06-01,,,,,,,,FORM CMS 1728-94,,,,,,,,,3290 (Cont.) HHA-BASED RURAL HEALTH CLINIC/,,,,,,,,PROVIDER NO.:,,,,PERIOD:,,,WORKSHEET S-4,, FEDERALLY QUALIFIED HEALTH CENTER,,,,,,,,_____________,,,,FROM: __________,,,,, PROVIDER STATISTICAL DATA,,,,,,,,COMPONENT NO.:,,,,TO: ___________,,,,, ,,,,,,,,_____________,,,,,,,,, Check ,,, [ ] RHC,,,,,,,,,,,,,, Applicable Box,,, [ ] FQHC,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, Clinic Address and Identification:,,,,,,,,,,,,,,,,, 1,Street:,,,,,,,,,,,,,,,,1 1.01,City:,,,,,,,State:,,,,Zip Code:,,County:,,,1.01 2,"Designation (for FQHCs only) - Enter ""R"" for rural or ""U"" for urban",,,,,,,,,,,,,,,,2 ,,,,,,,,,,,,,,,,, Source of Federal Funds:,,,,,,,,,,,,,Grant Award,,Date,, ,,,,,,,,,,,,,1 ,,2 ,, 3,"Community Health Center (Section 330(d), PHS Act)",,,,,,,,,,,,,,,,3 4,"Migrant Health Center (Section 329(d), PHS Act)",,,,,,,,,,,,,,,,4 5,"Health Services for the Homeless (Section 340(d), PHS Act)",,,,,,,,,,,,,,,,5 6,Appalachian Regional Commission,,,,,,,,,,,,,,,,6 7,Look-Alikes,,,,,,,,,,,,,,,,7 8,Other (specify),,,,,,,,,,,,,,,,8 ,,,,,,,,,,,,,,,,, Physician Information:,,,,,,,,,,,,,Physician,,Billing,, ,,,,,,,,,,,,,Name,,Number,, 9,Physician(s) furnishing services at the clinic or under agreement (see instructions),,,,,,,,,,,,,,,,9 ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,Physician,,Hours of,, ,,,,,,,,,,,,,Name,,Supervision,, 10,Supervisory physician(s) and hours of supervision during period (see instructions),,,,,,,,,,,,,,,,10 ,,,,,,,,,,,,,,,,, 11,"Does the facility operate as other than an RHC or FQHC? If yes, indicate number of other operations in column 2 and ",,,,,,,,,,,,,,,,11 ,list the other type(s) of operation(s) and hours on subscripts of line 12.,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,Enter the clinic hours on line 12 and list the other type(s) of operation(s) and hours on subscripts of line 12. (1),,,,,,,,,,,,,,,, ,,,Sunday,,Monday,,Tuesday,,Wednesday,,Thursday,,Friday,,Saturday,, ,,,from,to,from,to,from,to,from,to,from,to,from,to,from,to, ,0 ,,1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 12 ,Clinic,,,,,,,,,,,,,,,,12 12.01,Specify:,,,,,,,,,,,,,,,,12.01 12.02,Specify:,,,,,,,,,,,,,,,,12.02 12.03,Specify:,,,,,,,,,,,,,,,,12.03 ,,,,,,,,,,,,,,,,, ,"(1) List hours of operation based on a 24 hour clock. For example, 8:30am is 0830, 5:30pm is 1730 and 12 midnight is 2400. ",,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, 13,Has the facility been approved for an exception to the productivity standard?,,,,,,,,,,,,,,,,13 14,"Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the",,,,,,,,,,,,,,,,14 ,number of providers included in this report. List all provider names and numbers below.,,,,,,,,,,,,,,,, 15,Provider name: ______________________________,,,,,,,,Provider number: _______________,,,,,,,,15 15.01,Provider name: ______________________________,,,,,,,,Provider number: _______________,,,,,,,,15.01 15.02,Provider name: ______________________________,,,,,,,,Provider number: _______________,,,,,,,,15.02 15.03,Provider name: ______________________________,,,,,,,,Provider number: _______________,,,,,,,,15.03 16 ,"Are you claiming allowable and/or non-allowable GME costs as a result of ""substantial payment"" for interns",,,,,,,,,,,,,,,,16 ,"and residents? If yes, enter the number of Medicare visits in column 2 performed by interns and residents",,,,,,,,,,,,,,,, ,"and complete Worksheet RF-1, lines 20 and 27 as applicable.",,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, "FORM CMS-1728-94-S4 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3233)",,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,, Rev. 10,,,,,,,,,,,,,,,,,32-305.2