SAC/SAC-AA Application Attachments

Upload a map of the service area for the proposed project. It should show the proposed health center site(s) you list on Form 5B: Service Sites.

The map must clearly show:

•  Proposed service area ZIP codes
• Any medically underserved areas (MUAs) or medically underserved populations (MUPs)
• Health Center Program award recipients, look-alikes, and other health care providers serving the proposed ZIP codes

Use the Health Center Program GeoCare Navigator to create the map and table. Refer to the HCP GeoCare Navigator User Guide (PDF - 3 MB) for help.

You may need to manually place markers for the locations of other major private provider groups serving low income/uninsured patients.

Note: The table will display ZIP Code Tabulation Areas (ZCTAs), not ZIP codes. ZCTAs represent general areas of United States Postal Service ZIP Code service areas. The Census Bureau created ZCTAs to differentiate between these service areas and mail delivery routes. 

Upload current position descriptions for key management staff: project director (PD)/chief executive officer (CEO), clinical director (CD), chief financial officer (CFO), chief information officer (CIO), and chief operating officer (COO).

On the position descriptions, point out if you’ve combined key management positions or if any are part time. For example, we share CFO and COO roles.

Each position description should be one page and must include training and experience, qualifications, duties, and functions, at minimum. Information should match what you included on Form 2: Staffing Profile.

The PD/CEO position description must address the following duties and responsibilities:

• Directs health center’s employment
• Reports directly to the health center’s governing board
• Oversees other key management staff in carrying out the proposed project’s day-to-day activities

Upload current biographical sketches for key management staff: PD/CEO, CD, CFO, CIO, and COO.

Identify if the person will fill more than one key management position. Do not exceed two pages per biographical sketch.

When it applies, include training, language fluency, and experience working with the cultural and linguistically diverse populations you will serve.

Public center applicants with a co-applicant board must submit the most recent copy of the formal co-applicant agreement.

Ensure you send the entire agreement and both the co-applicant governing board and the public center signs it. 

See the RESOURCES/CAPABILITIES and GOVERNANCE sections of the Project Narrative for more details.

Describe all current or proposed patient service-related contracts and agreements. Make it consistent with Form 5A: Services Provided, Columns 2 and 3, respectively.  

Include any agreement for a substantial portion of the project and lease agreements, if it applies. 

If you contract with any one entity for most health care providers or have a subrecipient agreement, you must include that contract or agreement in Form 8: Health Center Agreements. Include an asterisk next to these providers. 

The summary must address the following items for each contract or agreement:

• Name of contractor or referral organization
• Whether it’s a contract or referral arrangement
• Brief description of the type of services you provide and how and where you provide them
• Timeframe for each contract or agreement (for example, ongoing contractual relationship, specific length of time)
• Process for tracking and referring patients back to the health center for appropriate follow-up care

Upload the official signatory page (seal page) of your Articles of Incorporation. 

A public center with a co-applicant must upload the co-applicant’s Articles of Incorporation signatory page, if it’s incorporated. 

A tribal organization must refer to its designation in the Federally Recognized Tribal Entity List that the Bureau of Indian Affairs maintains.

Include current, dated collaboration activities’ documents. These show your commitment to the project. See the COLLABORATION section of the Project Narrative for details on what we require. 

Address letters of support to the organization’s board, PD/CEO, or other relevant key management staff member (for example, the clinical director).

Note: Reviewers will only consider letters of support and other documentation of collaboration you submit with your application. However, we encourage you to consider the impact on your application’s page length if you choose to include documentation of collaboration that we do not require.

Upload the current SFDS for services you provide directly. Make it consistent with Form 5A: Services Provided, Column I. 

The structure of the SFDS must be consistent with the policy (as described in the RESPONSE section of the Project Narrative) and provide: 

• A full discount for individuals and families with annual incomes at or below 100% of the current FPG. Alternately, you can elect to charge a nominal fee, which would be less than the fee a patient would pay in the first sliding fee discount pay class above 100% of the FPG.
• Partial discounts for individuals and families with incomes above 100% of the current FPG and at or below 200% of the current FPG. 
  • Adjust discounts based on gradations in income levels 
  • Include at least three discount pay classes
  • No discounts to individuals and families with annual incomes above 200% of the current FPG.

Ensure your SFDS includes the current FPG. Upload all SFDSs if you have more than one for services you provide directly (medical, dental, for example).

A private, nonprofit organization must submit any one of the following as evidence of its status:

• Copy of a currently valid Internal Revenue Service (IRS) tax exemption letter/certificate.
• Statement from a state taxing body, state attorney general, or other appropriate state official certifying that your organization has a nonprofit status and that none of the net earnings accrue to any private shareholders or individuals.
• Certified copy of your organization’s certificate of incorporation or similar document (for example, Articles of Incorporation) showing the state or tribal seal that clearly establishes the nonprofit status of the organization.
• Any of the documents just listed for a state or local office of a national parent organization, and a signed statement from the parent organization stating that your organization is a local nonprofit affiliate.

A public agency applicant must provide documentation showing that you qualify as a public agency (for example, state or local health department).

We accept any of the following:

• Current dated letter affirming the your status as a
  • State, territory, county, city, or municipal government
  • Health department organized at the state, territorial, county, city, or municipal level
  • Subdivision or municipality of a United States (U.S.) affiliated sovereign state (for example, Republic of Palau)
• Copy of the law that created your organization and that grants one or more sovereign powers (for example, the power to tax, eminent domain, police power) to your organization (for example, a public hospital district).
• Ruling from the State Attorney General affirming your legal status as either a political subdivision or instrumentality of the State (for example, a public university).
• “Letter ruling” which provides a positive written determination by the IRS of your exempt status as an instrumentality under Internal Revenue Code section 115.

Tribal Organizations, as the Indian Self-Determination Act defines, must refer to your designation in the Federally Recognized Tribal Entity List that the Bureau of Indian Affairs maintains. This shows that you qualify as a public agency.

Urban Indian Organizations, as the Indian Health Care Improvement Act defines, must either submit evidence of its nonprofit status as we describe for all private, nonprofit organizations, or submit evidence that you’re a public agency as part of a tribal organization.

Refer to Apply for Service Area Competition for a sample.

You must include reasonable and time-framed activities. This ensures that within 120 days of the Notice of Award (NoA), all sites on Form 5B: Service Sites will have the necessary staff and providers in place to begin operating and delivering services as you describe on Form 5A: Services Provided. Note: On Form 5B, you must include all sites you describe in the Project Narrative.

Also include plans to hire, contract, or establish formal written referral arrangements with all providers. Begin providing services at all sites for the stated number of hours (consistent with Form 5B: Service Sites) within 1 year of the NoA’s release.

Note: This content must match with what you included on Form 2: Staffing Profile, Form 5A: Services Provided and Form 8: Health Center Agreements, and Attachment 7: Summary of Contracts and Agreements.

Upload an attachment with the narrative sections detailed in Appendix A to show that your comply with Health Center Program requirements. 

Each section notes the additional forms and other attachments we’ll review as part of assessing your compliance. Refer to the sample document on  Apply for Service Area Competition.

Upload an indirect cost rate agreement if it applies. If desired, include other relevant documents to support the proposed project (for example, charts, organizational brochures, lease agreements). We allow a maximum of two uploads. 

New and competing supplement applicants must include lease/intent to lease documentation in this attachment if you are leasing, or will lease, a proposed site.