2018-475-E Finance - Piedmont Health Services Inc outside agency agreement

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DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information n) Target Population (NOTE: As the target of requested funding, the medical population served is presented based on data from the electronic medical record. PHS does not project patient demographics but would anticipate the program to serve at least as many residents in 2018 as 2017 of similar demographics). Program Target Population Demographics Gender Male Female Total Ethnicity African - American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify: more than one race, unreported Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age 0 -5 years 6 -18 years 19 -50 years 51 + years Total Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Other (unincorporated above) Total Actual Actual Projected 2016 2017 2018 2,854 2,528 see note 4,205 3,888 see note 7,059 6,416 see note 730 676 see note 0 0 see note 807 715 see note 5,325 4,792 see note 0 0 see note 197 233 see note 7,059 6,416 see note 1,001 831 see note 4,512 4,036 see note 2,547 2,380 see note 7,059 6,416 see note 1,001 831 see note 1,987 1,684 see note 2,781 2,642 see note 1,290 1,259 see note 7,059 6,416 see note 574 296 see note 128 109 see note 1,629 1,466 see note 203 196 see note 85 71 see note 2,035 2,324 see note 1,156 1,116 see note 354 301 see note 240 209 see note 229 220 see note 426 108 see note 7,059 6,416 see note PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 18 of 23