Certificate Of Eligibility - Division Of Policy And Shortage Designation Bureau Of Health Workforce, Health Resources Services Administration Page 2

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Rural Health Clinic Information
(Please complete all items)
RHC Provider Number:
Rural Health Clinic Name
Address
City
State
Zip Code
National Health Service Corps Components
(Please check all that apply)
The above Rural Health Clinic:
Provides Primary Care, Dental, or Mental Behavioral Health Services.
Provides services regardless of a patient's ability to pay.
Offers discounted fees to patients who qualify.
Accepts patients covered by Medicare, Medicaid, and State's Children's Health
Insurance Program (SCHIP).
Do you have a pending Recruitment and Retention (R & R) application with NHSC?
Yes
No

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