Form HS 610 Medically Underserved or Health Professional Shortage Areas - California

Form HS610 is a California Department of Public Health form also known as the "Medically Underserved Or Health Professional Shortage Areas". The latest edition of the form was released in September 1, 2017 and is available for digital filing.

Download an up-to-date Form HS610 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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State of California—Health and Human Services Agency
California Department of Public Health
Centralized Applications Unit
P.O. Box 997377, MS 3207
Sacramento, CA 95899-7377
MEDICALLY UNDERSERVED OR HEALTH PROFESSIONAL
SHORTAGE AREAS
In order to expedite your request to establish eligibility, please include the following information along with
your completed application:
• Please provide this office with a census tract number for the address of the clinic. This information can
be obtained by contacting the County Planning Department for which the clinic is located.
• Please attach any documentation from the Office of Shortage Designation, Public Health Services, that
shows the clinic you are applying for is located in a Medically Underserved or Health Professional
Shortage Area. The documentation must be current and must include the address of the clinic you are
applying for.
• A census tract number may be obtained from the following website:
http://www.ffiec.gov/geocode/default.htm
or you may contact the Federal Financial Institutions Examination Council (FFEIC) by mail:
2100 Pennsylvania Avenue NW
Suite 200
Washington, DC 20037
For additional information regarding a census tract number, call (202) 872-7500 (FFEIC)
Clinic Name
Address
City
State
CENSUS TRACT NUMBER
HS 610 (9/17)
State of California—Health and Human Services Agency
California Department of Public Health
Centralized Applications Unit
P.O. Box 997377, MS 3207
Sacramento, CA 95899-7377
MEDICALLY UNDERSERVED OR HEALTH PROFESSIONAL
SHORTAGE AREAS
In order to expedite your request to establish eligibility, please include the following information along with
your completed application:
• Please provide this office with a census tract number for the address of the clinic. This information can
be obtained by contacting the County Planning Department for which the clinic is located.
• Please attach any documentation from the Office of Shortage Designation, Public Health Services, that
shows the clinic you are applying for is located in a Medically Underserved or Health Professional
Shortage Area. The documentation must be current and must include the address of the clinic you are
applying for.
• A census tract number may be obtained from the following website:
http://www.ffiec.gov/geocode/default.htm
or you may contact the Federal Financial Institutions Examination Council (FFEIC) by mail:
2100 Pennsylvania Avenue NW
Suite 200
Washington, DC 20037
For additional information regarding a census tract number, call (202) 872-7500 (FFEIC)
Clinic Name
Address
City
State
CENSUS TRACT NUMBER
HS 610 (9/17)

Download Form HS 610 Medically Underserved or Health Professional Shortage Areas - California

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