ࡱ> %` JbjbjNN N,, K/* * * $p TP$ 8x t44444444$9h0<5%* |@5:7R8* 44nc  * 7#l 7C=k! *< 78!<f<@7#<* 7#|4n^d44455[^4448 *,-D\pdJ *,-pN b p   APPLICANT INSTRUCTIONS  Purpose The purpose of this application is to provide instructions and forms necessary to apply for renewed EAPC funding for fiscal year (FY) 2009-2010. All clinics must continue to operate under the provisions and requirements set forth in the EAPC Request for Application Fiscal Years 2007-2010, i.e., clinic and patient population criteria, billing processes, type of service, redistribution criteria.  Format assembly and submission  Submit applications in typewritten form only. Assemble the application including all required forms and documents in the order listed on the Application Checklist (page 10). Clearly Paginate each page number in the upper right corner and staple the completed packet in the upper left corner. Include only the information requested in this application. Please do not return the application in a special cover or binder. Mail the original application and one copy to the following address: California Department of Health Care Services Expanded Access to Primary Care Program MS 8501 P.O. Box 997413 Sacramento, CA 95899-7413 Overnight Delivery Address: California Department of Health Care Services Expanded Access to Primary Care Program 1501 Capitol Avenue, Ste. 71.6044 MS 8501 Sacramento, CA 95814  Instructions Currently funded corporations must complete the forms as described. Refer to the top of each form for completion instructions. Page 3 requires information specifically regarding the Corporation. Pages 4 - 10 require information from ALL clinic sites requesting EAPC funding, including newly eligible clinic sites. All signatures must be in blue ink. Due date Applications must be received by 5:00 p.m. on April 30, 2009. Facsimile or Email Applications transmitted by facsimile (FAX) or email will not be accepted.  EAPC Web site This document may be viewed and downloaded from the EAPC Web site:  HYPERLINK "http://www.dhcs.ca.gov/services/rural/Pages/EAPCPage.aspx" http://www.dhcs.ca.gov/services/rural/Pages/EAPCPage.aspx  APPLICANT INSTRUCTIONS (continued)  Application Evaluation Applications will be evaluated prior to distribution of renewed funding to determine if all criteria set forth in Health and Safety Code Section 124910 (d) are met. New Clinic Applicants New clinic applicants will be awarded funds if they meet the minimum requirements and sufficient funding is available.  Denied Application Any applicant not selected for this funding will be notified of the denial in writing. Those denied funding may appeal CDHCSs decision.  Appeal Process Send appeals to:  Within five (5) working days from the date of notification on an alleged action by the Department, the applicant must deliver the grievance together with any evidence, in writing, to the Deputy Director, Health Care Operations, Primary and Rural Health Division. The grievance must state the issues in dispute, the legal authority or other basis for the applicants position, and the remedy sought. The Deputy Director or designee must respond to an applicants appeal within 20 working days of receipt of the grievance. The Deputy Director or designee may, in his/her sole discretion, meet with the applicant to review the issues raised. A written decision signed by the Deputy Director or designee shall be returned to the applicant within 60 working days of the filing of the appeal. The decision of the Deputy Director or designee shall be final. There is no further administrative appeal. This decision shall be the final administrative determination of the Department. Catherine Halverson, Deputy Director California Department of Health Care Services Health Care Operations Primary and Rural Health Division 1501 Capitol Avenue MS 8000 P.O. Box 997413 Sacramento, CA 95899-7413  EAPC RENEWAL APPLICATION COVER SHEET FY 2009-2010  Corporate information Legal Corporate Name (Type exactly as the name appears on the State license)  FORMTEXT      Current EAPC NPI Number  FORMTEXT       Ownership Change in FY 2008-2009? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Former Corporation Name:  FORMTEXT       Corporate Telephone Number (  FORMTEXT    )  FORMTEXT     -  FORMTEXT      Federal Employer ID Number  FORMTEXT      Executive Director  FORMTEXT      FAX Number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT      Executive Director s e-mail address  FORMTEXT      Executive Director s Telephone ( FORMTEXT    )  FORMTEXT     -  FORMTEXT      ext.  FORMTEXT      Corporate Mailing Address  FORMTEXT      City  FORMTEXT      County  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT     Corporate Street Address (If different than mailing address)  FORMTEXT      City  FORMTEXT      County  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT      Number of clinic site(s) for which the Corporation is requesting EAPC Funding:  FORMTEXT       (Including Intermittent Sites) EAPC Billing: Electronic Claims  FORMCHECKBOX  or Hardcopy Claims  FORMCHECKBOX  Number EAPC funded Clinic site(s) closed in FY 2008-2009:  FORMTEXT       Complete Attachment A with clinic name, location, Office of Statewide Health Planning and Development (OSHPD) number, and closure date.Contact Person (Individual to contact regarding this Application or any EAPC related questions)  FORMTEXT      Contact Person s Telephone (  FORMTEXT    )  FORMTEXT     -  FORMTEXT      ext. FORMTEXT      Contact Person s E-Mail Address (Where clinics can receive information, updates, and other communication from EAPC)  FORMTEXT      CERTIFICATIONThe undersigned hereby certifies under penalty of perjury and on behalf of the applicant that the information provided in this application is true, correct, and complete. The applicant agrees to comply with the statutes and the program requirements of the Expanded Access to Primary Care Program. Signature of Executive Director Date Signed  FORMTEXT        CLINIC SITE INFORMATION  INSTRUCTIONS Complete this form for each licensed site.Legal Corporation Name  FORMTEXT      Clinic Site Name  FORMTEXT      Clinic Street Address  FORMTEXT      City  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT     County  FORMTEXT      Clinic Telephone (  FORMTEXT    )  FORMTEXT     -  FORMTEXT      Current Medi-Cal NPI Number for this clinic site  FORMTEXT      OSHPD Number  FORMTEXT   - FORMTEXT      Please check the appropriate boxes:  FORMCHECKBOX  Site is located in an area designated as a  Frontier MSSA.  FORMCHECKBOX  Site is School-Based.  FORMCHECKBOX  Site is Federally Qualified Health Clinic (FQHC) designated.  FORMCHECKBOX  Site is FQHC look-a-like designated Clinic.  FORMCHECKBOX  Site is Indian Health Clinic  FORMCHECKBOX  Site is Rural Health Clinic (RHC) designated.  FORMCHECKBOX  Site is Free clinic.  FORMCHECKBOX  Site is Dental Only clinic. Was this clinic site providing services to Medi-Cal patients and billing the Medi-Cal Program ninety (90) days prior to the due date of this application? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is this site being added to the EAPC Program for FY 2009-2010? Yes  FORMCHECKBOX  No  FORMCHECKBOX   Check all ancillary services provided on site at this clinic: Pharmacy  FORMCHECKBOX  X-ray  FORMCHECKBOX  Lab  FORMCHECKBOX  If service is not provided on site, complete the Certification of Associated Service Agreements form for each site (page 9), as well as attach the Memorandum of Understanding (MOU) for each site.  Are there any Intermittent* clinics operating under this clinic license? Yes  FORMCHECKBOX  No  FORMCHECKBOX  (see definition on page 5) If yes, complete an  Intermittent Clinic Site Information sheet for each Intermittent site. Number of EAPC Program beneficiaries in the clinic s service area:  FORMTEXT       (i.e. total number of EAPC patients served by the clinic) If clinics exempt from licensure per Section 1206 (c)* Exempt (Check box)  FORMCHECKBOX  Unless exempt, attach a copy of the above clinics state license to this page. *Licensure Exemptions: Any clinic conducted, maintained, or operated by a federally recognized Indian tribe or tribal organization, and which is located on land recognized by the federal government.  INTERMITTENT CLINIC SITE INFORMATION  INSTRUCTIONS This form is to be completed for each intermittent clinic site. The Health and Safety Code, Section 1206(h), defines an intermittent clinic as follows: "A clinic that is operated by a primary care community or free clinic and that is operated on separate premises from the licensed clinic and is only open for limited services of no more than 20 hours a week. An intermittent clinic as described in this paragraph shall, however, meet all other requirements of the law, including administrative regulations and requirements, pertaining to fire and life safety. Legal Corporate Name  FORMTEXT       Name of Intermittent Clinic  FORMTEXT       Name of Parent Clinic  FORMTEXT      Intermittent Clinic s Street Address  FORMTEXT       City  FORMTEXT      County  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT     Hours of operation per week  FORMTEXT        SERVICE EXPANSION WORKSHEET Legal Corporate Name  FORMTEXT       Clinic Site Name  FORMTEXT        INSTRUCTIONS Complete this form for each clinic site. ITEM DESCRIPTIONClinic UseState Use 1 Projected Outpatient Encounters for FY 2009-2010: Enter the total number of encounters that are projected to be provided at the above site during FY 2009-2010. (Include all encounters regardless of payment source.)   FORMTEXT       2 Baseline Encounters*: Enter the total number of encounters provided at the above site for calendar year 1988, as reported to the Office of Statewide Health Planning and Development (OSHPD). Calendar year 1988 is considered the  baseline year for measuring expansion of access to primary care services. -OR- If this clinic site was not in operation during calendar year 1988, enter the total number of encounters during its baseline year, i.e., the calendar year prior to the first fiscal year the clinic received EAPC funds. Example: A clinic opened in 1992 and was funded by the EAPC Program in FY 1994-1995, the number of encounters reported to OSHPD for the 1993 calendar year is its baseline. Year Used:  FORMTEXT       OR- If a clinic has not previously received EAPC funds, enter the total number of encounters reported to OSHPD for calendar year 2008.   FORMTEXT       3 Projected Increase in Outpatient Encounters for FY 2009-2010: (Subtract figure in box 2 from figure in box 1.)   FORMTEXT       *For the purposes of the EAPC Renewal Application  encounters and  visits may be used interchangeably. PROOF OF SERVICES TO A MEDICALLY UNDERSERVED AREA OR POPULATION/HEALTH PROFESSIONAL SHORTAGE AREA (MUA/MUP/HPSA) Legal Corporate Name  FORMTEXT      Clinic Site Name  FORMTEXT       INSTRUCTIONS Complete this form for each clinic site.  EAPC clinics must meet one of the following conditions: Check appropriate Box below and attach a copy of the appropriate document:  FORMCHECKBOX  Clinic is located in a federal or state designated medically underserved area (MUA) , medically underserved population (MUP), or health professional shortage area (HPSA) as documented by one of the following: A copy of the designation letter from the U.S. Department of Health and Human Services, Bureau of Primary Care Services, Division of Shortage Designation; A copy of a designation letter obtained from OSHPD. A copy of the MUA/MUP or HPSA designated Census Tract printout from the Health Resources and Service Administration (HRSA) web site. See Appendex A (page 11) for additional information. -OR-  FORMCHECKBOX  Clinic is able to demonstrate that at least 50% of the patients served are persons with incomes at or below 200% of the federal poverty level as reported to OSHPD*. Federal Poverty Level website:  HYPERLINK "http://aspe.hhs.gov/poverty/08poverty.shtml" http://aspe.hhs.gov/poverty/08poverty.shtml Most recent calendar year data available:  FORMTEXT      Number and percentage of patients that is at or below 200% of the federal poverty level for this clinic site indicated above: Number: FORMTEXT       Percentage:  FORMTEXT      % *Reporting Exemption: Any clinic conducted, maintained, or operated by a federally recognized Indian tribe or tribal organization, and which is located on land recognized by the federal government. Tribal clinics meeting this exemption shall submit a description of the methodology used to determine the number of patients served with annual family incomes at or below 200% of the federal poverty level.  UNCOMPENSATED CARE ENCOUNTERS  Legal Corporate Name  FORMTEXT      Clinic Site Name  FORMTEXT      OSHPD ID #  FORMTEXT   - FORMTEXT       INSTRUCTIONS Complete this form for each clinic site. For the purpose of the EAPC Program an  uncompensated care (UCC) encounter is defined as a visit with a medical, dental, or mental health practitioner for examination or treatment for a person with an income at or below 200 percent of the Federal Poverty Level for which there is no third party reimbursement. Third party reimbursement includes unpaid EAPC claims as well as other unreimbursed visits. For calendar year 2008, provide the total number of UCC encounters for each category listed below. Enter calendar 2008 data that was submitted to OSHPD for the ANNUAL UTILIZATION REPORT OF PRIMARY CARE CLINICS  2008. * Refer to Section 6, entitled  Revenue and Utilization by Payer.  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Indicate the associated providers with whom you have written agreements to provide pharmacy, x-ray, and lab services. (Note: The agreement must state that the associated service(s) will be provided at no charge to the EAPC patient.) Complete this form for each clinic site that has its own agreements Attach a copy of the Memorandum of Understanding (MOU). PHARMACY  FORMTEXT      Telephone ( FORMTEXT    )  FORMTEXT     -  FORMTEXT      Street Address  FORMTEXT       City  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT     X-RAY  FORMTEXT      Telephone ( FORMTEXT    )  FORMTEXT     -  FORMTEXT      Street Address  FORMTEXT       City  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT     LABORATORY  FORMTEXT      Telephone ( FORMTEXT    )  FORMTEXT     -  FORMTEXT      Street Address  FORMTEXT       City  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT      APPLICATION CHECKLIST  Legal Corporate Name  FORMTEXT        INSTRUCTIONS Include the following items with the application and make reference to the appropriate page number. If an item is not applicable indicate  N/A . ITEMREFERENCE PAGE PAGE  EAPC APPLICATION CHECKLIST 1  FORMTEXT       EAPC RENEWAL APPLICATION COVER SHEET 3  FORMTEXT       CLINIC SITE INFORMATION INCLUDING COPY OF CURRENT CLINIC LICENSE FOR EACH SITE  4  FORMTEXT      INTERMITTENT CLINIC SITE INFORMATION 5  FORMTEXT       SERVICE EXPANSION WORKSHEET  6  FORMTEXT      PROOF OF SERVICES TO A MEDICALLY UNDERSERVED AREA OR POPULATION (MUA/MUP) HEALTH PROFESSIONAL SHORTAGE AREA (HPSA)(for each clinic site) 7  FORMTEXT       UNCOMPENSATED CARE ENCOUNTERS (for each clinic site) 8  FORMTEXT      ASSOCIATED SERVICES AGREEMENTS INCLUDING A COPY OF THE MEMORADUM OF UNDERSTANDING (MOU), (If applicable, for each clinic site) 9  FORMTEXT       ATTACHMENT A - CLINIC CLOSURE 3  FORMTEXT      APPENDIX A To access data on the clinics Medically Underserved Area (MUA), Medically Underserved Population (MUP), or Health Professional Shortage Area (HPSA) designation online using the HRSA Bureau of Health Professions website, simply follow the steps below: Obtain the census tract number: To check the status of your HPSA or MUA/MUP designation you must first know your census tract (CT) number. 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[3`UYH"\+`yl"*x3Z}b$ib660J9[`i                    T                                                                              .Ee'>=N[hu+>H4W^z3C)[t(2 < K ~ )N   H G_ z q6 >nx/ " sB.%ZZq`m_ +tX3@A "!du!g+"S"c"*t"0E#[#~"%D%{J&Gf&v-'['L(j_>z>?R?g@ AAAUNAhWAyAT8B\B CFC{CD~DDHDyhEe;F;FFQFSyFHvHQ\HqH6yH$IK3MJM!NS-N2N%'Oa7O< QYqQw S*SsaS TDMTtT+0UFUUV]VW2WIXXrJXnZvjZh]_ `axbb*b8bxWbob(c 6cbc*jdndXf2{fgPg\g=hRhhwh&jajk-Bkl>.l ?l@l nn8onznop^pp q q}=s GsWs+t>t3_t uu~uFvvw]w%x&xBxy{yt z]zOz::z}R)}t}t}~0~>~IxO,sG~iDPv\ye1(g $39lSm>BC ?/ '&;>n(>~_6Ovd<CN_e.?[@WU|rWKe5(ji'm>mp6lDr/34VRObHZ/Z!%y:?"#1Idqt@yu\v Pq__el`b+aIvGO*m 8]Ar ,04E~8h]d,7P5hNbi9DrX '"JVx.5=3C`tXZT[Z d(51H 08V|1cb@ *I?tIjzLB~,]]p&;)b %SGhNnL R-A'=?jEai7 uMx|5.!&Dw#B# |?RZ|Bb l8DG6DJ0;Et|SYv$^gqy%ETh&{|'(7,-./0H  ! ]   ?@XYop"lmLe7gh-. !<=wx>?Z%&UVA B !!!!!8$9$c$d$$$$$$$%0%`%a%%%%%%%%%%&&O&P&a&l&v&w&z&S'h'i'j'm'+++++++++,,,,,,,,,--33344444C4D4i44477777778%8&8F8[8\8888899 92939X9Y9;/;y;z;;;;;<L<M<q<<<<<$=%=I=b=========>>>>>>>>>>>>>>???g?j???????????@@@@@@AAAAAAAAAAHHHHHII0I1I3IGI[IoIpIrIIIIIIIIIIIJJ,J-J/JCJWJkJlJnJJJJJJJJJJSM"@   $%&a'a(a*a+a,a-a1a2<4<5<7<8<9<:<;<<<=<>P@PBPDPFP@PLP@PPP@PTPPPPPPPPPPP@@P @PPPP@Unknown Full NameState of CaliforniaFull Name20090402T094224024jԆ Full NameGz Times New Roman5Symbol3& z ArialCFComic Sans MS5& zaTahoma?5 z Courier New;Wingdings"0 h43&43&Ӧ6 ?&6 ?&!4dJJ 2qIP?%x2.EXPANDED ACCESS TO PRIMARY CARE (EAPC) PROGRAMJHamilto Full Name@         Oh+'0p  0< \ h t 0EXPANDED ACCESS TO PRIMARY CARE (EAPC) PROGRAM JHamiltoNormal Full Name2Microsoft Office Word@@Ͻ#@p#&@p#&6 ?GVT$m5  Nu&" WMFCbh 00lUT#m EMF0eU"   Rp@"Arial3&z Arialt|O[|0LN0dv%   TU@@ L`State of 2***T! U@@FLCalifornia EAPC Renewal6**)*22266**)5*T" U@@" L T U@@ !LPrimary and Rural Health Division2?*%*)*6**6)**6%%**TT U@@LP '!"  T AU@@2=LDepartment of Health Care Services Fiscal Year 206***>***6*)*6**2)%&*&-%&*1****TX AU@@ 2LP09)*TT AU@@ 2LP-TX C AU@@ 2LP20**TXD AU@@D 2LP10*)T AU@@ 25L Expanded Access to Primary Care Pro2$****)*1&&)&&*2?*%6**2*TdAU@@2LTgram*)?TTAU@@2LP '!" Rp@"Arial/ 0100 03&z Arial5- 0Pˮ0r0LN0dv%  TT  0U@@ LP18TT G 0U@@ LP 6!" Rp@BComic Sans MSCFComic ans MSTOS.0's*s0LN0dv%  Rp@BComic Sans MSXgXvx'0""4 l""l$0""ޝW1KT0CFComic ans MSk08/b1$0LN0dv% !URp@"Arial3&z Arial..T0TLN0ldv%  TTU@@NL&P 3!&" Rp@"Arial3&z ArialOS.0's*sT0TLN0ldv%  Tc' U@@L&xAPPLICANT INSTRUCTIONS;873>:<4<74<<<4@<7TT( cV U@@( L&P /Rp@"Arial3&z ArialOS.0's*sT0TLN0ldv%  TT ( ,U@@ L&P 3 '% Ld&!??%  % Ld%!??%  % Ld!??%  % Ld!??%  % Ld%a!??%  % Ld%a!??%  % LdEJE&!??%  % Ld&J&%!??%  % Ld&>&!??%  % Ld&>&!??%  % Ld,3!??%  % Ld,3!?&" WMFC 0i0?%  % LdEJ,E3!??%  % Ld&>,&3!??% %  TTPU@@LaP 3!a"  % TTTU@@L[9P 3 % Ld,P,%!??%  % LdKPK%!??%  % Ld,D,!??%  % Ld,D,!??%  % Ld,D,%!??%  % LdKPK%!??%  % Ld,]D,t!??%  % LdK]PKt!??%  % Ld^,D^,%!??%  % Ld^KP^K%!??%  % Ld,%D, !??%  % LdK%PK !??% % Ld&,>D&,!??% % LdE,JDE,!??% % Ld&KJP&K%!??%  % TT%U@@LaP 3!a"  % Tx%NU@@{La\Purpose=8$8833% TTO(U@@O{LaP 3!a"  TT%U@@L[9P 1 T\)3U@@|XL[9The purpose of this application is to provide instructions and forms necessary to apply 9323333.223-333.333.323-333.2.33.3322M-33.3--3-3333-Rp @"Arial/ 0\ˮ00 03&z Arial ssOS.05- 0Pˮ0rT0TLN0ldv% Rp @"Arial/ 0\ˮ00 03&z Arial$65- 0Pˮ0rT0TLN0ldv% %  % TdU@@L[9Tfor 3% TxU@@L[9\renewed$382H38% TT|U@@|L[9P % T, U@@%L[9EAPC funding for fiscal year (FY) 200===B333332-.3-338<323TT  U@@ L[9P93TT  U@@ L[9P-TX E U@@ L[9P2033TXF  U@@F L[9P1033TT  U@@ L[9P.TT  U@@ L[9P TT  U@@ L[9P TT (U@@ L[9P 0 TTbU@@OL[9P 1 TeCU@@EL[9All clinics must continue to operate under the provisions and require=.3..M3..3333333323233333232-.33.3333433TDeU@@DL[9tments set forth in M32-.3223 T/4U@@! L[9`the EAPC 33===BRp @ Arial2d0 ssOS.05- 0Pˮ0rss5- 00r3&z ArialPa ta00LN0dv% % TD0 4U@@0!)L[9Request for Application Fiscal Years 2007B2433-3=33.3338..3=33.2333TT  4U@@ !L[9P-Td  4U@@ !L[9T20103333' % Ld0+ 10+!??% ( T i4U@@ !L&" WMFC 0I0[9, i.e., clinic and patient 3.3.3333333 % T,7U@@PL[9population criteria, billing processes, type of service, redistribution criteria3333333.2333333.3-.3.-332.2-.333.3333-33% TT46U@@L[9P.% TT77gU@@7L[9P 1 TTU@@L[9P 3![9" % Ld^5^ !??%  % TT uU@@aLaP 3!a"  Txt/U@@La\Format 88$R3!a"  THU@@4 La`assembly 3333R81!a"  TdGU@@LaTand 388!a"  T U@@ La`submission388R3288TT U@@ LaP 2!a"  TT  U@@p LaP 3!a"  % TTuU@@bL[9P 1 % T|wU@@L[9\Submit a=33M3TwD U@@L[9pplications in typewritten fo33.333-3-33A332TXE w U@@E L[9PrmL% Tl t U@@ L[9X only881% T` w U@@ L[9T. 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Clearly B33-TKU@@ L[9`Paginate =34332TKoU@@:L[9each page number in the upper right corner and staple the 32.3324332M33333233342.233332.23333 TH  U@@ *L[9completed packet in the upper left corner..3M333233-/333333332.233T   U@@  L[9` Include 3.333T  U@@  "L[9only the information requested in 33-3322M2332433-333 % T  U@@q L[9pthis application.3.333.333T b U@@q L[9l Please do not=33.33333% TTc  | U@@c q L[9P % T}  O U@@} q 4L[9return the application in a special cover or binder.23232333.33333.33.3.3-323333TTP  U@@Pq L[9P 0 TT  U@@ L[9P 1![9"  % T V U@@C L[9`Mail the K433Rp @ ArialV 2dT!OS.05- 0Pˮ0rss5- 00r3&z ArialPa ta00LN0dv% % T| 3W U@@C L[9\original8$783' % LdM 3V M K !??% ( % T4 V U@@4C L[9p application and 333.333333% T| ` W U@@ C L[9\one copy8833881' % Ld M ` V M  !??% (&" WMFC 0)0 % Ta XV U@@a C L[9 to the following address:33333B343332..TTY V U@@YC L[9P 0 TTZ  U@@ L[9P e1Rp @"Arial3&z ArialOS.0's*sT0TLN0ldv%  T` V  U@@ .L[9California Department of Health Care Services <....=...G...=...<..8.**.*TTW  U@@W  L[9P - T|$  U@@n L[9\Expanded7*../../T$  U@@n L[9 Access to Primary Care Programn7**.**.7G.(<..7...GTT $  U@@ n L[9P o, Tx  U@@ L[9\MS 8501eE7../.TT  U@@ L[9P a. T ? U@@. L[9lP.O. Box 997413d7A8.*./../.TT 5? U@@. L[9P E. TD  U@@ L[9tSacramento, CA 958997.*.G...<8./...TTD  U@@ L[9P-lTd D  U@@  L[9T7413//..TTD  U@@ L[9P E. TT  U@@ L[9P E- % T ^ U@@L L[9`OvernighttA/. 333T ^ U@@L L[9p Delivery Addressd<./.!-:34 /..TT ^ U@@L L[9P:PTT ^ U@@L L[9P t. TT_  U@@ L[9P o. % T` V U@@ .L[9California Department of Health Care Services <....=...G...=...<..8.**.*TTW U@@W L[9P - T8# ~U@@m'L[9Expanded Access to Primary Care Program47*../../7**.**.7G.(<..7...GTT # ~U@@ mL[9P 1, T U@@!L[91501 Capitol Avenue, Ste. 71.6044.../<.//7*../.7.../...TT  U@@ L[9P . Tx=U@@,L[9\MS 8501BE7../.TT=U@@,L[9P v. TBU@@L[9lSacramento, CA 7.*.G...<8TlBU@@L[9X95814 ./...TTBU@@L[9P h. % TTU@@L[9P 83 % Ld^ 5 ^  !??%  % TT uU@@aLaP C3!a"  TtU@@ LadInstructions83$82883TTtU@@LaP B2!a"  TTHU@@4LaP 3!a"  % T4uU@@bQL[9Currently funded corporations must complete the forms as described. Refer to the B333-33332.332233.M3..2M333333M-3-33..332B22333 T`x U@@.L[9top of each form for completion instructions. 33233.22M3.3L33333.3-33.TT x U@@ L[9P 0 TTHU@@5L[9P 1Rp@Symbol l0Yxs.0h 0 ޝW10@̪0̪0F0 Y?dYructo5Symbol0LN0dv%  % TT$HMU@@$L[9P*% TTNQU@@NL[9P lTQ U@@L[9Page 3 requires information=34322433.23M333T Q U@@  L[9h specifically.33..3-T &" WMFC 0 0QpU@@ L[9 regarding the Corporation. 34332332B333233TTqQU@@qL[9P 0![9"  % TT$M'U@@$L[9P*% TTN'U@@NL[9P lT|#'U@@L[9\Pages 4 =343-3TT$B'U@@$L[9P-TTC\'U@@CL[9P TX]'U@@]L[9P1032T 'U@@L[9x require information f243222M233T, 'U@@ %L[9rom ALL clinic sites requesting EAPC 3L=33.3..3.2432.24===B![9"  Tt* U@@}1L[9funding, including newly eligible clinic sites. 333333.333333A-3433.3..3.TT * U@@ }L[9P 0![9"  % TT$MU@@$L[9P*% TTNU@@NL[9P lT U@@"L[9All signatures must be in blue ink=.43323.M3-3233332/TT  U@@ L[9P.TT B U@@ L[9P 2![9" % Ld^ 5 ^  !??%  % TT8U@@LaP 3!a"  T|c U@@La\Due dateB83833TTd U@@dLaP 2!a"  % TT<U@@L[9P 1 T\ U@@-L[9Applications must be received by 5:00 p.m. on=33.333.M3-323-3-333-3333L32T 1 U@@  L[9` April 30=233Tl2  U@@2 L[9X, 200333TX J U@@ L[9P9.2TTK| U@@KL[9P 2 % Ld^659^6 !??%  % TTU@@LaP 3!a"  TU@@o La`Facsimile8333Q2TdU@@oLaT or 8#!a"  TlU@@LaXEmail=R3TTU@@LaP 2!a"  % TTU@@L[9P 1 % T,S U@@o%L[9Applications transmitted by facsimile=33.333.33-M333-3-.M3TpT \ U@@T oL[9X (FAX)8<>T]  U@@] o L[9` or email32L3Tp l U@@ oL[9X will B% Tpm U@@m oL[9Xnot be8883% T(U@@o L[9` accepted.3..3333TT)XU@@)oL[9P 0 TTU@@L[9P 3 % Ld^5^ !??%  % TTXU@@DLaP 3!a"  TWU@@ La`EAPC Web >@>BW38!a"  Td~+U@@LaTsite33TT+U@@LaP 2!a"  % TTXU@@EL[9P 1 % T[KU@@CL[9This document may be viewed and downloaded from the EAPC Web site: 93.32.3M32M3-33-3A3333333A4333333M33===BZ23.3 % T+U@@9L[9http://www.dhcs.ca.gov/services/rural/Pages/EAPCPage.aspx88HGI88323387233$2333$8$3=3833>@>B=3833383'% Ld!*!s !??% (&R WMFC0 0 TT+U@@L[9P TT4+U@@L[9P TT5f+U@@5L[9P 2 % TT.U@@L[9P 1 TTU@@L[9P 3 % Ld^5^ !??%  % Ld[8[ !??% " % ( 666666666666666666666666666666666666 6 66 6  6 66 6  6 66 6  6 66 6  6 66 6 66666666666666666666  ~.@"Arial- 2 A ~State of t2 gF~California EAPC Renewal82 `~ =2 !~Primary and Rural Health Division 2 M~ |,~'g2 )A=~Department of Health Care Services Fiscal Year 202 )J~09 2 )U~-|2 )Y~202 )d~10[2 )o5~ Expanded Access to Primary Care Pro 2 )P~gram 2 )h~ |,~'@"Arial- 2 gV~1| 2 g]~ |,~'@BComic Sans MS-@BComic Sans MS-,A?.@"Arial- 2 P-=v~ |,Av?='@"Arial-,2 ] =v~APPLICANT INSTRUCTIONS 2 ]=v~ |@"Arial- 2 kZ=v~ |- @ !?8-- @ !?8-- @ !A:-- @ !A:-- @ !9?=-- @ !9A=-- @ !?z-- @ !?v-- @ !Av-- @ !Av-- @ !)E:-- @ !)E8-- @ !)Ez-- @ !)Ev-- 2 A:~ |,A?:'- 2 x~ |- @ !n8-- @ !r8-- @ !n:-- @ !n:-- @ !n=-- @ !r=-- @ !VnB-- @ !VrB-- @ !n-- @ !r-- @ !n-- @ !r-- @ !nv-- @ !nz-- @ !rv-- 2 A:~ |,A?:'-2 A:~Purposee- 2 s:~ |,A?:' 2 x~ |2 Xx~The purpose of this application is to provide instructions and forms necessary to apply  @"Arial- @"Arial- - -2 x~for - 2 x~renewede - 2 x~ |-C2 %x~EAPC funding for fiscal year (FY) 200  2 x~9| 2 x~-|2 x~202 x~10 2 x~.| 2 x~ | 2 x~ | 2 x~ | 2 x~ |s2 Ex~All clinics must continue to operate under the provisions and requirel (2 x~ments set forth in 2 x~the EAPC   @ Arial- -I2 )x~Request for Application Fiscal Years 2007   2 x~-|2 x~2010- @ !- 42 x~, i.e., clinic and patient -2 Px~population criteria, billing processes, type of service, redistribution criteria- 2 /x~.|- 2 3x~ | 2 x~ |,Ax?'- @ !-- 2 A:~ |,A?:'2 A:~Format e ,A?:'2 A :~assembly  ,A?:'2 +A:~and ,A?:'2 9A :~submission  2 9:~ |,A?:' 2 GA:~ |,A?:'- 2 x~ |-2 x~Submit a 72 x~pplications in typewritten fo 2 dx~rm -2 sx~ onlyt-2 x~.  2 x~A| D2 &x~ssemble the application including all  2 Sx~required forms and documents in the order listed on the Application Checklist (page    2 hx~ |2 +x~102 + x~). Clearly 2 + x~Paginate lb2 +:x~each page number in the upper right corner and staple the  J2 9*x~completed packet in the upper left corner. 2 9 x~ Include >2 9"x~only the information requested in  -%2 Hx~this application."2 Hx~ Please do not- 2 HFx~ |-Y2 HI4x~return the application in a special cover or binder. 2 HYx~ | 2 Vx~ |,Ax?'-2 d x~Mail the @ Arial- -2 dx~original- @ !-e- -%2 dx~ application and -2 dTx~one copy- @ !7eT- -22 dx~ to the following address:  2 dx~ | 2 rx~ |@"Arial- P2 .x~California Department of Health Care Services   2 x~ |2 x~Expanded:2 x~ Access to Primary Care Program  2 yx~ |2 x~MS 8501d  2 x~ |"2 x~P.O. Box 997413 2 x~ |)2 x~Sacramento, CA 95899  2 x~-|2 x~7413 2 0x~ | 2 x~ |-2  x~Overnight %2 x~ Delivery Address8 2 3x~:| 2 7x~ | 2 x~ |- P2 .x~California Department of Health Care Services   2 x~ |F2 'x~Expanded Access to Primary Care Program  2 yx~ |=2 !x~1501 Capitol Avenue, Ste. 71.6044r 2 Mx~ |2 x~MS 8501d  2 x~ |"2 x~Sacramento, CA  2 x~958140 2 x~ |- 2 )x~ |- @ !-- 2 8A:~ |,A?:'2 FA :~Instructions 2 F:~ |,A?:' 2 UA:~ |,A?:'-2 8Qx~Currently funded corporations must complete the forms as described. Refer to the      P2 G.x~top of each form for completion instructions.    2 Gx~ | 2 Ux~ |@Symbol-- 2 dx~|- 2 dx~ |42 dx~Page 3 requires information 2 d_ x~ specifically72 dx~ regarding the Corporation.   2 d;x~ |,Ax?'- 2 sx~|- 2 sx~ |2 sx~Pages 4  2 sx~-| 2 sx~ |2 sx~10,2 s x~ require information f C2 s%x~rom ALL clinic sites requesting EAPC a   ,Ax?'U2 1x~funding, including newly eligible clinic sites. e  2 x~ |,Ax?'- 2 x~|- 2 x~ |>2 "x~All signatures must be in blue ink  2 |x~.| 2 x~ |,Ax?'- @ !,-- 2 A:~ |,A?:'2 A:~Due date  2 v:~ |,A?:'- 2 x~ |O2 -x~Applications must be received by 5:00 p.m. on  2  x~ April 302 x~, 200a2 x~9. 2 x~ |- @ !-- 2 A:~ |,A?:'2 A :~Facsimile 2 z:~ or ,A?:'2 A:~Emaila  2 b:~ |,A?:'- 2 x~ |-C2 %x~Applications transmitted by facsimile  2 fx~ (FAX)2  x~ or email 2 x~ will  -2 x~not be-2  x~ accepted. 2 1x~ | 2 x~ |- @ !-- 2 A:~ |,A?:'2 A :~EAPC Web   ,A?:'2 !A:~site 2 !W:~ |,A?:'- 2 x~ |-p2 Cx~This document may be viewed and downloaded from the EAPC Web site:         -a2 !9x~http://www.dhcs.ca.gov/services/rural/Pages/EAPCPage.aspx   - @ !k"- 2 ! x~ | 2 ! x~ | 2 !x~ |- 2 /x~ | 2 >x~ |- @ !-- @ !@-'"System-~~~~~~~~~~~~}}}}}}}}}}}}}}}}||||||||||EAPC Renewal ApplicationBR)http://www.ffiec.gov/geocode/default.htm".,http://aspe.hhs.gov/poverty/08povertns:ds="http://schemas.openxmlformats.org/officeDocument/2006/customXml"/>w>ffice/2006/metadata/longProperties"/>Document ID GeneratPropertiesR12WCWLQ==2 OA OAItem vJPropertiesV ?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&')*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrsuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F OAData (1Tablet=WordDocumentNSummaryInformation(DocumentSummaryInformation8 CompObjqMsoDataStore OA OA , !"#$%&'()*+2-/01;3456789:Z<=>?@ABCDEFGHIJKLMNOPQSTUWXY[\]^_`abcdefghi  FMicrosoft Office Word Document MSWordDocWord.Document.89q ds:itemID="{9D220246-AF47-4286-A33A-18FB3565C33E}" xml4OU2OUOCFLLQICA==2 OA OAItem  PropertiesRIU4KONWXDP==2 OA OAItem  Properties YTMSRS0A3DU5NA==2 OA OAItem .on="Contact Name is a site column created by the Publishing feature. 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