Federally Qualified Health Center Forms

Cost Reports

• Cost Report Instructions
• Cost Report Forms
• Payment Methodology Agreement Form
• Pharmacy Overhead Allocation Form

ACC PMPM Appendix

• FQHC ACC PMPM Appendix 2020

Scope-of-Service Rate Adjustments

• Scope-of-Service Rate Adjustment Instructions
• Scope-of-Service Rate Adjustment Application

Alternative Payment Methodology 2

• Alternative Payment Methodology 2 Billing Guidance

Managed Care Accuracy Audit Reports - for FQHCs

• MCAAR FQHC Instructions
• MCAAR FQHC Data Section
• MCAAR FQHC Attestation Statement

Managed Care Accuracy Audit Reports - for MCEs

• MCAAR MCE Instructions
• MCAAR MCE Data Section
• MCAAR MCE Attestation Statement