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Form 5A: Services Provided OMB No.: 09150285. Expiration Date: 3/31/2023DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration RSA USE ONLY Grant Number Application Tracking

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It is a form used for reporting services provided by a health center under the BPHC HRSA program.

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Information such as the types of services provided, the number of patients served, and other relevant data must be reported.

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