Utilizing the HRSA Form 5A Self-Assessment Worksheet to Complete Form 5A

As outlined by “Chapter Four – Required and Additional Health Services” of the Health Resources and Services Administration (HRSA) Health Center Program Compliance Manual (Chapter Four – Required and Additional Health Services), ensuring the accuracy of Form 5A is essential for health centers to demonstrate compliance.  The HRSA Form 5A Self-Assessment Worksheet (Self-Assessment Worksheet for Form 5A: Services Provided) is a valuable tool that helps to streamline the process of completing Form 5A.  Below are some tips on how to effectively utilize the Form 5A Worksheet to facilitate the smooth and accurate completion and ongoing review of Form 5A. 

• Understand the Purpose:  Form 5A outlines the Required, Additional and any Specialty Services provided by the health center, within the health center’s scope of project.  Additionally, Form 5A reflects the manner in which services are delivered, which may be directly (Column I), through formal written contracts (Column II), and through formal written referral arrangements (Column III). The Form 5A Self-Assessment Worksheet is a structured document developed by HRSA that corresponds to the sections of Form 5A in the HRSA Electronic Handbooks (EHB) and is designed to guide health centers through the process of gathering and organizing the required information.
• Gather Information: The completion of the Form 5A Self-Assessment Worksheet requires information from various sources including staff, formal written contracts for Column II services and formal written referral arrangements for Column III services.  Additionally, completion of the Form 5A Self-Assessment Worksheet will require a review of the staffing profile to identify any services that may be provided by 1099 individual contractors.
• Utilize the Service Descriptors: The Service Descriptors for Form 5A: Services Provided (Services Provided Descriptors) outline what elements are included for a particular service.  In the case of Required Services, the descriptors provide a “floor” for what services/procedures, at a minimum, may be included.  Additional Service Descriptors provide details as to what may, but is not required to be, included for a specific service.  The Service Descriptors for Form 5A: Service Delivery Methods (Service Delivery Method Descriptors) outline the description and specific requirements for each of the three service delivery methods.
• Complete the Worksheet: Utilize the Form 5A Worksheet as a checklist to ensure all necessary information has been collected.  Complete the worksheet, following the instructions and guidance provided, to ensure proper completion of the corresponding section(s) in Form 5A.
• Review and Revise: Once completed, review the document and corresponding information to ensure consistency and accuracy.  Questions regarding any potential inaccuracies can be submitted through the Bureau of Primary Health Care Contact Form (BPHC Contact Form ) or via the health center’s Point of Contact (POC).

It is important to remember that a review of Form 5A should be completed on an ongoing basis.  As a health center adds services and staff, Form 5A will change.  By utilizing the HRSA resources available, including the Form 5A Self-Assessment Worksheet, the process can be simplified, contributing to the overall efficiency and quality of health care services.