HomeMy WebLinkAboutExhibit F-CYSHCN Annual Reporting 2021-2022
507 N. Nanum Street, Suite 102 Ellensburg, WA 98926
T: 509.962.7515 F: 509.962.7581
www.co.kittitas.wa.us/health/
HP Version: 1 Supersedes: 0 Date Adopted: 9/29/21 Modified/Created By: Chelsey Loeffers Approval By: T Lamb
Exhibit âFâ
Annual Reporting Form
Unduplicated Count of Individuals Served Under Title V by Class of Individuals and Percent of
Health Coverage
Email report to: chelsey.loeffers@co.kittitas.wa.us or fax: 933-8246 by November 30th 2022.
Facility reporting: CHCW-E Date:
Report the unduplicated number served for each population category served if a direct or
enabling service (the top two levels of the MCH Pyramid) was fully or partially supported with
your total MCH allocation. Estimate the percent with Title XIX, Title XXI, Other, or No/Unknown
Health Coverage.
Population
Category
A.
Total #
Served
with Title V
(partially
or fully
funded
with MCH
allocation)
B.
Estimated
% with
Title XIX
coverage
C.
Estimated
% with
Title XXI
coverage
D.
Estimated %
with
Private/Other
coverage
E.
Estimated %
with No
health
coverage
F.
Estimated
%
Unknown
health
coverage
Total %
(should
be 100%)
Pregnant
Women
0.00%
Infants<1
yr. of age
0.00%
Children 1
to 22 yr.
0.00%
CYSHCN 0.00%
Others 0.00%
TOTAL 0
507 N. Nanum Street, Suite 102 Ellensburg, WA 98926
T: 509.962.7515 F: 509.962.7581
www.co.kittitas.wa.us/health/
HP Version: 1 Supersedes: 0 Date Adopted: 9/29/21 Modified/Created By: Chelsey Loeffers Approval By: T Lamb
Instructions for Completing Report:
1. Column
A:
Enter the unduplicated number of individuals in each population category who received a
direct or enabling service (in person, by phone) that was fully or partially supported with
Title V (MCH Block Grant) funds. These services would generally be included in direct and
enabling services, and would not include those individuals encountered in Public Health
Services and Systems work. NOTE: There will be overlap between the figures listed for
Column (A) and the remaining columns.
2. Columns
B - F:
Estimate for each population category the proportion with Title XIX, Title XXI,
Private/Other, No or Unknown health coverage.