HRSA Form 5A Services Provided: Submission via Change in Scope

To fill out HRSA Form 5A, open your center’s current form in the HRSA Electronic Handbooks, confirm each service you provide is listed under the right delivery column, gather the contracts or referral agreements that back up those entries, and submit any additions, deletions, or delivery changes through a Change in Scope (CIS) request. The form is the official record of your Health Center Program scope of project, and every service on it must match how care is actually delivered. Services that aren’t on the form sit outside your approved scope, which affects both compliance and Federal Tort Claims Act (FTCA) malpractice coverage.¹

Find Your Current Form 5A in the EHBs

Any edit starts from the version HRSA already has on file. Log into the Electronic Handbooks, open the Grants tab, locate your H80 awardee or look-alike number on the right, select Grant Folder, then under Approved Scope on the left choose Services. What loads is your currently approved scope: the services HRSA recognizes and the delivery columns tied to each.²

Compare that record against what your center actually does. Gaps in either direction — a service you deliver that isn’t listed, or a listing you no longer support — are what the CIS process exists to correct.

Work Through the Service List

Form 5A groups services into three categories, all grounded in Section 330 of the Public Health Service Act.³

Required Services

Every health center must provide the baseline of required primary health services: general primary medical care (family medicine, internal medicine, pediatrics, obstetrics, gynecology), diagnostic laboratory and radiology, preventive services including immunizations and prenatal and postpartum care, emergency coverage during and after hours, pharmaceutical services as appropriate, referrals for services not offered directly, and patient case management and enabling services. These appear pre-printed on the form. Your task is to indicate how you deliver each one, not whether to include it.³

Additional Services

Additional services are elective offerings your center provides based on community need. Once one is listed, it carries the same compliance and reporting obligations as a required service. The current service descriptors recognize additional dental services, behavioral health (mental health and substance use disorder services), optometry, recuperative care, environmental health, nutrition, occupational therapy, physical therapy, speech-language pathology or therapy, and complementary and alternative medicine.⁴

Adding any of these to your scope requires a formal CIS request.

Enabling and Supportive Services

The additional enabling and supportive services category covers the non-clinical supports that help patients reach and use care: case management, eligibility assistance for Medicaid and other programs, health education, outreach, transportation, and translation and interpretation for patients with limited English proficiency or communication-related disabilities. These don’t generate traditional clinical visits, but listing them keeps them inside your funded scope and covered by your compliance framework.⁴

Pick the Right Delivery Column

For every service, you check one or more of three delivery columns. Each column carries different documentation, financial, and legal implications, so accuracy here matters as much as the service list itself.⁵

Column I: Direct

Column I is for services delivered by the center’s own salaried employees, including National Health Service Corps staff. The center holds full clinical and administrative control. This is the default for core primary care performed by your payroll providers at your approved sites.

Column II: Formal Written Contract or Agreement

Column II applies when another entity delivers the service on your center’s behalf under a written contract, and your center pays for or bills for that care. The contract must address, at a minimum, how the service will be documented in the patient’s health center record, how the center will pay for or bill for the service, and how the center’s policies (including the sliding fee discount program) will apply to the contracted care.⁵

The sliding fee point trips up many centers. Your discount schedule has to reach the contracted service, not stop at the clinic door.⁶

Column III: Formal Written Referral Arrangement

Column III covers services delivered by an outside entity where the health center does not pay for the care. You refer the patient under a formal written arrangement — a memorandum of understanding, memorandum of agreement, or equivalent. The agreement must describe how referrals are made and managed, how patients are tracked, and how they are referred back for follow-up. Information from the referral visit has to return to the center and enter the patient record. During site visits, HRSA looks for operating procedures showing your tracking process and will sample up to three written referral arrangements per service.⁷

Contract and referral arrangements for non-clinical services like transportation or outreach don’t need patient record documentation or follow-up tracking; those requirements apply only to clinical care.²

Assemble the Documentation Before You Submit

A CIS request stalls without the paperwork behind it. Before you start, pull together:

For Column II services, the signed contract with provisions for patient record documentation, payment or billing terms, and application of your sliding fee schedule.
For Column III services, the executed referral agreement describing the referral process and how patient information flows back to your center.
For any expired agreement, an updated version with current dated signatures. If the arrangement has ended and won’t be replaced, plan to remove the service from scope rather than refresh it.
For Column I services, verification that your providers are properly licensed and credentialed to deliver the care being listed.

HRSA publishes a Form 5A self-assessment worksheet that walks through each service category, prompts you to list the entities behind Column II and III entries, and flags common discrepancies. Running it before submission catches errors that would otherwise surface during a site visit.²

Submit Through the Change in Scope Process

Not every operational change requires a formal submission. A full CIS request is required when you add a new service to scope, delete an existing service, or add a new target population. A lighter scope adjustment CIS applies when you update a required service or modify how an existing additional or specialty service is delivered. Routine changes such as hiring a new provider for a service already in scope, or expanding an in-scope service to another approved site, don’t require a CIS.⁸

Timing

Submit at least 60 days before you want the change to take effect. HRSA issues a final decision within 60 days of receiving a complete request. Complex cases — including potential service area overlap with another health center — may run longer, but HRSA notifies you of any extension within the initial window.⁹

Certification and Review

Your center’s Authorized Official certifies the submission in the EHBs. From there it routes to your assigned HRSA Project Officer.

Approval and Implementation

Approved grantees receive a Notice of Award reflecting the updated scope; look-alikes get notification through the EHBs. The effective date corresponds to when BPHC recommends approval, not when you submitted. Once approved, you have 120 days to implement — open the site, start providing the service — and you must complete a verification step in the EHBs for any addition or deletion to be officially documented.⁹

If HRSA disapproves the request, you’ll receive an EHB notification explaining the decision. The service does not become part of your scope. Delivering it as though it had been approved creates both compliance and liability exposure.

Temporary Sites During Declared Emergencies

The standard 60-day timeline has one exception worth knowing. During officially declared emergencies (governor, HHS Secretary, or Presidential declaration), HRSA offers a streamlined process for adding temporary service sites. Without an official declaration, extraordinary circumstances can be raised with HRSA for a case-by-case determination. The temporary site still has to meet the service site requirements, and any services delivered there must already be within your approved Form 5A scope.¹⁰

Why Accuracy on Form 5A Matters for FTCA Coverage

For deemed health centers, FTCA replaces private malpractice insurance for covered acts. That protection has a hard boundary: the activity must fall within your HRSA-approved scope of project. A service a provider delivers that isn’t listed on your Form 5A likely won’t qualify for FTCA coverage. Volunteer health professionals deemed as Public Health Service employees carry the same limit — their protection extends only to services within the center’s approved scope.¹¹

A mismatch between what providers actually do and what the form says they do can leave individual clinicians personally exposed to malpractice liability. That is the single most consequential reason to keep the form current.

Cross-Check Against Form 5B and Review Annually

Form 5A records what services you provide and how. Form 5B records where — permanent locations, seasonal sites, and mobile units. Together they define your complete scope of project. When reviewing Form 5A, confirm each service is available at one or more approved Form 5B sites; delivering in-scope services at unapproved locations is a compliance gap site visitors will flag.¹²

Contracts expire, referral partners change, and service mixes evolve. Misclassifying a service — showing Column I when the work is actually contracted, or leaving a Column III referral on the books after the arrangement lapsed — can produce compliance findings, conditions on your award, corrective action plans, or restrictions on funding. Build a Form 5A review into your compliance calendar at least annually, and file a CIS promptly whenever your service delivery model shifts.²

1
Health Resources & Services Administration. Chapter 21: Federal Tort Claims Act (FTCA) Deeming Requirements
2
Health Resources and Services Administration. Health Center Self-Assessment Worksheet for Form 5A: Services Provided
3
Office of the Law Revision Counsel. 42 USC 254b – Health Centers
4
Bureau of Primary Health Care (BPHC). Service Descriptors for Form 5A: Services Provided
5
Health Resources and Services Administration. HRSA Form 5A Services Provided – Column Descriptors
6
Health Resources & Services Administration. Chapter 9: Sliding Fee Discount Program
7
Health Resources & Services Administration. Required and Additional Health Services
8
Health Resources & Services Administration. Updating Health Center Information and Scope of Project FAQs
9
Health Resources and Services Administration. Program Assistance Letter 2014-10 – Updated Process for Change in Scope Submission, Review and Approval Timelines
10
Health Resources & Services Administration. Requesting Temporary Service Sites in Response to Emergency Events: Resource and Submission Template
11
Health Resources & Services Administration. FTCA Policies and Program Guidance
12
Health Resources & Services Administration. Documenting Scope of Project