DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 5B - SERVICE SITES

FOR HRSA USE ONLY

Submission Tracking Number

Grant Number

*Name of Service Site

*Service Site Type

*Location Type

Location Setting

Number of Service Delivery Locations
(Voucher Screening Only)

Number of times site Opens and Closes
(Intermittent Only)

Web URL

Site Operated by

[_]Grantee [_]Sub-Recipient [_]Contractor

Date Site was Opened

*Date Site was Added to Scope

Date Site will be Operational

Medicare Billing Number

Medicaid Billing Number

Medicaid Pharmacy Billing Number

*Site Phone Number

Site Fax Number

*Administration Phone

Site Physical Address

Site Mailing Address

Service Area Zipcodes

Service Area Census Tracts

Service Area Population

[_]Urban [_]Rural

*Operational Schedule

[_]Full-Time [_]Part-Time

*Calendar Schedule

[_]Year-Round [_]Seasonal

Total Hours of Operation when Patients will be Served per Week (include extended hours)

Months of Operation