New York "State 30" Program Application Cover Sheet Page 2
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3IV. SERVICES TO THE MEDICALLY INDIGENT
The purpose of this section is to determine the amount of services that are, or will be, provided annually to medically indigent patients
by the physician listed in Section I at the worksite listed in Section III.
Please estimate the number of patient visits, by source of payment, for the actual physician listed in Section I for the most recent 12-month
period for which data is available. Indicate the 12-month period below.
If the physician for whom the waiver is requested is NOT currently employed at the site listed in Section III, please estimate visit data
based on visits provided by one currently or recently-employed physician practicing in a similar specialty at the site listed in Section III.
IF THAT IS NOT POSSIBLE, THEN estimate visits provided by one currently or recently-employed physician practicing in a similar specialty
at another similar site.
INCLUDE PATIENT VISITS FOR THE PHYSICIAN ONLY ; DO NOT LIST ALL VISITS FOR THE SITE OR FACILITY. Please answer questions 1-3
as accurately and specifically as possible.
Source of Payment
Number of Visits to Physician
1. MEDICAID (e.g., Medicaid, Medicaid FFS, Medicaid Managed Care, HMO/PHSP Medicaid,
including Child Health Plus and Family Health Plus)
2. PARTIAL SELF-PAY or FREE (e.g., Sliding Scale, Partial Fee, or Free)
3. ALL OTHERS (e.g., Medicare, Medicare Managed Care, Commercial, Other Managed Care,
Workers Compensation, No-fault, Government, Blue Cross/Blue Shield, HMO/PHSP, Full Self-Pay, Other)
4. TOTAL 1 + 2 + 3 =
0
CHECK ONE
Visit data above refers to services provided by actual physician for which the waiver is requested.
Visit data above refers to services provided by another physician in a similar specialty at the site listed in III above.
Visit data above refers to services provided by another physician in similar specialty at another, similar site.
12-month period for above data ____________________________________________________________________________
Name ______________________________________________________________________
Source/contact for above data
–
–
Phone Number
1. Is the physician listed in Section I filling a vacant position at the site?
Yes
No
If yes, for how long was the position vacant? _________ months
2. Is the physician proposing to practice at least 40 hours per week in a HPSA or MUA? (Check one:)
Yes
Indicate the HPSA/MUA/MUP name(s) below. Ignore Section V.
HPSA(s) _________________________________________________________________________________
MUA/P(s) _________________________________________________________________________________
No
Go to Section V.
DOH-4371 (8/16) Page 2 of 3
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