
  Internists        
  OB/GYNs        
  Pediatricians        
  Psychiatrists        
  Other Specialty Physicians (attach list by type)        
  Physician Assistants/Nurse Practitioners        
  Certified Nurse Midwives        
  Nurses (RNs)        
  Pharmacist        
  Other Medical Personnel (attach list by type)        
  Laboratory Personnel        
  X-ray Personnel        
  Clinical Support Staff        
DENTAL STAFF        
  Dentists        
  Dental Hygienists        
  Dental Assistants, Aides, Technicians        
MENTAL HEALTH STAFF        
  Mental Health Specialists        
  Substance Abuse Specialists        
  Case Managers        
  Other Professional Personnel        
OTHER STAFF        
  Patient Education Specialist        
  Homemaker/Aide        
  Outreach        
  Other Enabling        
  Other staff        

FORM 3 - INCOME ANALYSIS FORMAT

YEAR   1 checkbox   YEAR 2 checkbox   YEAR 3 checkbox

PAYOR CATEGORY NUMBER OF VISITS AVERAGE CHARGE PER VISIT TOTAL CHARGES (a * b) AVERAGE ADJUSTMENT PER VISIT AMOUNT BILLED [c-(a*d)] COLLECTION RATE(%) PROJECTED INCOME(e * f) ACTUAL ACCRUED INCOME (most recent 12 months)
(a) (b) (c) (d) (e) (f) (g) (h)
FEE FOR SERVICE                
Medicaid: Fee for Services                
Medicaid: EPSDT                
Medicaid: Capitated                
    Subtotal: Medicaid                
Medicare: Fee for Services                
Medicare: Capitated                
    Subtotal: Medicare                
Private Insurance                
Self-Pay: 100 percent                
Self-Pay: Sliding Fee Scale                
Self-Pay: Zero (0) percent                
Other: Capitation                
Other: Contracts                
SUB-TOTAL                
OTHER INCOME                
Contributions/Donations                
Fund Raising                
330 BPHC Grant                
Other Federal Grants                
State Grants                
Local Support                
Foundation Grants                
Other                
GRAND TOTAL                

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