|
|
|
(A) Medicaid |
(B) Other means-tested government programs |
| 1. |
Gross patient charges from the programs |
1. |
___________ |
___________ |
| Less Adjustments |
| 2. |
Ratio of patient cost to charges (from Worksheet 2, if used) |
2. |
_________% |
_________% |
| 3. |
Cost (multiply line 1 by line 2, or obtain from cost accounting) |
3. |
___________ |
___________ |
| 4. |
Medicaid provider taxes |
4. |
___________ |
___________ |
| 5. |
Total community benefit expense (add lines 3 and 4; enter amount from column (A) on Part I, line 7b, column (c); and enter amount from column (B) on Part I, line 7c, column (c)) |
5. |
___________ |
___________ |
| Direct Offsetting Revenue |
| 6. |
Net patient service revenue |
6. |
___________ |
___________ |
| 7. |
Payments from uncompensated care pools or programs |
7. |
___________ |
___________ |
| 8. |
Other revenue |
8. |
___________ |
___________ |
| 9. |
Total direct offsetting revenue (add lines 6 through 8; enter amount from column (A) on Part I, line 7b, column (d) and enter amount from column (B) on Part I, line 7c, column (d)) |
9. |
___________ |
___________ |
| 10. |
Net community benefit expense (subtract line 9 from line 5; enter amount from column (A) on Part I, line 7b, column (e); enter amount from column (B) on Part I, line 7c, column (e)) |
10. |
___________ |
___________ |
| 11. |
Total expense (enter amount from Form 990, Part IX, line 25, Column (A) on Part I, line 7b, column (f); enter amount from column (B) on Part I, line 7c, column (f)) |
11. |
___________ |
___________ |
| 12. |
Percent of total expense (line 10 divided by 11; enter amount from column (A) on Part I, line 7b, column (f); enter amount from column (B) on Part I, line 7c, column (f)) |
12. |
_________% |
_________% |
