SAC/SAC-AA Application Attachments

Upload a map of the service area for the proposed project, indicating the organization’s proposed health center site(s) listed on Form 5B: Service Sites. The map must clearly indicate the proposed service area zip codes; any medically underserved areas (MUAs) and/or medically underserved populations (MUPs); and Health Center Program award recipients, look-alikes, and other health care providers serving the proposed zip codes. Maps and tables should be created using UDS Mapper. Markers may need to be manually placed for the locations of other major private provider groups serving low income/uninsured patients. Note that the table will display Zip Code Tabulation Areas (ZCTAs) and not zip codes. ZCTAs are generalized areal representations of United States Postal Service ZIP Code service areas. ZCTAs were created to differentiate between areal service areas and mail delivery routes. See ZIP Code Tabulation Areas for more information. For a tutorial, see Specific Use Cases: Create a Service Area Map and Data Table available on the UDS Mapper Tutorials & Resources webpage.

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

• New: C
• Competing Continuation and Competing Supplement: R

• Name of contract/referral organization.
• Type of contract or agreement (e.g., contract, referral agreement, Memorandum of Understanding or Agreement).
• Brief description of the type of services provided and how and where services are provided.
• Timeframe for each contract or agreement (e.g., ongoing contractual relationship, specific duration).

If a contract or agreement will be attached to Form 8: Health Center Agreements (e.g., subrecipient agreement; contract or subaward to a parent, affiliate, or subsidiary organization), denote this with an asterisk (*). Contracts for substantive programmatic work and subrecipient agreements must be included in Form 8.

• New: R
• Competing Continuation and Competing Supplement: N/A

Upload current dated documentation of collaboration activities to provide evidence of commitment to the project. See the COLLABORATION section of the Project Narrative for details on required documentation. Letters of support should be addressed to the organization’s board, PD/CEO, or other appropriate key management staff member (e.g., clinical director).

Note: While reviewers will only consider letters of support and other documentation of collaboration submitted with the application you are encouraged to consider the impact on your application’s page length when providing non-required documentation of collaboration.

Upload the current sliding fee discount schedule(s) (SFDS) for services provided directly (consistent with Form 5A: Services Provided, Column I). The SFDS structure must be consistent with the policy (as described in the RESPONSE section of the Project Narrative) and provide discounts as follows:

• A full discount is provided for individuals and families with annual incomes at or below 100 percent of the current FPG, unless a health center elects to have a nominal charge, which would be less than the fee paid by a patient in the first sliding fee discount pay class above 100 percent of the FPG.
• Partial discounts are provided for individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG, and those discounts adjust based on gradations in income levels and include at least three discount pay classes.
• No discounts are provided to individuals and families with annual incomes above 200 percent of the current FPG.

Ensure the SFDS has incorporated the current FPG. If you have more than one SFDS for services provided directly (e.g., medical, dental), upload all SFDSs.

• New: C
• Competing Continuation and Competing Supplement: N/A

New applicants must upload evidence of nonprofit or public center status. This attachment does not count toward the page limit.

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

• A copy of a currently valid Internal Revenue Service (IRS) tax exemption letter/certificate.
• A 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.
• A certified copy of your organization’s certificate of incorporation or similar document (e.g., Articles of Incorporation) showing the state or tribal seal that clearly establishes the nonprofit status of the organization.
• Any of the above documentation for a state or local office of a national parent organization, and a statement signed by the parent organization that your organization is a local nonprofit affiliate.

A public agency applicants must provide documentation demonstrating that the organization qualifies as a public agency (e.g., state or local health department). Any of the following is acceptable:

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

Tribal Organizations, as defined under the Indian Self-Determination Act, must reference its designation in the Federally Recognized Tribal Entity List maintained by the Bureau of Indian Affairs as documentation demonstrating that the organization qualifies as a public agency. Urban Indian Organizations, as defined under the Indian Health Care Improvement Act, must either submit evidence of its nonprofit status as described above for all private, nonprofit organizations, or submit evidence that it is a public agency as part of a tribal organization.

• New and Competing Supplement: R
• Competing Continuation: N/A

The plan must include reasonable and time-framed activities which assure that within 120 days of release of the NoA, all sites on Form 5B: Service Sites (all sites described in the Project Narrative must be included on Form 5B) will have the necessary staff and providers in place to begin operating and delivering services as described on Form 5A: Services Provided. Also include plans to hire, contract, and/or establish formal written referral arrangements with all providers (consistent with Forms 2: Staffing Profile, 5A: Services Provided and 8: Health Center Agreements, and Attachment 7: Summary of Contracts and Agreements) and begin providing services at all sites for the stated number of hours (consistent with Form 5B: Service Sites) within 1 year of release the NoA.

Upload an indirect cost rate agreement if applicable. If desired, include other relevant documents to support the proposed project (e.g., charts, organizational brochures, lease agreements). You are permitted a maximum of two uploads.

New and competing supplement applicants must include lease/intent to lease documentation in this attachment if a proposed site is or will be leased.