Instructions for Form 5B: Service Sites

What is a Service Site?

Sites are one of five elements that comprise the scope of project, as described in PIN 2008-01.1 Specifically, the scope of project defines the approved service sites, services, providers, service area(s) and target population(s) which are supported (wholly or in part) under the total budget approved for the health center.

Health centers are required to provide services at times and locations that assure accessibility and meet the needs of the population to be served. All sites within the approved Health Center Program scope of project must be appropriately recorded on Form 5B: Service Sites (Form 5B) in the HRSA Electronic Handbooks (EHB) Scope Module.

A service site is any location where a health center, either directly or through a subrecipient or other established arrangement (i.e., contract), provides primary health care services.2 to a defined service area or target population and where all of the following conditions are met:

  • Health center visits are generated by documenting in the patients' records face-to-face contacts between patients and providers;
  • Providers exercise independent judgment in the provision of services to the patient;
  • Services are 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; and
  • Services are provided on a regularly scheduled basis (e.g., daily, weekly, first Thursday of every month). However, there is no minimum number of hours per week that services must be available at an individual site.

Based on the service needs of the target population and other factors, sites may be identified as permanent, seasonal, mobile van, migrant voucher or intermittent as described in the table below. Health centers also record Administrative Sites, defined in the table below, on their Form 5B. Not all Form 5B fields are required for Administrative Sites.

How do Health Centers Complete or Change Form 5B Fields?

The following table provides the instructions for completing or making changes to Form 5B. It also provides information on whether and how to update specific parts of a Form 5B site entry.

Health centers adding new service sites complete all fields on Form 5B unless otherwise indicated.

If a health center has an existing HRSA-approved service site, it has three ways to make scope-related changes that can result in a change to a field in Form 5B, each of which requires submission through EHBs:

  1. Formal Change in Scope requests are for significant changes to the scope of the project and require prior approval from HRSA;
  2. Scope Adjustment requests are for minor changes or adjustments to the scope of the project and require prior approval from HRSA; and,
  3. Self-Updates are for fields that automatically update without HRSA approval.
Field Name Field Format Description of and Instructions for each Form 5B Field Methods for Making Changes to a Field
Site Name Text

Provide a unique name for each site you operate. This name will be displayed in the Find a Health Center tool on HRSA's website.

You may change the site name without HRSA’s approval via the Self-Update Module.
Physical Site Address Street Address City, State, ZIP (or
urbanization code if Puerto Rico)

Provide the physical street address for the site, including street number, street name, city, state, and ZIP code (or urbanization code for Puerto Rico). This information will be standardized by HRSA to align with accepted address formats. This address will be displayed in the Find a Health Center tool on HRSA's website; therefore, do not provide Post Office boxes or other non-physical addresses. HRSA does not collect the street address for confidential domestic violence shelters, and these confidential sites are not displayed in Find a Health Center. 

For sites that are located within a larger building or campus: 

  • If the site has a suite, office, or another unique identifier, you must provide this information as part of the physical address (e.g., 123 Main St., Suite A).
  • If the site does not have a unique identifier (e.g., sites within schools and shelters), you must provide the standardized physical address (e.g., 123 Main St.).

You must complete a Formal Change in Scope request for prior approval to add a new site if the site would have a separate physical address, including a different suite/office/building number. For example, you must submit a Formal Change in Scope request if your health center operates a site at 345 Main Street, Suite #4 and you plan to add a new site in a different suite at 345 Main Street, Suite #12. 

In cases where the suites, rooms, floors, or buildings have separate entry points, you must record each area separately on Form 5B. For example:

  • Your health center provides pediatric services in suite A of a building and will add adult primary care services in suite F of the same building, and there is a separate entry point for each suite. You would add Suite F to the scope as a separate Form 5B Service Site.
  • Your health center provides services in Building 5 and will now also provide services in Building 12 — a separate building on the same campus. You would add Building 12 to scope as a separate Form 5B Service Site.

If you have any questions about other situations where your health center plans to expand into additional suites, rooms, or floors within an existing Form 5B service site (e.g., your health center provides services in Suite A and expands into Suite B of the same building with a single point of entry to the expanded suite) and whether those expansions require a separate physical address and Change in Scope request, contact your Project Officer.

If your site moves from one physical address to another, the “Physical Site Address” field cannot be updated.

Instead, you must change the physical site address by submitting a Formal Change in Scope request to delete the existing site, and another Formal Change in Scope request to add the site with the new physical address. 

If the physical address of the site is changed by another entity (e.g., due to 911 reassignment; US Postal Service changes) contact Health Center Program Support.

If the physical address where a mobile unit is parked changes, contact Health Center Program Support.

Site Phone Number Phone Number (xxx- xxx-xxxx)

Provide a phone number for the site; this will populate the Find a Health Center tool on HRSA's website.

You may change the site phone number without HRSA approval via the Self-Update Module.
Web URL
(optional)
URL format

Provide a website address for your organization or for the site if you have a site-specific web page. This will populate the Find a Health Center tool on HRSA's website.

You may add/delete/change the web URL without HRSA approval via the Self-Update Module.
Site Type Multiple Choice Options:
  • Administrative/ Service Delivery Site
  • Service Delivery Site
  • Administrative Site

Service Delivery Sites are locations where all of the following conditions are met:

  • Health center visits are generated by documenting in the patients' records face-to-face contacts between patients and providers;
  • Providers exercise independent judgment in the provision of services to the patient;
  • Services are 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; and
  • Services are provided on a regularly scheduled basis (e.g., daily, weekly, first Thursday of every month). However, there is no minimum number of hours per week that services must be available at an individual site.

Administrative/Service Delivery Sites are locations that meet the service site definition and also serve as a site where administrative work is performed.

Administrative Sites are sites at which only non-clinical services are provided and/or administrative work is performed (i.e., the site does not meet the definition of a service site).

You may change between "Service Delivery Site" type and "Administrative/Service Delivery Site" type without HRSA approval via the Self-Update Module.

You cannot update the “Site Type” field when changing between "Administrative Site" type and "Service Delivery Site" or "Administrative/Service Delivery Site" types.

Instead, you must change the site type by submitting a Scope Adjustment Change in Scope request to delete the existing administrative site and a Formal Change in Scope request to add the site with the new site type.

Location Type Multiple Choice Options:
  • Permanent
  • Seasonal
  • Mobile
  • Migrant Voucher Screening
  • Intermittent

Carefully review the location types as they are described in Policy Information Notice 2008-01: Defining Scope of Project & Policy for Requesting Changes, specifically Section III.B.1.

Permanent sites operate at a fixed address and are open year-round. 

  • Seasonal sites operate at a fixed location for less than 12 months during the year.
  • Mobile sites are fully equipped and staffed by health center clinicians providing direct primary care services at various locations on behalf of the health center.
    • Mobile sites must meet the definition of a service site, except that services do not need to be provided on a regularly scheduled basis (although this is encouraged to provide continuity and access to care for the target population).
    • You must separately list each mobile van/unit (i.e., Mobile Van #1, Mobile Van #2, etc.) as a site. The address must be the primary address where the mobile site is parked. This may be an existing Form 5B Administrative or Service Delivery Site or another location not listed on Form 5B.3 You do not need to list the specific locations where the unit provides direct health care services.
  • Migrant Voucher Screening sites are screening site(s) where the clinical needs of a patient are assessed and then a referral for care is made to a local provider through an established contractual arrangement.
  • Intermittent sites are sites that meet the definition of a service site above but operate on a regularly scheduled basis for a short period of time (e.g., two months or less) at locations that change as necessary to continue services to the target population.
If a site changes from "Permanent" to "Seasonal" or vice versa, submit a Scope Adjustment Change in Scope request for HRSA review. You must attach supporting documentation that explains the need for the change (e.g., data related to decrease or increase demand for services at the site, loss or gain of providers, patient survey results) and describes the impact on patients.

You cannot update the “Location Type” field when making changes to "Mobile", "Migrant Voucher Screening", or "Intermittent" location types.

Instead, you must change the location type by submitting a Formal Change in Scope request to delete the existing site and another Formal Change in Scope request to add the site with the new location type.

Site Setting Multiple Choice Options:
  • All Other Clinic Types
  • Hospital
  • School

Most sites will fall into the category of "All Other Clinic Types."

A hospital setting is a health center site located within a hospital building or on a hospital campus.

A school setting is a health center site located within a facility whose primary purpose is education.

You may change the site setting without HRSA approval via the Self- Update Module.
Date Site was Added to Scope Populated by HRSA: MM/DD/YYYY This field corresponds to the date that HRSA approves the funded application or Change in Scope request; the field will be populated by HRSA. You cannot change the date site was added to scope.
Site Operational Date Populated by HRSA: MM/DD/YYYY This field corresponds to the date that the health center verifies its site as operational via the verification submission task in EHB; the field will be populated by HRSA.

The health center should verify its site as operational in EHB once it is providing some level of care and seeing patients at the site.

Look-alike health centers should consult with their Project Officers on the verification process.

You cannot change the site operational date.
FQHC Site Medicare Billing Number Status Multiple Choice Options:
  • This site is neither permanent nor seasonal per CMS (i.e., does not require unique FQHC Medicare Billing Number)
  • Health center does not/will not bill under the FQHC Medicare system at this site
  • Number is pending; application for this site has been submitted to CMS
  • Application for this site has not yet been submitted to CMS
  • This site has a Medicare billing number and it will be entered in the next field
This field refers to the FQHC (Federally Qualified Health Center) Site Medicare Billing Number assigned to your site by CMS, once your 855 application is submitted and approved.

Choose the option (of the five provided) that applies to the site.

If you select "Number is pending; application for this site has been submitted to CMS" or "Application for this site has not yet been submitted to CMS", you must update this status to "This site has a Medicare billing number and will be entered in the next field" upon assignment of your Medicare billing number by CMS. You must also update the FQHC Site Medicare Billing Number field at that time.

You may change this status without HRSA approval via the Self-Update Module.
FQHC Site Medicare Billing Number Number (5-6 digits) required if "This site has a Medicare billing number and it will be entered in the next field" was selected in
previous field
If this site has an assigned FQHC Site Medicare Billing Number, enter the assigned 5- or 6-digit number. This field is required if you select option "This site has a Medicare billing number and it will be entered in the next field" for the FQHC Site Medicare Billing Number Status field. You may change this number without HRSA approval via the Self-Update Module.
FQHC Site National Provider Identification (NPI) Number (optional) Number (10 digits)

The FQHC site NPI is the National Provider Identifier (NPI) assigned by CMS to the FQHC site (not an individual healthcare provider’s NPI). You can find your FQHC site NPI in CMS’ searchable registry.

If your site does not have an NPI, you can register for an NPI at CMS’ National Plan and Provider Enumeration System (NPPES) website. Once an NPI is assigned, update this 5B field with your assigned site NPI number.

You may change this number without HRSA approval via the Self-Update Module.
Total Hours of Operation (per week) Number ( > 0 through 168) Provide the total number of hours the health center site is in operation (i.e., providing services to patients) each week.

HRSA considers a full-time site to be in operation 40 or more hours per week. HRSA considers a part-time site to be in operation less than 40 hours per week.

You may request to update your total hours of operation by submitting a Scope Adjustment Change in Scope request for HRSA review. You must attach supporting documentation that explains the need for the change (e.g., data related to decrease or increase in demand for services at the site, loss or gain of providers, patient survey results) and describes the impact on patients.
Months of Operation Checkbox next to each month

Select the duration that the health center is providing services at this site:

  • Permanent sites will select all 12 months of the year.
  • Mobile sites and Voucher sites are in operation up to 12 months of the year.
  • Seasonal sites are in operation up to 11 months of the year.

Intermittent sites are in operation 2 or fewer months of the year.

You may not request to change months of operation for a Permanent Site; however, you may request to change months of operation for other location types by submitting a Scope Adjustment Change in Scope request for HRSA review. You must attach supporting documentation that explains the need for the change (e.g., data related to decreases or increases in demand for services at the site, loss or gain of providers, patient survey results, etc.) and describes the impact on patients.
Service Area ZIP Codes One or more 5-digit ZIP codes

Each health center must define a service area, also referred to as catchment area, that is the geographic area in which the majority of the health center's patients reside. Once defined, this service area is reviewed at least annually, to ensure its accuracy and appropriateness, and updated as appropriate in the health center's application for ongoing funding/designation, if any changes are identified. The ZIP codes are identified for each site on Form 5B, consistent with patient origin data reported by ZIP code in the health center's annual Uniform Data System (UDS) report.

Mobile sites should list the ZIP codes where the mobile site provides services, which may or may not include the ZIP code where the site is parked.

You may request to update your service area ZIP codes by submitting a Scope Adjustment Change in Scope request for HRSA review. You must attach supporting documentation that explains why the service area is changing (e.g., new UDS patient origin data, need data related to decrease/shift in patient origin or influx of new patients) and how it may impact neighboring health centers (e.g., letters of support).
Number of Contract Service Delivery Locations (required when “Migrant Voucher Screening” is selected as the Location Type) Number > 0 Use this field to enter the total number of migrant voucher screening site(s). You do not need to list the specific locations where the health center maintains contracts for direct services; however, you should indicate on Form 5B the number of such locations and should review and update as needed at least annually. You may change this number without HRSA approval via the Self-Update Module.
Number of Intermittent Sites (required when “Intermittent” is selected as the Location Type) Number > 0  Use this field to enter the number of intermittent site(s). The specific locations where the health center establishes intermittent sites to provide services do not need to be listed; however, the number of such locations should be indicated on Form 5B and should be reviewed at least annually and updated if necessary. You may change this number without HRSA approval via the Self-Update Module.
Site Operated by Multiple Choice Options:
  • Health Center/Applicant
  • Subrecipient
  • Contractor

Select "Health Center/Applicant" if the site is directly operated by the health center organization.

If the health center is not operating the site, carefully review the documentation required and questions posed in the Add New Service Site Checklist (PDF - 245 KB) 4 that explain the components of a subrecipient versus contractor relationship 5 ,6

Select "Subrecipient" if the proposed site is operated by a third party on behalf of the health center through a written subrecipient agreement between the health center and the subrecipient organization. Specifically, the health center is providing a subaward to the organization to carry out a portion of the grant-supported program or project for the operation of the proposed site. The subrecipient arrangement must be approved by HRSA, and:

  • Subrecipients must be compliant with applicable Health Center Program requirements; and
  • All subrecipients must also comply with applicable grants requirements, particularly those set forth in 45 CFR 75.351-353.

Select "Contractor" if the proposed site is operated by a third party on behalf of the health center through a written contractual agreement between the health center and the third party (i.e., the health center is contracting with a third party for part or full operation of this service site). The contract must be secured according to written procurement procedures that comply with all federal requirements, particularly those set forth in 45 CFR Part 75. 7

Refer to Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information.

 

You cannot change the “Site Operated by” field as this is considered a significant change in scope and must be submitted through the EHB Prior Approval Module with appropriate documentation. Contact your Project Officer for more information.
Subrecipient or Contractor Information Organization Name, Address and Employee Identification Number (EIN) required if “Contractor" or "Subrecipient” is selected in previous field If a contractor or subrecipient is operating the site, provide that organization’s name, main organizational address, and EIN number. You may request to update Subrecipient or Contractor identifying information by submitting a Scope Adjustment Change in Scope request for HRSA review. You must attach supporting documentation that explains why the subrecipient’s or contractor’s organizational address or EIN number has changed.

 

Footnotes:

  • 1. Refer to Policy Information Notice (PIN) 2008-01: Defining Scope of Project and Policy for Requesting Changes for further information.
  • 2. A service site may provide comprehensive primary care services or may provide a single service such as oral or mental health services, based on the identified needs in the community/population.
  • 3. Contact your State Medicaid Agency for information or questions related to Medicaid-specific requirements for recording the address of a mobile site.
  • 4. Change in Scope Checklist previews are available on the Scope of Project website.
  • 5. For more information on determining whether an agreement for the disbursement of federal program funds casts the party receiving the funds in the role of a subrecipient or a contractor, please review 45 CFR 75.351. Please note that contractors are not able to qualify as federally qualified health centers.
  • 6. Note that certain entities may be eligible to receive additional federal benefits associated with the receipt of Health Center Program funding -- including Federally Qualified Health Center (FQHC) payment rates under Medicaid and Medicare (§1861(aa)(4) and §1905(l)(2)(B) of the Social Security Act), 340B Drug Pricing, and Federal Tort Claims Act (FTCA) coverage. However, such benefits have additional requirements and may require additional actions by recipients and/or subrecipients to obtain them.
  • 7. Applicable requirements include, but are not limited to, Procurement Standards; 45 CFR 75.351(b). Contract - A contract is used for the purpose of obtaining goods and services for the health center’s own use and creates a procurement relationship with the contractor. Characteristics indicative of a procurement relationship between the health center and a contractor are when the contractor (1) Provides the goods and services within normal business operations; (2) Provides similar goods or services to many different purchasers; (3) Normally operates in a competitive environment; (4) Provides goods or services that are ancillary to the operation of the federal program; and (5) Is not subject to compliance requirements of the federal program as a result of the agreement, though similar requirements may apply for other reasons.
Date Last Reviewed:  August 2021