Form HS610 "Medically Underserved or Health Professional Shortage Areas" - California

What Is Form HS610?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form HS610 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form HS610 "Medically Underserved or Health Professional Shortage Areas" - California

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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)