Get Dhhs Hrsa Form 3: Income Analysis

Filling out the DHHS HRSA Form 3: Income Analysis is a crucial step in reporting projected income for health center services. This guide offers detailed instructions to help users complete the form accurately and efficiently online.

Follow the steps to complete the DHHS HRSA Form 3: Income Analysis online

1. Click ‘Get Form’ button to obtain the form and access it easily in your preferred editor.
2. In Part 1, Patient Service Revenue – Program Income, enter the projected number of patients in Column (a) based on their primary medical insurance.
3. Insert the total number of billable visits in Column (b). Ensure to only include reimbursable visits and not other services.
4. Calculate the income per visit for each payer category in Column (c) by dividing projected income in Column (d) by the number of billable visits in Column (b).
5. Fill out the projected income in Column (d), ensuring it accounts for all accrued net revenue from patient services.
6. Enter the prior fiscal year income in Column (e) based on available data.
7. In Part 2, Other Income, list any other federal, state, or local income in the respective lines for lines 7 to 14.
8. Calculate the total non-federal income in Line 15, which combines Program Income and Other Income.
9. Use the Comments/Explanatory Notes section to explain any discrepancies or additional details as necessary.
10. Finally, save your changes, and download, print, or share the completed form as needed.

Complete your DHHS HRSA Form 3: Income Analysis online for timely submission.