Sites: Documentation

You will be required to upload copies of documentation that your sites meets NHSC site requirements when you submit your site application. Compile the required documentation well in advance of the application deadline to be sure you are able to submit a complete application.

Policies on Non-Discrimination. Upload a copy of the site’s policies on non-discrimination of patients based upon race, color, sex, national origin, disability, religion, age, or sexual orientation, as per the NHSC Site Agreement.  

Sliding Fee Schedule Documents. Upload documentation (see list below) of the site’s sliding fee schedule (SFS).  For examples and more information on the SFS requirement, visit the NHSC website and download the Discounted/Sliding Scale Fee Information Package (PDF – 965 KB).

NHSC Comprehensive Behavioral Health Services Checklist (PDF – 170 KB). Submit a completed copy of the NHSC Comprehensive Behavioral Health Services Checklist.

  • Discounted Fee Schedule/SFS   
    • Reflects the most recent HHS Poverty Guidelines
    • Offers a full (100%) discount to those at or below 100% of poverty
    • Offers a sliding schedule of discounts up to 200% of poverty
  • Patient Application for SFS. Discounts should be based on family size and income.
  • Site’s Policy on the SFS. These policies should describe how the SFS is implemented at the site, including how the SFS will be advertised, procedures for patients to apply, and site’s policies and procedures on processing applications.  Ensure that the site’s SFS applies to all residents of the site’s HPSA(s).

Required Signage. Upload a photograph or copy of posted signage at the applicant site that meets the requirements of the NHSC Site Agreement.  For an example of acceptable signage, please reference the Site Policy Poster on the NHSC website.

Proof of Access to Ancillary, Inpatient and Specialty Care. Upload proof of referral arrangements for ancillary, inpatient, and specialty care that is not available on-site.  Acceptable documents include Memorandums of Understanding (MOU), Memorandums of Agreement (MOA) or contracts with ancillary, inpatient, and specialty facilities.  If formal referral arrangements do not exist, the applicant site should provide a description of how it refers patients to ancillary, inpatient, and specialty care.

NHSC Site Data Tables. Upload completed NHSC Site Data Tables (to access Tables, go to Downloadable Resources page) with information on the individual site location.  Read all instructions carefully before completing the Tables.

EXCEPTIONS:  Free clinics, Indian Health Service, Tribal Clinic, and Urban Indian Health Clinics and correctional facilities are exempt from submitting certain required documents, including SFS documents and required signage, due to their inability to bill and charge for services.

REQUIREMENT FOR SIX MONTHS OF DATA:  In order to demonstrate that applicant sites can meet the terms of the NHSC Site Agreement, they must submit six continuous months of data in the NHSC Site Data Tables.  This helps ensure the NHSC that the applicant site adheres to sound fiscal management policies and is able to allow potential NHSC clinicians to maintain a primary care clinical practice as indicated in their NHSC contracts.