Form B - Budget Summary– Health Care Services & Facility Operations

Existing New Facility

Source Clinic Year 1 Year 2

1 PATIENT VISITS Form C 1,685 1,825 1,825

PATIENT REVENUE
2a Medical Form D 6,195 8,508 8,763
2b Dental Form D 27,280 39,428 40,611
2c Mental Health Form D 0 0 0
2d Other Form D 0 0 0
2e Misc Form D 0 0 0
2 Total Gross Patient Revenue Add Lines 2a-2e 33,475 47,936 49,374
DEDUCTIONS FROM REVENUE
3a Contractual Adjustments ___%
3b Write-Offs / Bad Debt Expense ___%
3c Sliding Scale/Other Discounts ___%
3 Total Deductions from Revenue Add Lines 3a-3c 0 0 0

4 NET Patient Revenue Line 2 - Line 3 33,475 47,936 49,374

NON-PATIENT REVENUE
5a Local Support
State Grants to
5b State Grants KANA 121,325 50,000 50,000
5c Community Health Center Grants
AFN Wellness
5d Other Federal Grants Funds to KANA 88,426
5e Private Foundation Grants
IHS Compacts/Contracts/Tribal Shares received
5f directly by clinic
5g Contributions/Donations
5h Interest Income
5i Other
5j Rental of Clinic Building Space
5k IHS Village Based Clinic Lease Program
5l IHS Maintenance & Improvement Program
Indian Health
Allocation from Regional Health Corp or Other Service contract w/
5m organization KANA 544,502 500,000 500,000
5 Total Non-Patient Revenue Add Lines 5a -5m 754,253 550,000 550,000
6 TOTAL REVENUE Line 4 + Line 5 787,728 597,936 599,374
EXPENSES
7 Salaries & Wages Form E 250,523 258,039 265,782
8 Employee Benefits Form E 60,126 61,929 63,788
9 Travel Form E 32,634 33,614 34,621
10 Minor Equipment (items <$5,000) Form E 3,940 4,059 4,180
11 Supplies Form E 8,969 9,238 9,516
12 Contracted Services Form E 80,697 83,118 85,611
13 Other Form E 62,546 64,422 66,355
14 Facility Expenses Form G 17,008 21,261 21,898
15 TOTAL EXPENSES Add Lines 7 to 14 516,443 535,680 551,751
REVENUE OVER/(UNDER) EXPENSES Line 6 - Line 15 $271,285 $62,257 $47,623
Form C - Schedule of Patient Visits
Existing
Source Clinic Year 1 Year 2
Provider Type
Community Health Aide / Practitioner Daily Log 933 958 958
Nurse
Emergency Medical Technician
Physician Assistant / Nurse Practitioner
Physician Daily Log 307 332 332
Subtotal Medical Visits – To Form D 1,240 1,290 1,290

Dental Health Aide

Dental Hygienist / Tech 73 98 98
Dentist 122 137 137
Subtotal Dental Visits – To Form D 195 235 235

Mental Health Provider / Social Worker 125 150 150

Subtotal Mental Health Visits – To Form D 125 150 150

Community Health Representative 125 150 150

Health Educator
Subtotal Other Visits – To Form D 125 150 150

TOTAL VISITS – To Form B 1,685 1,825 1,825

Form C (1) – Supplemental Schedule - Patient Visits per Month
***This form must be filled out if your patient volume has a seasonal change of 25% or more***
Show the number of patient visits monthly/annually by provider type
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

Provider Type Month Month Month Month Month Month Month Month Month Month Month Month
1 2 3 4 5 6 7 8 9 10 11 12 Total
Community Health Aide / Practitioner
Nurse
Emergency Medical Technician
Physician Assistant / Nurse Practitioner
Physician
Total Medical Visits - To Form D

Dental Health Aide

Dental Hygienist / Tech

Dentist
Total Dental Visits – To Form D

Mental Health Provider / Social Worker

Total Mental Health Visits – To Form D

Community Health Representative

Health Educator
Total Other Visits – to Form D

TOTAL VISITS – To Form B

Form C (1) – Supplemental Schedule - Patient Visits per Month
***This form must be filled out if your patient volume has a seasonal change of 25% or more***
Show the number of patient visits monthly/annually by provider type
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

Provider Type Month Month Month Month Month Month Month Month Month Month Month Month
1 2 3 4 5 6 7 8 9 10 11 12 Total
Community Health Aide / Practitioner
Nurse
Emergency Medical Technician
Physician Assistant / Nurse Practitioner
Physician
Total Medical Visits - To Form D

Dentist
Dental Hygienist / Tech
Dental Health Aide
Total Dental Visits – To Form D

Mental Health Provider / Social Worker

Total Mental Health Visits – To Form D

Community Health Representative

Health Educator
Total Other Visits – to Form D

TOTAL VISITS – To Form B

Form C (1) – Supplemental Schedule - Patient Visits per Month
***This form must be filled out if your patient volume has a seasonal change of 25% or more***
Show the number of patient visits monthly/annually by provider type
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

Provider Type Month Month Month Month Month Month Month Month Month Month Month Month
1 2 3 4 5 6 7 8 9 10 11 12 Total
Community Health Aide / Practitioner
Nurse
Emergency Medical Technician
Physician Assistant / Nurse Practitioner
Physician
Total Medical Visits - To Form D

Dentist
Dental Hygienist / Tech
Dental Health Aide
Total Dental Visits – To Form D

Mental Health Provider / Social Worker

Total Mental Health Visits – To Form D

Community Health Representative

Health Educator
Total Other Visits – to Form D

TOTAL VISITS – To Form B

Form D - Revenue Worksheet – Health Care Services
Existing New Clinic
Source Clinic Year 1 Year 2
2a MEDICAL REVENUE
Total Medical Visits From Form A 1,362 1,412 1,412
BillableMedical Visits 150 200 200
Average Charge per Visit $41.30 $42.54 $43.82
Total Medical Revenue visits x charge $6,195 $8,507.80 $8,763.03

2b DENTAL REVENUE
Total Dental Visits From Form A 308 358 358
Billable Dental Visits 124 174 174
Average Charge per Visit $220 $226.60 $233.40
Total Dental Revenue visits x charge $27,280 $39,428 $40,611

2c MENTAL HEALTH REVENUE

Total Mental Health Visits From Form A 125 150 150
Billable Mental Health Visits
Average Charge per Visit
Total Mental Health Revenue visits x charge $- $- $-

2d OTHER REVENUE
Total Other Visits From Form A 125 150 150
Other Visits
Average Charge per Visit
Total Other Revenue visits x charge $- $- $-

2e Miscellaneous REVENUE
Total Misc Revenue
(Please identify source)

Note: Applicants may need to separate billable (revenue generating) visits from total
visits.
e.g. Community Health Aide visits are not all billable. CHA’s must be Level 3 or higher
before services can be billed. Medicaid is currently the only insurance company that will
reimburse for CHA services
 Form E - Expense Budget –Health Care Services
Totals by category must be entered in Form B - Budget Summary
Page 1 of 2
Existing New/Expanded Clinic
Source Clinic Year 1 Year 2

7 SALARIES & WAGES (use Form F - Salaries & Wages worksheet to calculate salaries)
7a Medical Providers Form F 15,850 16,325 16,815
7b Dental Providers Form F 13,585 13,993 14,413
7c Mental Health Providers Form F 4,528 4,664 4,804
7d Administrative Staff Form F 33,963 34,982 36,032
7e Clinical Staff Form F 158,496 163,251 168,149
7f Other Form F 24,101 24,824 25,569
Total Salaries & Wages Add Lines 7a - 7f 250,523 258,039 265,782

8 EMPLOYEE BENEFITS ** (calculate as a percentage of total Salaries & Wages)

8a Percentage 24%
Total Employee Benefits Total Salaries x Line 8a 60,126 61,929 63,788

9 TRAVEL (airfare and per diem)

9a Provider Travel 14,751 15,194 15,649
9b Administrative Staff KANA Van & Indirect 3,132 3,226 3,323
9c Clinical Staff 14,751 15,194 15,649
Total Travel Add Lines 9a – 9c 32,634 33,614 34,621

10 MINOR EQUIPMENT (Items less than $5,000 – DO NOT include capital items)
10a Medical 1,000 1,030 1,061
10b Dental
10c Information Systems 1,052 1,084 1,116
10d Office/Administrative 1,888 1,945 2,003
10e Other
Total Minor Equipment Add Lines 10a-10e 3,940 4,059 4,180

11 SUPPLIES – (items consider “disposable” or that are consumed in use)

11a Medical 5,645 5,814 5,989
11b Dental 1,324 1,364 1,405
11c Lab
11d Pharmacy
11e X-Ray
11f Office/Administrative 2,000 2,060 2,122
11g Other
Total Supplies Add Lines 11a -11g 8,969 9,238 9,516
Form E - Expense Budget –Health Care Services
Page 2 of 2

Existing New/Expanded Clinic

Source Clinic Year 1 Year 2
12 CONTRACTED SERVICES
12a Provider Services 80,697 83,118 85,611
(Locums Tenems )
12b Lab Fees
12c Dental Lab Fees
12d Radiology
12e Transcription
12f Other (Hazardous waste, etc)
Total Contractual Services Add Lines 12a –12f 80,697 83,118 85,611

13 OTHER
13a Consultant Fees Includes Directors Fees 2,344 2,414 2,487
13b Continuing Education 3,986 4,106 4,229
13c Equipment Maintenance 3,334 3,434 3,537
13d Equipment Rental/Lease
13e Information Services/
Computer Fees Includes Indirect IT 7,428 7,651 7,880
13f Interest Expense
13g Legal/Accounting/Audit Fees Includes Indirect Acctg 20,279 20,887 21,514
13h Liability Insurance 2,605 2,683 2,764
13i Non-Staff (Board) travel 1,813 1,867 1,923
13j Postage / Shipping 1,335 1,375 1,416
13k Recruitment / Moving Exp 3,131 3,225 3,322
13l Subscriptions / Journals / Dues Includes Licenses 4,195 4,321 4,450
13m Telephone / Internet / Cable 3,508 3,613 3,722
13n Other (please identify below) 8,588 8,846 9,111
Total Other Add Lines 13a – 13n 62,546 64,422 66,355

TOTAL HEALTH CARE SERVICE EXPENSES 499,435 514,419 529,853

13n Identify "Other" Expenses

KANA Building Taxes 1,540
KANA Building Utilities 3,006
KANA Building Maintenance 4,042
Total 8,588
 Form F - Salaries and Wages Worksheet (optional)
Page 1 of 2
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

NOTE: If personnel work for more than one clinic, or also spend time on another program,
only include those hours that are directly related to this clinic

***HEALTH CARE SERVICES***

Position Hours per x Weeks = Annual x Hourly = Annual
Week per Year Hours Rate Wages
Comm Health Aide/Practitioner 0 0
EMT 0 0
Nurse Practitioner/ Physician Assistant 0 0
Physician 0 0
Other 0 0
SUBTOTAL MEDICAL To Form E, Line 7A 0 0

Dental Health Aide 0 0

Dental Hygienist 0 0
Dental Technician 0 0
Dentist 0 0
Other 0 0
SUBTOTAL DENTAL To Form E, Line 7B 0 0

Mental Health Aide 0 0

Mental Health Provider 0 $ 0
Social Worker / Other 0 $ 0
SUBTOTAL MENTAL HEALTH To Form E, Line 7C 0 0

Receptionist 0 0
Insurance Biller 0 0
Accounting/Payroll 0 0
Administrative Assistants 0 0
Manager(s) 0 0
Director / Administrator 0 0
Other 0 0
SUBTOTAL ADMIN To Form E, Line 7D 0 0

Medical Assistant/CAN 0 0
Nurse (RN/LPN) 0 0
Phlebotomist 0 0
Other 0 0
SUBTOTAL CLINICAL To Form E, Line 7E 0 0

Community Health Rep 0 0

Health Educator 0 0
Other 0 0
SUBTOTAL OTHER To Form E, Line 7F 0 0
Form F - Salaries and Wages Worksheet (optional)
Page 2 of 2
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

NOTE: If personnel work for more than one clinic, or also spend time on another program,
only include those hours that are directly related to this clinic

***FACILITY SERVICES***
Position Hours per x Weeks = Annual x Hourly = Annual
Week per Year Hours Rate Wages
Custodian 0 0
Maintenance 0 0
Administrative 0 0
Other 0 0
SUBTOTAL FACILITY To Form G, Line14A 0 0
 Form F - Salaries and Wages Worksheet (optional)
Page 1 of 2
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

NOTE: If personnel work for more than one clinic, or also spend time on another program,
only include those hours that are directly related to this clinic

***HEALTH CARE SERVICES***

Position Hours per x Weeks = Annual x Hourly = Annual
Week per Year Hours Rate Wages
Comm Health Aide/Practitioner 0 0
EMT 0 0
Nurse Practitioner/ Physician Assistant 0 0
Physician 0 0
Other 0 0
SUBTOTAL MEDICAL To Form E, Line 7A 0 0

Dental Health Aide 0 0

Dental Hygienist 0 0
Dental Technician 0 0
Dentist 0 0
Other 0 0
SUBTOTAL DENTAL To Form E, Line 7B 0 0

Mental Health Aide 0 0

Mental Health Provider 0 0
Social Worker / Other 0 0
SUBTOTAL MENTAL HEALTH To Form E, Line 7C 0 0

Receptionist 0 0
Insurance Biller 0 0
Accounting/Payroll 0 0
Administrative Assistants 0 0
Manager(s) 0 0
Director / Administrator 0 0
Other 0 0
SUBTOTAL ADMIN To Form E, Line 7D 0 0

Medical Assistant/CAN 0 0
Nurse (RN/LPN) 0 0
Phlebotomist 0 0
Other 0 0
SUBTOTAL CLINICAL To Form E, Line 7E 0 0

Community Health Rep 0 0

Health Educator 0 0
Other 0 0
SUBTOTAL OTHER To Form E, Line 7F 0 0
Form F - Salaries and Wages Worksheet (optional)
Page 2 of 2
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

NOTE: If personnel work for more than one clinic, or also spend time on another program,
only include those hours that are directly related to this clinic

***FACILITY SERVICES***
Position Hours per x Weeks = Annual x Hourly = Annual
Week per Year Hours Rate Wages
Custodian 0 0
Maintenance 0 0
Administrative 0 0
Other 0 0
SUBTOTAL FACILITY To Form G, Line14A 0 0
 Form F - Salaries and Wages Worksheet (optional)
Page 1 of 2
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

NOTE: If personnel work for more than one clinic, or also spend time on another program,
only include those hours that are directly related to this clinic

***HEALTH CARE SERVICES***

Position Hours per x Weeks = Annual x Hourly = Annual
Week per Year Hours Rate Wages
Comm Health Aide/Practitioner 0 0
EMT 0 0
Nurse Practitioner/ Physician Assistant 0 0
Physician 0 0
Other 0 0
SUBTOTAL MEDICAL To Form E, Line 7A 0 0

Dental Health Aide 0 0

Dental Hygienist 0 0
Dental Technician 0 0
Dentist 0 0
Other 0 0
SUBTOTAL DENTAL To Form E, Line 7B 0 0

Mental Health Aide 0 0

Mental Health Provider 0 0
Social Worker / Other 0 0
SUBTOTAL MENTAL HEALTH To Form E, Line 7C 0 0

Receptionist 0 0
Insurance Biller 0 0
Accounting/Payroll 0 0
Administrative Assistants 0 0
Manager(s) 0 0
Director / Administrator 0 0
Other 0 0
SUBTOTAL ADMIN To Form E, Line 7D 0 0

Medical Assistant/CAN 0 0
Nurse (RN/LPN) 0 0
Phlebotomist 0 0
Other 0 0
SUBTOTAL CLINICAL To Form E, Line 7E 0 0

Community Health Rep 0 0

Health Educator 0 0
Other 0 0
SUBTOTAL OTHER To Form E, Line 7F 0 0
Form F - Salaries and Wages Worksheet (optional)
Page 2 of 2
A separate form is needed for each year Year (circle one): Existing Year 1 Year 2

NOTE: If personnel work for more than one clinic, or also spend time on another program,
only include those hours that are directly related to this clinic

***FACILITY SERVICES***
Position Hours per x Weeks = Annual x Hourly = Annual
Week per Year Hours Rate Wages
Custodian 0 0
Maintenance 0 0
Administrative 0 0
Other 0 0
SUBTOTAL FACILITY To Form G, Line14A 0 0
 Form G – Expense Budget - Facility Operations & Maintenance

Existing New/Expanded Clinic

14 FACILITY EXPENSES Source Clinic Year 1 Year 2
14a Salaries & Wages - Building Form F 9,012 11,265 11,603
14b Benefits % of Salary 0 0
14c Building Rent 0 0
Building Depreciation / Reserve for
14d Repairs & Replacement 0 0
Property Taxes
14e 0 0
14f Building Repairs 0 0
14g Building Maintenance 1,000 1,250 1,288
14h Building Insurance 0 0
14i Building Supplies 0 0
14j Utilities 6,997 8,746 9,008
14k Janitorial 0
14l Building Expense Other 0 0
TOTAL FACILITIES EXPENSES Add Lines 14a to 14l 17,008 21,261 21,898

Building Square Feet 1,581 2,570 2,570

Average Facility Expense per Square Foot $10.76 $8.27 $8.52

(“Total Facilities Expenses” divided by “Building Square Feet”)

Note:
§ Sustainable projects are expected to cover normal facility expenses AND repairs and maintenance to
ensure upkeep of the building.

§ Be sure to note your method of estimating utilities and other expenses in Section 8-C of the Business
Plan