2 Patient Travel Miles Saved

5.Patient Travel Miles Saved
Complete Form 4. Volume of Services, by Site and Specialty before inputting data in this form. Only include sites that are supported with BHI EB TNP funding. For the table below, capture the service provided, total miles saved, and the number of encounters by each service provided. If the miles are in decimals, round to the nearest whole number.
	Patient Travel Miles Saved
	Primary Service Provided to Patient / Specialty	Total Miles Saved	Total Encounters
	TOTAL	0	0
	Patient Travel Miles Saved Form Comments

5.Patient Travel Miles Saved
Complete Form 4. Volume of Services, by Site and Specialty before inputting data in this form. Only include sites that are supported with BHI EB TNP funding. For the table below, capture the service provided, total miles saved, and the number of encounters by each service provided. If the miles are in decimals, round to the nearest whole number.
	Patient Travel Miles Saved
	Primary Service Provided to Patient / Specialty	Total Miles Saved	Total Encounters
	Behavioral Health	65,351	122
	Substance Use Disorder	49,832	109
	Opioid Use Disorder	223,564	469
	TOTAL	338,747	700
	Patient Travel Miles Saved Form Comments

Public Burden Statement: The purpose of this collection is to collect performance and clinical measures for the Behavioral Health Integration (BHI) Evidence Based Telehealth Network Program (EB-TNP). 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-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (42 U.S.C. 254c-14). Data will remain private to the extent allowed by the law. Public reporting burden for this collection of information is estimated to average 5 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov.  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.