Form 4 - Community Characteristics - Health Resources And Services Administration Page 2

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Target
Target
Service Area
Service Area
Hispanic or Latino Ethnicity
Population
Population
Number
Percent
Number
Percent
will auto-
will auto-
Unreported/Declined to Report
calculate in EHB
calculate in EHB
(if applicable)
will auto-
will auto-
Total:
100%
100%
calculate in EHB
calculate in EHB
Target
Target
Income as a Percent of
Service Area
Service Area
Population
Population
Poverty Level
Number
Percent
Number
Percent
will auto-
will auto-
Below 100%
calculate in EHB
calculate in EHB
will auto-
will auto-
100-199%
calculate in EHB
calculate in EHB
will auto-
will auto-
200% and Above
calculate in EHB
calculate in EHB
will auto-
will auto-
Total:
100%
100%
calculate in EHB
calculate in EHB
Target
Target
Principal Third Party Payment
Service Area
Service Area
Population
Population
Source
Number
Percent
Number
Percent
will auto-
will auto-
Medicaid
calculate in EHB
calculate in EHB
will auto-
will auto-
Medicare
calculate in EHB
calculate in EHB
will auto-
will auto-
Other Public Insurance
calculate in EHB
calculate in EHB
will auto-
will auto-
Private Insurance
calculate in EHB
calculate in EHB
will auto-
will auto-
None/Uninsured
calculate in EHB
calculate in EHB
will auto-
will auto-
Total:
100%
100%
calculate in EHB
calculate in EHB

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