Technical Assistance Subsidy Application
Rural Health Care Support Program
Description of Subsidy Request
*
Describe the problem or need that you hope to address with the services to be subsidized by IHFA. Please provide details on service providers, timing, goals, and estimated costs.
Organization Name
*
Organization Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Application Contact
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First Name
Last Name
Contact Title
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Status
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Critical Access Hospital
Rural Emergency Hospital
Federally Qualified Health Center
Other
Licensed Bed Capacity
If Applicable
Services to be Utilized
Financial Assistance
Financial Review
Restructuring Fiscal Services
Accounts Receivable Management
Management Reporting
Productivity Analysis
Cost Report Analysis/Consulting
Charge System Reviews
Fiscal Management Seminars
Other
Legal Assistance
Board of Director's Training
Compliance Planning
Specialized Legal Services
Review of Contracts/Transactions
Other
Organizational/Management Development
CMS Audit Readiness Survey (up to $1,000 subsidy)
Scope of Services Development
Board Development and Training
Leadership Training
Teambuilding
Strategic Planning Facilititation
Other
Which consultant(s) or firms(s) will you use?
*
Description of Organization
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Describe the organization's location, demographics, and any special populations or considerations.
Other Relevant Information
Most Recent Audited Financial Statements
*
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