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<br /> <br /> <br /> <br />507 N. Nanum Street, Suite 102 Ellensburg, WA 98926 <br /> T: 509.962.7515 F: 509.962.7581 <br />www.co.kittitas.wa.us/health/ <br />HP Version: 1 Supersedes: 0 Date Adopted: 9/29/21 Modified/Created By: Chelsey Loeffers Approval By: T Lamb <br /> <br /> <br /> <br /> <br />Exhibit “F” <br />Annual Reporting Form <br />Unduplicated Count of Individuals Served Under Title V by Class of Individuals and Percent of <br />Health Coverage <br /> <br />Email report to: chelsey.loeffers@co.kittitas.wa.us or fax: 933 -8246 by November 30th 2022. <br /> <br />Facility reporting: CHCW-E Date: <br /> <br /> <br />Report the unduplicated number served for each population category served if a direct or <br />enabling service (the top two levels of the MCH Pyramid) was fully or partially supported with <br />your total MCH allocation. Estimate the percent with Title XIX, Title XXI, Other, or No/Unknown <br />Health Coverage. <br /> <br /> <br /> <br />Population <br />Category <br />A. <br />Total # <br />Served <br />with Title V <br />(partially <br />or fully <br />funded <br />with MCH <br />allocation) <br />B. <br />Estimated <br />% with <br />Title XIX <br />coverage <br />C. <br />Estimated <br />% with <br />Title XXI <br />coverage <br />D. <br />Estimated % <br />with <br />Private/Other <br />coverage <br />E. <br />Estimated % <br />with No <br />health <br />coverage <br />F. <br />Estimated <br />% <br />Unknown <br />health <br />coverage <br />Total % <br />(should <br />be 100%) <br />Pregnant <br />Women <br /> 0.00% <br />Infants<1 <br />yr. of age <br /> 0.00% <br />Children 1 <br />to 22 yr. <br /> 0.00% <br />CYSHCN 0.00% <br />Others 0.00% <br />TOTAL 0 <br /> <br /> <br /> <br /> <br /> <br /> <br />