2020 UDS Tables - Health Resources and Services Administration

REPORTING TABLES FOR 2020 HEALTH CENTER DATA

REPORTING TABLES FOR 2020 HEALTH CENTER DATA

Table: Patients by ZIP Code

Reporting Period: January 1, 2020, through December 31, 2020

ZIP Code (a)

[Blank for demonstration]

None/ Uninsured

(b)

[Blank for demonstration]

Medicaid/ CHIP/Other Public

(c)

[Blank for demonstration]

Medicare (d)

[Blank for demonstration]

Private (e)

Total Patients (f)

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

Other ZIP Codes

Unknown Residence Total

[Blank for demonstration] [Blank for demonstration] [Blank for demonstration]

[Blank for demonstration] [Blank for demonstration] [Blank for demonstration]

[Blank for demonstration] [Blank for demonstration] [Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

[Blank for demonstration]

Note: This is a representation of the form. The actual online output from the EHBs will display ZIP codes entered by the health center in Column A.

2 2020 UDS TABLES ? Bureau of Primary Health Care

REPORTING TABLES FOR 2020 HEALTH CENTER DATA

Table 3A: Patients by Age and by Sex Assigned at Birth

Reporting Period: January 1, 2020, through December 31, 2020

Line

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Age Groups

Under age 1 Age 1 Age 2 Age 3 Age 4 Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11 Age 12 Age 13 Age 14 Age 15 Age 16 Age 17 Age 18 Age 19 Age 20 Age 21 Age 22 Age 23 Age 24 Ages 25?29 Ages 30?34 Ages 35?39 Ages 40?44 Ages 45?49 Ages 50?54 Ages 55?59 Ages 60?64 Ages 65?69 Ages 70?74 Ages 75?79 Ages 80?84 Age 85 and over

Total Patients (Sum of Lines 1-38)

Male Patients (a)

Female Patients (b)

3 2020 UDS TABLES? Bureau of Primary Health Care

REPORTING TABLES FOR 2020 HEALTH CENTER DATA

Table 3B: Demographic Characteristics

Reporting Period: January 1, 2020, through December 31, 2020

Patients by Race and Hispanic or Latino/a Ethnicity

Line

1 2a 2b

2

3 4 5 6 7

8

Patients by Race

Asian Native Hawaiian Other Pacific Islander Total Native Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b) Black/African American American Indian/Alaska Native White More than one race Unreported/Refused to report race

Total Patients (Sum of Lines 1 + 2 + 3 to 7)

Hispanic or Latino/a (a)

NonHispanic or

Latino/a (b)

Unreported/Refused to Report Ethnicity (c)

Total (d)

(Sum Columns a+b+c)

Line Patients Best Served in a Language Other than English

12

Patients Best Served in a Language Other than English

Number (a)

Line Patients by Sexual Orientation

divider

Number (a)

Line

Patients by Gender Identity

Number (a)

13 Lesbian or Gay 14 Heterosexual (or straight) 15 Bisexual

16 Something else

17 Don't know

18 Chose not to disclose

18a Unknown

19

Total Patients (Sum of Lines 13 to 18a)

divider

20

Male

divider

21

divider

22

divider

23

divider

24

Female

Transgender Man/Transgender Male Transgender Woman/Transgender Female

Other

divider

25

Chose not to disclose

25a Unknown

divider

26

Total Patients (Sum of Lines 20 to 25a)

4 2020 UDS TABLES? Bureau of Primary Health Care

REPORTING TABLES FOR 2020 HEALTH CENTER DATA

Table 4: Selected Patient Characteristics

Reporting Period: January 1, 2020, through December 31, 2020

Line Income as Percent of Poverty Guideline

Number of Patients (a)

1

100% and below

2

101?150%

3

151?200%

4

Over 200%

5

Unknown

6

TOTAL (Sum of Lines 1?5)

Line

7 8a 8b 8 9a 9

10a 10b 10 11 12

Principal Third-Party Medical Insurance

None/Uninsured Medicaid (Title XIX) CHIP Medicaid

Total Medicaid (Line 8a + 8b) Dually Eligible (Medicare and Medicaid) Medicare (Inclusive of dually eligible and other Title

XVIII beneficiaries) Other Public Insurance (Non-CHIP) (specify___) Other Public Insurance CHIP

Total Public Insurance (Line 10a + 10b) Private Insurance

TOTAL (Sum of Lines 7 + 8 + 9 +10 +11)

0-17 years old (a)

18 and older (b)

Line Managed Care Utilization

Medicaid (a)

13a 13b

13c

Capitated Member Months Fee-for-service Member Months

Total Member Months (Sum of Lines 13a + 13b)

Medicare (b)

Other Public

Including

Non-Medicaid

CHIP

(c)

Private (d)

TOTAL (e)

5 2020 UDS TABLES ? Bureau of Primary Health Care

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