| Total Community Benefit Expense |
| 1. |
Medical students |
1. _______________ |
| 2. |
Interns, residents, and fellows |
2. _______________ |
| 3. |
Nursing |
3. _______________ |
| 4. |
Other allied health professions |
4. _______________ |
| 5. |
Continuing health professions education |
5. _______________ |
| 6. |
Other students |
6. _______________ |
| 7. |
Total community benefit expense (add lines 1 through 6; enter on Part I, line 7f, column (c)) |
7. _______________ |
| Direct offsetting revenue |
| 8. |
Medicare reimbursement for direct GME |
8. _______________ |
| 9. |
Medicaid reimbursement for direct GME |
9. _______________ |
| 10. |
Continuing health professions education reimbursement/tuition |
10. _______________ |
| 11. |
Other revenue |
11. _______________ |
| 12. |
Total direct offsetting revenue (add lines 8 through 11; enter on Part I, line 7f, column (d)) |
12. _______________ |
| 13. |
Net community benefit expense (line 7 minus line 12; enter on Part I, line 7f, column (e)) |
13. _______________ |
| 14. |
Total expense (enter amount from Form 990, Part IX, Line 25, column (A), and include the organization's share of joint venture expenses) |
14. _______________ |
| 15. |
Percent of total expense (line 13 divided line 14; enter amount of Part I, line 7f, column (f)) |
15. _____________% |
