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Sites

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Thank you for your interest in serving Utah's rural and underserved populations. Please note that this application must be completed in one sitting. You may not save and come back to it later. If you have questions or concerns, please email opcrh@utah.gov.

 
 
Add  Application
  • Site Information
  • Applying Health Professionals
  • Site Description
  • Site Financial Information
  • Staffing Needs
  • Funding Sources
  • Certification
Site must be open for at least one year to be considered for the Health Care Workforce Financial Assistance Program.
 *
 *  *  *  *
 *  * ext.
Site Match Verification
Sites must agree to match 20% of the award amount in addition to the provider's salary and benefits. Sites may not reduce a provider's salary to meet the match requirement.
 *

Health Professional Shortage Area
If you are unsure of the Health Professional Shortage Area (HPSA) status for your site, please click here to look up your address. This will give you the HPSA ID number and score.

HPSA scores are listed for primary care (PC), dental health (DH) and mental health (MH). Please only enter the HPSA information for the services you provide.
 *

If your site is not located in a HPSA, please supply at least 2 letters of recommendation. Combine letters into one PDF file.

R-434-40 (10)
(4) The Department may give preference to sites that provide letters of support from the area served by the prospective employer, such as from:
(a) a majority of practicing health care professionals;
(b) county and civic leaders;
(c) hospital administrators;
(d) business leaders, local chamber of commerce, citizens; and
(e) local health departments
Sponsoring or Corporate Organization
Only fill out this section if the sponsoring agency information is different than the information of the practice site.
ext.
Additional Information
 *










If you have current or potential staff that are applying for this program, please provide their name, provider type, specialty, current/expected FTE, and the number of hours per week.

Additionally, please attach a copy of their employment agreement or contract. If he/she does not have an employment agreement, please attach a copy of the benefits package that is offered.
Provider Name Provider Type Specialty FTE Hours per Week Employment Agreement
Service Area
If your facility were to close, how long would it take your patients to reach the next healthcare facility that would provide the same services?
Facility Description
Please indicate the number of encounters for each service over the last 12 months
Please enter the encounters for each of the special population groups as a percent of the total patient encounters for the facility.
General
Please provide the following financial information for the last year
Payer Mix
Please indicate the percent of total encounters from each payer source
 *  *
 *  *
 *  *
 *
 *

                                                                                       
Number of Dentists
Number of Mental Health
Therapists
Number of Mid-Level
Practitioners
(e.g. APRN, PA, etc.)
Number of Physicians
Number of Staff Nurses
Total Current Staffing
How many of your current staff are you
requesting with this site application?
Projected New Staff Needed
How many new staff needed are you
requesting with this site application?




Please fill out the information for the individual filling out this application.
ext.
* 
 *  *
SUBMIT
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Can I annotate fields to indicate their intended use?

Yes. You can provide "Help" to your users for any field:

1. On any page in your application, click "Customize" then "Fields". If it is a multi-table application, select the table.

2. Click the "Edit" button next to the field for which you want to add an annotation.

3. In the "Help" text input box, enter text that will assist your users, and click "Save".

Your text will appear when the user hovers over or clicks on the question mark icon next to that field on the Add Record and Edit Record pages.
 
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Description
Reports and Charts Panel
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