Requesting Temporary Service Sites in Response to Emergency Events: Resource and Submission Template

Use these Self-Assessment Checklist questions to determine whether a location is eligible for the temporary service site request process. If all of the Self-Assessment Checklist answers are “Yes,” a health center may submit a temporary service site request to HRSA. Refer to the “How to Submit a Temporary Service Site Request” section for submission request details.

PAL 2020-05: Requesting a Change in Scope to Add Temporary Service Sites in Response to Emergency Events (PDF - 266 KB) contains additional information.

1.1. Has an emergency been officially declared by an authorized public official (such as a governor, the Secretary of the United States (U.S.) Department of Health and Human Services, or the President of the U.S.)? Yes / No

1.2. If 1.1 is “No”: Are there case-specific, extraordinary circumstances faced by the health center? Yes / No

If 1.2 is “Yes”: In situations where an authorized public official has not officially declared an emergency that affects the overall patient population and/or the community at large, HRSA may evaluate on a case-by-case basis whether extraordinary circumstances justify a determination that the situation faced by the health center constitutes an emergency for the purposes of approving a temporary service site request. A health center must contact HRSA to initiate such a request and should use the BPHC Contact Form (preferred) or email BPHCOHCPMHCESupport@hrsa.gov. If submitting a temporary service site request using the BPHC Contact Form, refer to the How Do I Submit a Request for a Temporary Service Site in Response to Emergency Events FAQ on where to navigate. 

If 1.2 is “No”: The temporary service site request is not in response to an emergency event and is not eligible for the temporary service site request process.

2. Does the temporary location meet all service site definition criteria?

2.1. Are health center visits generated by documenting in the patients' records face-to-face contacts between patients and providers? Yes / No

2.2. Do providers exercise independent judgment in the provision of services to the patient? Yes / No

2.3. Are services provided directly by or on behalf of the health center, whose governing board retains control and authority over the provision of the services at the location? Yes / No

2.4. Are services provided on a regularly-scheduled basis (for example, daily, weekly, first Thursday of every month)? Yes / No

NOTE: There is no minimum number of hours per week that services must be available at an individual site.

If “No” for ANY of the site definition criteria (2.1, 2.2, 2.3, OR 2.4): The location does not meet the definition of a service site and is not eligible for the temporary service site request process.

3. Will health center staff provide services at the proposed service site on a temporary basis? (For the purposes of this question, “health center staff” can include an individual contractor(s).) Yes / No

If “No”: The location is not eligible for the temporary service site request process.

4. Will all services provided by health center staff at the proposed temporary service site be within the health center’s approved scope of project? (For the purposes of this question, “health center staff” can include an individual contractor(s).) Yes / No

If “No”: The health center needs to submit a change in scope request(s) to HRSA for any service(s) that is not in the health center’s scope of project and that the health center would like to be included in its scope of project. Only services approved by HRSA and recorded on the health center’s Form 5A: Services Provided are considered in the health center’s scope of project. For more information on submitting a change in scope request(s) to add a service(s), refer to the BPHC Scope of Project webpage. A health center can contact HRSA with any questions by using the BPHC Contact Form (preferred) or by emailing BPHCOHCPMHCESupport@hrsa.gov.

5. Will all activities conducted by health center staff at the proposed temporary service site be provided on behalf of the health center? (For the purposes of this question, “health center staff” can include an individual contractor(s).) Yes / No

If “No”: The location is not eligible for the temporary service site request process because only those activities that are performed on behalf of the health center can be included in the health center’s scope of project.

6. Is any part of the health center’s service area within the geographic area of the declared emergency? Yes / No

Please use the applicable sections of the remaining checklist below.

If “Yes”: The health center is considered “Impacted” by the declared emergency. Proceed to 7.1 and 7.2. Skip 8.

If “No”: The health center is considered to be “Non-Impacted” by the declared emergency. Proceed to 8. Skip 7.1 and 7.2.

If Any Part of the Health Center’s Service Area Is Within the Geographic Area of the Declared Emergency (Impacted):

7.1. Is the proposed temporary service site within or adjacent to the health center’s service area? Yes / No

7.2. If 7.1 is “No”: Is the purpose of the temporary service site to provide services primarily to the health center’s original health center patient population impacted by the emergency OR to provide services to other medically underserved populations that may have been impacted by the emergency? Yes / No

If “No” for BOTH 7.1 and 7.2: The location is not eligible for the temporary service site request process.

If No Part of the Health Center’s Service Area is Within the Geographic Area of the Declared Emergency (Non-Impacted):

8. Is the proposed temporary service site in an area adjacent to the health center’s service area? Yes / No

If “No”: The location is not eligible for the temporary service site request process.

Submit a temporary service site request as soon as possible and no later than 15 calendar days after initiating emergency response activities at the location. HRSA will determine on a case-by-case basis whether extraordinary circumstances justify an exception to the 15-day requirement.

A health center may use this OPTIONAL submission template (PDF - 183 KB) to support the request. However, the use of this template is not required.

A health center should use the BPHC Contact Form (preferred) or email BPHCOHCPMHCESupport@hrsa.gov to submit a temporary service site request. If submitting a temporary service site request using the BPHC Contact Form, refer to the How Do I Submit a Request for a Temporary Service Site in Response to Emergency Events FAQ on where to navigate.

If a health center is unable to access the BPHC Contact Form or to email BPHCOHCPMHCESupport@hrsa.gov, a health center should contact Health Center Program Support at 1-877-464-4772.

Required Information

1. Health center name and Award/Look-Alike number
2. The name of a health center representative (i.e., health center point of contact regarding the emergency temporary service site request) and this person’s contact information (including phone number)
3. A brief description of the declared emergency, including whether a state of emergency has been officially declared by an authorized public official such as a governor, the Secretary of the United States (U.S.) Department of Health and Human Services, or the President of the U.S., or if there has been an official warning issued regarding an anticipated emergency event by an authorized public official
4. A brief description of planned emergency response activities at the proposed temporary service site (this should be no more than one to two sentences)
5. A summary of the requested change in scope of project, including:
   • Temporary Address Information:
     • Site Name
     • Site Address (including zip code and office/suite/floor number if applicable)
   • The date emergency response activities at the site were or will be initiated (“effective date” if the proposed site is approved by HRSA)
   • Any other summary information for the requested change in scope of project
6. Explanation and/or assurance that all criteria for adding a temporary service site will be met (i.e., the service site definition criteria in PIN 2008-01: Defining Scope of Project and Policy for Requesting Changes (PDF - 224 KB) and the temporary site criteria outlined in the Self-Assessment Checklist in PAL 2020-05: Requesting a Change in Scope to Add Temporary Service Sites in Response to Emergency Events (PDF - 266 KB))

HRSA cannot approve the addition of a temporary service site without this information. If the information submitted is insufficient, HRSA may request additional information.

A health center should contact HRSA by using the BPHC Contact Form (preferred) or by emailing BPHCOHCPMHCESupport@hrsa.gov before the end of the 90-day approval period to provide an update on the status of the temporary service site and to discuss site options (upcoming site expiration, removing the site from scope, requesting an extension, or making the site permanent).

Expiration or Removal

HRSA’s approval of a temporary service site will expire 90 days after the temporary service site’s approved effective date, regardless of the issue date of formal documentation.

After the 90-day expiration deadline, HRSA may administratively remove a temporary site from a health center’s scope of project.

If a health center would like to ensure removal of a temporary site from the health center’s scope of project, either before or after the 90-day expiration deadline, the health center should contact HRSA by using the BPHC Contact Form (preferred) or by emailing BPHCOHCPMHCESupport@hrsa.gov

Temporary Extension or Permanent Addition

To temporarily extend HRSA’s approval of a temporary service site past the initial 90-day approval period, a health center must contact HRSA before the end of the 90-day period. HRSA will determine on a case-by-case basis whether extraordinary circumstances, such as continuing national or local emergencies, justify an extension.

A health center should use the BPHC Contact Form (preferred) or email BPHCOHCPMHCESupport@hrsa.gov to submit an extension request. If submitting an extension request using the BPHC Contact Form, refer to the How Do I Submit a Request to Extend the Operational Time of a HRSA-Approved Temporary Service Site FAQ on where to navigate.

If a health center is unable to access the BPHC Contact Form or to email BPHCOHCPMHCESupport@hrsa.gov, a health center should contact Health Center Program Support at 1-877-464-4772.

If a health center would like to permanently add a temporary service site to the health center’s scope of project, the health center must submit a change in scope (CIS) request to HRSA. Refer to BPHC Scope of Project webpage for information on CIS requests.

For further details on temporary service site requests, refer to PAL 2020-05: Requesting a Change in Scope to Add Temporary Service Sites in Response to Emergency Events (PDF - 266 KB)