FORM - HRSA FORHP COVID-19 Data Report

OMB No.: 0906-0056

Expires: 04/30/2024

Rural Health Clinic COVID-19 (RHC COVID-19) Reporting Portal

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of Rural Health Clinic (RHC) organizations, number of COVID-19 tests conducted, and the types of allowable RHC services provided with RHC COVID-19 Testing funding. FORHP will use these data to show how RHC COVID-19 Testing funding is used. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0056 and it is valid until 04/30/2024. This information collection is required to obtain or retain a benefit (FY 2020 Paycheck Protection Program and Health Care Enhancement Act- P.L. 116-139; FY 2021 American Rescue Plan Act- P.L. 117-2). Public reporting burden for this collection of information is estimated to average 0.33 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

URLs
RHCCovidReporting.com
RHCCovidReporting.org
Title of Webpage
Rural Health Clinic COVID-19 Reporting Portal
Page 1 - Splash Page (Introduction + Public Burden Statement + Eligibility + Privacy Statement)
Welcome to the Rural Health Clinic COVID-19 Reporting Portal
This portal is the official reporting website for the Rural Health Clinic COVID-19 Testing and Mitigation (RHCCTM) Program (allocated June 2021) and the Rural Health Clinic COVID-19 Testing (RHCCT) Program (allocated May 2020). You are required by the Rural Health Clinic COVID-19 Testing Program Terms and Conditions and the Rural Health Clinic COVID-19 Testing and Mitigation Program Terms and Conditions to report required data on this website if your organization received funding. If you do not know if your organization received funding please visit our FAQ page for next steps. Please click CONTINUE below to login/register:
Public Burden Statement
The purpose of this data collection system is to collect aggregate data on the number of Rural Health Clinic (RHC) organizations, number of COVID-19 tests conducted, number of COVID-19 positive tests, number of at-home COVID-19 tests distributed, and the types of allowable RHC services provided with RHC COVID-19 Testing Program funding and RHC COVID-19 Testing and Mitigation Program funding. FORHP will use these data to show how RHC COVID-19 Testing Program and RHC COVID-19 Testing and Mitigation funding is used. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0056 and it is valid until 04/30/2024. This information collection is required to obtain or retain a benefit (FY 2020 Paycheck Protection Program and Health Care Enhancement Act- P.L. 116-139; FY 2021 American Rescue Plan Act- P.L. 117-2). Public reporting burden for this collection of information is estimated to average .33 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
Privacy Act Statement
The following statement serves to inform you of the purpose for collecting personal information required by the RHCCovidReporting.com and how it will be used.
AUTHORITY: Paycheck Protection Program and Health Care Enhancement Act (Public Law No: 116-139) and American Rescue Plan Act (Public Law No: 117-2). This page is managed by the National Association of Rural Health Clinics under cooperative agreement G27RH42182 with the Federal Office of Rural Health Policy, Health Resources and Services Administration (HRSA).
PURPOSE: To collect information per the requirements as specified in the terms and conditions for the “Rural Testing Relief Fund,” also known as the RHC COVID-19 Testing Program and to collect information per the requirements as specified in terms and conditions for the “Rural Health Clinic COVID-19 Testing and Mitigation Program” This reporting system does not replace any other reporting requirements that RHC organizations may have with respect to COVID-19, such as those required for public health surveillance purposes.
ROUTINE USES: The information collected will be used by HRSA to monitor and assess the effectiveness of the funding provided to RHCs for COVID-19 testing and related expenses.
DISCLOSURE: Mandatory. RHCs that kept the RHC COVID-19 Testing Funds, or the RHC COVID-19 Testing and Mitigation funds, are expected to provide information monthly.
CONTINUE Button
Page 2
You must be registered to use this site.
Register [button]
If you are already registered, please click on the LOGIN button below to sign into your profile.
Login [button]
Page 3 – Registration
You must register to use this site for your RHC COVID-19 Testing and Mitigation Program and RHC COVID-19 Testing Program Report Once you register, you will receive a confirmation email from RHCcovidreporting@narhc.org with a link to activate your account. Save RHCcovidreporting@narhc.org in your contacts to make sure you receive the confirmation email. You will be locked out of RHCcovidreporting.com for a period of time if you attempt to login before you activate your account. You may register only one TIN per email address. If you need to register multiple TINs, you must use a separate email address for each TIN.
[Standard 2 factor authentication sign-in/registration]1
Page 4 – Profile Creation
NEW USERS 1. Complete and submit the form below. 2. Complete monthly testing data entry.
RETURNING USERS 1. Update and/or confirm the information on this page and submit. 2. Complete monthly testing data entry.
RHC COVID-19 Testing and Mitigation Program
As a part of the Rural Health Clinic COVID-19 Testing and Mitigation (RHCCTM) Program, the Health Resources and Services Administration (HRSA) within the Department of Health and Human Services (HHS) allocated $100,000.00 to each eligible Rural Health Clinic (RHC). Organizations that own multiple RHCs received $100,000.00 times the number of eligible RHCs they own. This money was allocated to organizations through their tax identification number (TIN). For the purposes of this report, please provide data at the organization (as represented by the TIN) level. Please create your Profile by entering your organization information below. You will be able to edit your Profile if there are any changes during the reporting period. The website only accepts one TIN organization per account. Individuals who represent multiple TIN organizations will need to create additional accounts with separate email addresses. Organizations must spend all of the RHCCTM Program funds or identify allowable, otherwise unreimbursed incurred expenses by December 31, 2022. Reporting on the RHCCTM Program is required through January 2023.
RHC COVID-19 Testing Program
As a part of the Rural Health Clinic COVID-19 Testing (RHCCT) Program, HHS, allocated $225 million among all eligible RHCs$49,461.42 for each eligible RHC. Organizations that own multiple RHCs should have received $49,461.42 times the number of eligible RHCs they own. Organizations must spend all of the RHCCT Program funds or identify allowable, otherwise unreimbursed incurred expenses by December 31, 2021. Reporting on the RHCCT Program is required through January 2022.
Please enter the Tax Identification Number of the organization that received the RHC COVID-19 Testing and Mitigation Program and/or RHC COVID-19 Testing Program funds
[validated answer]
Please enter the name and address of the TIN organization
[Name Address Line 1 Address Line 2 City State Zip Code]
Please enter the CMS Certification Number(s) – also known as CCN/PTAN number(s) – for each RHC associated with this TIN organization
CMS # [6 digit validation]
[Dropdown Menu]
Independent/Freestanding
Provider Based/Hospital Owned
Do you have another CCN/PTAN number?
Add [button] 2
Remove [button]
Does your TIN organization have a testing location?
Yes
No
Please enter the name and address of any/all testing location(s) your TIN organization operates. (If you are providing testing in a temporary structure, such as in the parking lot of the hospital, please provide the most reasonable address for such testing)
[Location 1 Name Address Line 1 Address Line 2 City State Zip Code]
Add [button]3
Remove [button]
*If you edit your TIN within your profile, you will need to re-enter any previously entered testing data.”
Page 5 – Testing or Testing Related Expenses
For what COVID-19 testing or testing related purpose(s) has your TIN organization used RHC COVID-19 Testing or RHC COVID-19 Testing and Mitigation Program funds? Please select all activities that took place in July 2021, August 2021, September 2021: Building or construction of temporary structures Leasing of properties Retrofitting facilities to support COVID-19 testing Planning for implementation of a COVID-19 testing program Procuring equipment or supplies to provide testing Purchasing personal protective equipment (PPE) Training providers and staff on COVID-19 testing procedures Items and/or services furnished to an individual that results in an order or the administration of COVID-19 testing Staff time and salary associated with COVID-19 testing Other expenses to secure and maintain personnel to carry out testing (bonuses, retention payment, childcare, transportation, housing, etc.) Other activities related to testing [Text box] please provide a short description: ___________ Did not spend program funds on testing this quarter
Page 6 – Mitigation and Mitigation Related Expenses
For what COVID-19 mitigation or mitigation related purpose(s) has your TIN organization used RHC COVID-19 Testing and Mitigation Program funds? Please select all activities that took place in July 2021, August 2021, September 2021: Planning for implementation of COVID-19 mitigation efforts Develop and implement systems to deal with supporting needs of patients with long COVID Develop and implement policies and procedures to keep staff and patients healthy Maintain healthy environments for staff and local communities Implement strategies to address employee stress and burnout Investigate COVID-19 cases and conduct contact tracing Retrofit facilities or construct temporary structures to support mitigation efforts Equipment purchase to support mitigation  Use of digital technologies to strengthen RHC response to COVID-19 Supporting referrals to testing, clinical services and other supports to mitigation strategies Training providers and staff on COVID-19 mitigation Supporting personnel responsible for mitigation activities through bonuses, temporary housing, etc. Community education efforts Other activities related to mitigation [Text box] please provide a short description: ___________ Did not spend program funds on mitigation this quarter
Page 7 - At-Home COVID-19 Test Kits
At-home (i.e., home collection; direct-to-consumer; over-the-counter) COVID-19 test kits are allowable expenses for the RHC COVID-19 Testing Program and the RHC COVID-19 Testing & Mitigation Program. Please report any test kits distributed for free by your RHC to your community and/or patients. RHCs are not required to use the RHCCTM funding for at-home COVID-19 test kits and may skip this page if not applicable. These test kits should not be counted in the total tests administered or positive tests on the following page. If your RHC offers at-home test kits, your RHC should ensure the following safeguards: (1) free COVID-19 testing is offered to all who request it, regardless of insurance coverage or lack thereof; (2) individuals who receive positive test results should be instructed to consult with a health care professional and would not be referred/directed to the RHC or to any other specific provider as an effort to generate new patients to your RHC; (3) the RHC would not offer special discounts or any other free or discounted items or services to those who received free COVID-19 testing; (4) no payor, including the beneficiary, a commercial insurance company, or a Federal health care program, would be billed for or pay any costs in connection with the COVID-19 testing services; and (5) the COVID-19 tests are cleared or approved by the Food and Drug Administration (FDA), are subject to an FDA-issued Emergency Use Authorization, or are covered by the Medicare program. Please read and follow additional U.S. Health and Human Services Office of the Inspector General (OIG) Coronavirus Disease 2019 (COVID-19) Public Health Emergency FAQs found here.
Month		# of Distributed At-Home COVID-19 Test Kits
May 2020
June 2020
July 2020
August 2020
September 2020
October 2020
November 2020
October 2020
December 2020
January 2021
February 2021
March 2021
April 2021
May 2021
June 2021
July 2021
August 2021
September 2021
Page 8 -Testing Data
Reporting If you received RHC COVID-19 Testing and Mitigation Program funding you must report monthly with data from June 2021 to December 2022. If you received RHC COVID-19 Testing Program funding you must report monthly with data from May 2020 to December 2021. If you received BOTH, you must report monthly with data from May 2020 to December 2022. Months are reported when the month ends (i.e., report June data in July). Every field requires an entry, you should enter a 0 for each month in which you did not yet need to report data or in which you have no data to report.
Testing is defined in the RHC COVID-19 Testing and Mitigation Program and the RHC COVID-19 Testing Program Terms and Conditions. The specimen collection portion of a test counts as a test for the purposes of this report. Testing includes all viral test to diagnose active COVID-19 infections, antibody tests to diagnose past COVID-19 infections, and other tests that the Secretary and/or Centers for Disease Control and Prevention determines appropriate in guidance.
How many tests has your TIN organization conducted in the selected month? Provide the most accurate count possible for “# of Tests.” Estimate to the best of your ability the number of tests in the selected month.4
For TIN: [corresponding TIN #]
Month	# of Tests		# Positive Tests
May 2020
June 2020
July 2020
August 2020
September 2020
October 2020
November 2020
December 2020
January 2021
February 2021
March 2021
April 2021
May 2021
June 2021
July 2021
August 2021
September 2021
Update [button]
Page 9 – RHCCT Program Closeout
The period of availability for the Rural Health Clinic Testing (RHCCT) Program was January 27, 2020 through December 31, 2021. In the below question, select the most appropriate response to closeout your TIN organization reporting requirements for the RHCCT Program funds ($49,461.42 per RHC). If you have remaining RHCCT Program funds, but have not returned the remaining amount to HHS, you can view full and partial return instructions here.
I am reporting for TIN: 00-0000000
Please select one of the following responses: (Fully spent) This TIN spent all of the funds or can identify allowable, otherwise unreimbursed incurred expenses for the entire RHCCT Program payment of $49,461.42 per RHC between January 27, 2020 and December 31, 2021. (Partially spent and completed partial return) This TIN did not spend all of the funds or identify allowable, otherwise unreimbursed incurred expenses for the entire RHCCT Program payment of $49,461.42 per RHC between January 27, 2020 and December 31, 2021, and completed the partial return process for the remaining amount of funds. (Fully returned) This TIN completed the full return process for the RHCCT Program payment of $49,461.42 per RHC. (Funds remaining and have not completed full or partial return) This TIN did not spend all of the funds or identify allowable, otherwise unreimbursed incurred expenses for the entire RHCCT Program payment of $49,461.42 per RHC between January 27, 2020 and December 31, 2021, and will complete the full or partial return process by March 2, 2022. (Not applicable) This TIN did not receive the RHC COVID-19 Testing Program payment of $49,461.42 and only received the RHC COVID-19 Testing and Mitigation Program payment of $100,000 per RHC.
Signature [electronic signature field]
Date [pre-populated field]
Before you submit the form, PRINT this page for your records
[If response 1 is selected --- reporting entities will see the following language appear] Thank you for your diligent reporting on the RHC COVID-19 Testing Program. This concludes your reporting requirements for the RHC COVID-19 Testing Program; however, you must maintain appropriate records and cost documentation according to the RHCCT Program Terms and Conditions. If your organization received the RHC COVID-19 Testing and Mitigation (RHCCTM) Program payment ($100,000 per RHC issued in 2021), your TIN must continue reporting on the RHC COVID-19 Reporting Portal (RHCcovidreporting.com) monthly through January 31, 2023. Please contact rhccovidreporting@narhc.org with any questions.
[If response 2 is selected --- reporting entities will see the following language appear.] Thank you for your diligent reporting on the RHC COVID-19 Testing Program. If you have returned the remaining RHCCT Program funds, this concludes your reporting requirements for the RHC COVID-19 Testing Program; however, you must maintain appropriate records and cost documentation according to the RHCCT Program Terms and Conditions. If your TIN received the RHC COVID-19 Testing and Mitigation (RHCCTM) Program payment ($100,000 per RHC issued in 2021), your TIN must continue reporting on the RHC COVID-19 Reporting Portal (RHCcovidreporting.com) monthly through January 31, 2023. Please contact rhccovidreporting@narhc.org with any questions.
[If response 3 is selected --- reporting entities will see the following language appear.] If you returned the entire RHC COVID-19 Testing Program payment, this concludes your reporting requirements for the RHC COVID-19 Testing Program. If your organization received the RHC COVID-19 Testing and Mitigation (RHCCTM) Program payment ($100,000 per RHC issued in 2021), your TIN must continue reporting on the RHC COVID-19 Reporting Portal (RHCcovidreporting.com) monthly through January 31, 2023. Please contact rhccovidreporting@narhc.org with any questions
If response 4 is selected --- reporting entities will see the following language appear. Thank you for your diligent reporting on the RHC COVID-19 Testing Program. To remain in compliance with RHC COVID-19 Testing Program requirements, you must return the full or partial remaining amount of RHC COVID-19 Testing Program funds by following the return process by March 2, 2022. Please contact rhccovidreporting@narhc.org with any questions.
If response 5 is selected --- reporting entities will see the following language appear. If your TIN received the RHC COVID-19 Testing and Mitigation (RHCCTM) Program payment ($100,000 per RHC allocated in 2021), your TIN must continue reporting on the RHC COVID-19 Reporting Portal (RHCcovidreporting.com) monthly through January 31, 2023. Thank you for your diligent reporting. Please contact rhccovidreporting@narhc.org with any questions.
Page 10 – Confirmation of Closeout
Your response was successfully submitted for TIN:
00-0000000
Thank you!
Please check your email for a confirmation of your submission. The email will come from “Rural Health Clinic COVID-19 Testing (RHC CTR)”. If you have not received the email within a few minutes, please check your JUNK or SPAM folders. If you have questions about the delivery of the confirmation email, please contact support@lan2wan.com. [Email confirmation of submission set to corresponding email of TIN and includes the language of the selected response.]
Page 11 - Thank You for Reporting
Thank you for reporting your test data. Please remember to report your data each month until instructed otherwise by the Health Resources and Services Administration of the U.S. Department of Health and Human Services, visit https://www.hrsa.gov/coronavirus/rural-health-clinics/testing/important-dates for more information on reporting timelines
Links at bottom of each page:
For more information click on the links below:
Rural Health Clinic COVID-19 Testing and Mitigation (RHCCTM) Program (Health Resources and Services Administration): https://www.hrsa.gov/coronavirus/rural-health-clinics/testing
Coronavirus Disease (COVID-19)– Federal Office of Rural Health Policy (Health Resources and Services Administration): https://www.hrsa.gov/rural-health/coronavirus
National Association of Rural Health Clinics: https://www.narhc.org
Rural Health Clinic COVID-19 Testing and Mitigation Program Terms and Conditions: https://www.hrsa.gov/sites/default/files/hrsa/ruralhealth/rhc-testing-mitigation-terms-conditions.pdf
Rural Testing Relief Fund Terms and Conditions: https://www.hhs.gov/sites/default/files/terms-and-conditions-rural-testing-relief-fund.pdf
Copyright ©2020 All Rights Reserved OMB Number (0906-0056) Expires 04/30/2024

Acronym List:
CCN	Centers for Medicare & Medicaid Services Certification Number
PTAN	Provider Transaction Access Number
RHC	Rural Health Clinic
RHC CTR	Rural Health Clinic COVID-19 Testing Report
TIN	Tax Identification Number

1 Automated password recovery process available

2 Ability to add up to 30 CCN/PTAN

3 Ability to add as many locations as necessary

4 Month available at the completion of applicable month