Válasszon nyelvet

990 forma utasítás H menetrendre

Oktatások H-es menetrendre (Form 990), kórházak

Rev. 2023

Kapcsolódó űrlapok

Részletek
Fájlformátum PDF
Méret 339.6 KB
Letöltés
Department of the Treasury  
Internal Revenue Service  
2023  
Instructions for Schedule H  
(Form 990)  
Hospitals  
Section references are to the Internal Revenue Code unless  
Purpose of Schedule  
otherwise noted.  
Hospital organizations use Schedule H (Form 990) to provide  
information on the activities and policies of, and community  
benefit provided by, its hospital facilities and other non-hospital  
health care facilities that it operated during the tax year. This  
includes facilities operated either directly or through disregarded  
entities or joint ventures.  
Future Developments  
For the latest information about developments related to Form  
990 and its instructions, such as legislation enacted after they  
were published, go to IRS.gov/Form990.  
Who Must File  
General Instructions  
An organization that answered “Yes” on Form 990, Part IV,  
line 20a, must complete and attach Schedule H to Form 990.  
Note. Terms in bold are defined in the Glossary of the  
Instructions for Form 990.  
Schedule H (Form 990) must be completed by a hospital  
organization that operated at any time during the tax year at  
least one hospital facility. A hospital facility is one that is  
required to be licensed, registered, or similarly recognized by a  
state as a hospital. A hospital organization may treat multiple  
buildings operated by a hospital organization under a single  
state license as a single hospital facility.  
Background. The Patient Protection and Affordable Care Act  
(Affordable Care Act), enacted March 23, 2010, P.L. No.  
111-148, added section 501(r) to the Code. Section 501(r)  
includes additional requirements a hospital organization must  
meet to qualify for tax exemption under section 501(c)(3) in tax  
years beginning after March 23, 2010. These additional  
requirements address a hospital organization's financial  
assistance policy (FAP), policy relating to emergency medical  
care, billing and collections, and charges for medical care. Also,  
for tax years beginning after March 23, 2012, the Affordable  
Care Act requires hospital organizations to conduct community  
health needs assessments.  
The organization must file a single Schedule H (Form 990)  
that combines information from:  
1. Hospital facilities directly operated by the organization.  
2. Hospital facilities operated by disregarded entities of  
which the organization is the sole member.  
Because section 501(r) requires a hospital organization to  
meet these requirements for each of its hospital facilities, Part  
V, Facility Information, has been expanded to include a  
Section A, Hospital Facilities. In this section, a hospital  
organization must list its hospital facilities; that is, its facilities  
that, at any time during the tax year, were required to be  
licensed, registered, or similarly recognized as a hospital under  
state law. Part V also includes Section B, Facility Policies and  
Practices, for reporting of information on policies and practices  
addressed in section 501(r). The hospital organization must  
complete a separate Section B for each of its hospital facilities or  
facility reporting groups listed in Section A.  
Section 6033(b)(15)(B) also requires hospital organizations to  
submit a copy of their audited financial statements to the IRS.  
Accordingly, a hospital organization that is required to file Form  
990 must attach a copy of its most recent audited financial  
statements to its Form 990. If the organization was included in  
consolidated audited financial statements but not separate  
audited financial statements for the tax year, then it must attach a  
copy of the consolidated financial statements, including details  
of consolidation. See the instructions for Form 990, Part IV,  
line 20b.  
3. Other health care facilities and programs of the hospital  
organization or any of the entities described in 1 or 2, even if  
provided separately from the hospital's license.  
4. Hospital facilities and other health care facilities and  
programs operated by any joint venture treated as a  
partnership, to the extent of the hospital organization's  
proportionate share of the joint venture.  
“Proportionate share” is defined as the ending capital account  
percentage listed on the Schedule K-1 (Form 1065), Partner's  
Share of Income, Deductions, Credits, etc., Part II, line J, for the  
partnership tax year ending in the organization's tax year being  
reported on the organization's Form 990. If Schedule K-1 (Form  
1065) isn't available, the organization can use other business  
records to make a reasonable estimate, including the most  
recently available Schedule K-1 (Form 1065), adjusted as  
appropriate to reflect facts known to the organization, or  
information used for purposes of determining its proportionate  
share of the venture for the organization's financial statements.  
5. In the case of a group return filed by the hospital  
organization, hospital facilities operated directly by members of  
the group exemption included in the group return, hospital  
facilities operated by a disregarded entity of which a member  
included in the group return is the sole member, hospital facilities  
operated by a joint venture treated as a partnership to the extent  
of the group member's proportionate share (determined in the  
manner described in 4, earlier), and other health care facilities or  
programs of a member included in the group return even if such  
programs are provided separately from the hospital's license.  
Part V, Section D, requires an organization to list all of its  
non-hospital health care facilities that it operated during the tax  
year, whether or not such facilities were required to be licensed  
or registered under state law. The organization shouldn't  
complete Part V, Section B, for any of these non-hospital  
facilities.  
Sec. 501(r) final regulations are effective for tax years  
beginning after 12/29/15.  
TIP  
Example. The organization is the sole member of a  
disregarded entity. The disregarded entity owns 50% of a joint  
Oct 23, 2023  
Cat. No. 51526B  
 
venture treated as a partnership. The partnership in turn owns  
50% of another joint venture treated as a partnership that  
operates a hospital and a freestanding outpatient clinic that isn't  
part of the hospital's license. (Assume the proportionate shares  
of the partnerships based on capital account percentages listed  
on the partnerships' Schedule K-1 (Form 1065), Part II, line J,  
are also 50%.) The organization would report 25% (50% of 50%)  
of the hospital's and outpatient clinic's combined information on  
Schedule H (Form 990).  
Note that while information from all the above sources is  
combined for purposes of Schedule H (Form 990), the  
organization is required to list and provide information regarding  
each of its hospital facilities in Part V, Sections A, B, and C,  
whether operated directly by the organization or through a  
disregarded entity or joint venture treated as a partnership. In  
addition, the organization must list in Part V, Section D, each of  
its other health care facilities (for example, rehabilitation clinics,  
other outpatient clinics, diagnostic centers, skilled nursing  
facilities) that it operated during the tax year, whether operated  
directly by the organization or through a disregarded entity or a  
joint venture treated as a partnership.  
assistance at its hospital(s) and other facilities, if any. Financial  
assistance includes free or discounted health services provided  
to persons who meet the organization's criteria for financial  
assistance and are unable to pay for all or a portion of the  
services. Financial assistance doesn't include: bad debt or  
uncollectible charges that the organization recorded as revenue  
but wrote off due to a patient's failure to pay, or the cost of  
providing such care to such patients; the difference between the  
cost of care provided under Medicaid or other means-tested  
government programs or under Medicare and the revenue  
derived therefrom; self-pay or prompt pay discounts; or  
contractual adjustments with any third-party payers.  
Line 2. Check only one of the three boxes. “Applied uniformly to  
all hospitals” means that all of the organization's hospital  
facilities use the same FAP. Applied uniformly to most  
hospitals” means that the majority of the organization's hospital  
facilities use the same FAP. Generally tailored to individual  
hospitals” means that the majority of the organization's hospital  
facilities use different financial assistance policies. If the  
organization operates only one hospital facility, check “Applied  
uniformly to all hospitals.”  
Organizations aren't to enter information from hospitals  
located outside the United States in Parts I, II, III, or V.  
Information from foreign joint ventures and partnerships must be  
reported in Part IV, Management Companies and Joint Ventures.  
Information concerning foreign hospitals and facilities may be  
described in Part VI.  
Except as provided in Part IV, don't report on Schedule H  
(Form 990) information from an entity organized as a separate  
legal entity from the organization and treated as a corporation for  
federal income tax purposes (except for members of a group  
exemption included in a group return filed by the organization),  
even if such entity is affiliated with or otherwise related to the  
organization (for example, part of an affiliated health care  
system).  
If an organization isn't required to file Form 990 but chooses  
to do so, it must file a complete return and provide all of the  
information requested, including the required schedules.  
An organization that didn't operate one or more facilities  
during the tax year that satisfy the definition of hospital facility  
above shouldn't file Schedule H (Form 990).  
Line 3. Answer lines 3a, 3b, and 3c, based on the financial  
assistance eligibility criteria that apply to (1) the largest number  
of the organization's patients based on patient contacts or  
encounters, or (2) if the organization doesn't operate its own  
hospital facility, the largest number of patients of a hospital  
facility operated by a joint venture in which the organization has  
an ownership interest. For example, if the organization has two  
hospital facilities, use the financial assistance eligibility criteria  
used by the hospital facility that has the most patient contacts or  
encounters during the tax year.  
Line 3a. “Federal Poverty Guidelines” (FPG) are the Federal  
Poverty Guidelines published annually by the U.S. Department of  
Health and Human Services. If the organization has established  
a family or household income threshold that a patient must meet  
or fall below to qualify for free medical care, check the box in the  
Yes” column and indicate the specific threshold by checking the  
appropriate box. For instance, if a patient's family or household  
income must be less than or equal to 250% of FPG for the  
patient to qualify for free care, then check the box marked  
“Other” and enter “250%.”  
Line 3b. If the organization has established a family or  
household income threshold that a patient must meet or fall  
below to qualify for discounted medical care, check the box in  
the “Yes” column and indicate the specific threshold by checking  
the appropriate box.  
Line 3c. If applicable, describe the other criteria used, such  
as asset test or other means test or threshold for free or  
discounted care, on Part VI, line 1, of this schedule. An “asset  
test” includes (i) a limit on the amount of total or liquid assets that  
a patient or the patient's family or household can own for the  
patient to qualify for free or discounted care, and/or (ii) a criterion  
for determining the level of discounted medical care patients can  
receive, depending on the amount of assets that they and/or  
their families or households own.  
The definition of “hospital” for Schedule A (Form 990),  
Public Charity Status and Public Support, Part I, line 3,  
and the definition of “hospital” for Schedule H (Form  
TIP  
990) aren't the same. Accordingly, an organization that checks  
box 3 in Part I of Schedule A (Form 990) to enter that it is a  
hospital or cooperative hospital service organization must  
complete and attach Schedule H to Form 990 only if it meets the  
definition of hospital facility for purposes of Schedule H (Form  
990), as explained above.  
Specific Instructions  
Line 4. “Medically indigent” means persons whom the  
organization has determined are unable to pay some or all of  
their medical bills because their medical bills exceed a certain  
percentage of their family or household income or assets (for  
example, due to catastrophic costs or conditions), even though  
they have income or assets that otherwise exceed the generally  
applicable eligibility requirements for free or discounted care  
under the organization's FAP.  
Part I. Financial Assistance and  
Certain Other Community Benefits at  
Cost  
Part I requires reporting of financial assistance policies, the  
availability of community benefit reports, and the cost of financial  
assistance and other community benefit activities and programs.  
Worksheets and accompanying instructions are provided at the  
end of the instructions to this schedule to assist in completing  
the table in Part I, line 7.  
Line 5. Answer lines 5a, 5b, and 5c based on the organization's  
budgeted amounts under its FAP.  
Line 5a. Answer “Yes” if the organization established or had  
in place at any time during the tax year an annual or periodic  
Line 1. An FAP, sometimes referred to as a charity care policy, is  
a policy describing how the organization will provide financial  
-2-  
Instructions for Schedule H  
 
budgeted amount of free or discounted care to be provided  
under its FAP. If “No,” skip to line 6a.  
calculating the amount entered on line 7, column (f), enter this  
bad debt expense on Part VI, line 1.  
Line 5b. Answer “Yes” if the free or discounted care the  
organization provided in the applicable period exceeded the  
budgeted amount of costs or charges for that period. If “No,skip  
to line 6a.  
Line 5c. Answer “Yes” if the organization denied financial  
assistance to any patient eligible for free or discounted care  
under its FAP or under any of its hospital facilities' financial  
assistance policies because the organization's or the facility's  
financial assistance budget was exceeded.  
The following are descriptions of the type of information  
reported in each column of the table.  
Column (a). “Number of activities or programs” means the  
number of the organization's activities or programs conducted  
during the year that involve the community benefit entered on the  
line. Enter each activity and program on only one line so that it  
isn't counted more than once. Entering in this column is optional.  
Column (b). “Persons served” means the number of patient  
contacts or encounters in accordance with the filing  
organization's records. Persons served can be entered in  
multiple rows, as services across different categories may be  
provided to the same patient. Entering in this column is optional.  
Column (c). Total community benefit expense” means the  
total gross expense of the activity incurred during the year,  
calculated by using the pertinent worksheets for each line item.  
Total community benefit expense” includes both “direct costs”  
and “indirect costs.Direct costs” means salaries and benefits,  
supplies, and other expenses directly related to the actual  
conduct of each activity or program. “Indirect costs” means costs  
that are shared by multiple activities or programs, such as  
facilities and administrative costs related to the organization's  
infrastructure (space, utilities, custodial services, security,  
information systems, administration, materials management, and  
others).  
Column (d). “Direct offsetting revenue” means revenue from  
the activity during the year that offsets the total community  
benefit expense of that activity, as calculated on the worksheets  
for each line item. “Direct offsetting revenue” includes any  
revenue generated by the activity or program, such as payment  
or reimbursement for services provided to program patients.  
Line 6. Answer lines 6a and 6b based on the community benefit  
report that the organization prepared for the organization as a  
whole during the tax year.  
Line 6a. Answer “Yes” if the organization prepared a written  
report during the tax year that describes the organization's  
programs and services that promote the health of the community  
or communities served by the organization. If the organization's  
community benefit report is contained in a report prepared by a  
related organization, answer “Yes” and identify the related  
organization on Part VI, line 1. If “No,skip to line 7.  
Line 6b. Answer “Yes” if the organization made the  
community benefit report it prepared during the tax year  
available to the public.  
Examples of how an organization can make its  
community benefit report available to the public are to  
post the report on the organization's website and to  
TIP  
make a paper copy of the community health needs assessment  
(CHNA) report available for public inspection upon request and  
without charge at the hospital facility.  
Lines 7a through 7k. Enter on the table (lines 7a through 7k),  
at cost, the organization's financial assistance (as defined in the  
instructions for line 1) and certain other community benefits (as  
defined in the instructions to Worksheets 1–8). Enter on line 7i  
contributions that the organization restricts, in writing, to one or  
more of the community benefit activities listed on lines 7a  
through 7h. Don't enter such contributions on lines 7a through  
7h. To calculate the amounts to be entered on the table, use the  
worksheets or other equivalent documentation that substantiates  
the information entered consistent with the methodology used on  
the worksheets. Don't include bad debt in these amounts. Bad  
debt will be entered in Part III.  
“Direct offsetting revenue” also includes restricted grants or  
contributions that the organization uses to provide a community  
benefit, such as a restricted grant to provide financial assistance  
or fund research. “Direct offsetting revenue” doesn't include  
unrestricted grants or contributions that the organization uses to  
provide a community benefit. Organizations may describe any  
inconsistencies from reporting in prior years in Part VI.  
Examples. The organization receives a restricted grant from  
an unrelated organization that must be used by the organization  
to provide financial assistance. The amount of the restricted  
grant is entered as direct offsetting revenue on line 7a, column  
(d).  
The organization receives an unrestricted grant from an  
unrelated organization. The organization decides to use the  
grant to increase the amount of financial assistance it provides.  
The amount of the unrestricted grant isn't entered as direct  
offsetting revenue on line 7a, column (d).  
Columns (e) and (f). Don't enter negative numbers. If the  
net community benefit expense is less than $0, enter “0.”  
Similarly, don't enter a negative percent in column (f), but enter  
“0.”  
Group return filers. The “total expense” denominator for  
purposes of determining the percent of total expense for column  
(f) is the amount entered on Form 990, Part IX, line 25, column  
(A), of the group return.  
If the organization completed worksheets other than on a  
combined basis (for example, facility by facility, joint  
venture by joint venture), the organization should  
TIP  
combine all information from these worksheets for purposes of  
entering amounts on the table. Only the portion of each joint  
venture or partnership that represents the organization's  
proportionate share, based on capital interest, can be entered on  
lines 7a through 7k. See Purpose of Schedule for instructions on  
aggregation.  
Use the organization's most accurate costing methodology  
(cost accounting system, cost-to-charge ratio, or other) to  
calculate the amounts entered on the table. If the organization  
uses a cost-to-charge ratio, it can use Worksheet 2, Ratio of  
Patient Care Cost to Charges, for this purpose. See the  
instructions for Part VI, line 1, regarding an explanation of the  
costing methodology used to calculate the amounts entered on  
the table.  
Column (f) “percent of total expense” is based on  
column (e) “net community benefit expense,rather than  
column (c) “total community benefit expense.”  
TIP  
Organizations that enter amounts of direct offsetting revenue  
might also wish to enter total community benefit expense (Part I,  
line 7, column (c)) as a percentage of total expenses. Although  
this percentage cannot be entered on Part I, line 7, column(f), it  
can be entered on Schedule H (Form 990), Part VI, line 1.  
If the organization included any costs for a physician clinic as  
subsidized health services on Part I, line 7g, enter these costs on  
Part VI, line 1.  
If the organization included any bad debt expense on Form  
990, Part IX, line 25, but subtracted this bad debt for purposes of  
-3-  
Instructions for Schedule H  
 
vulnerable populations and creating new employment  
opportunities in areas with high rates of joblessness.  
Worksheets for Part I, Line 7  
(Financial Assistance and Certain  
Other Community Benefits at Cost)  
Line 3. “Community support” can include, but isn't limited to,  
child care and mentoring programs for vulnerable populations or  
neighborhoods, neighborhood support groups, violence  
prevention programs, and disaster readiness and public health  
emergency activities, such as community disease surveillance or  
readiness training beyond what is required by accrediting bodies  
or government entities.  
Worksheets 1 through 8 give the definitions of community benefit  
to be used in completing Schedule H (Form 990), Part I, lines 7a  
through 7k. Use of the worksheets isn't required, and the  
organization can use alternative equivalent documentation,  
provided that the methodology described in these instructions  
(including the instructions to the worksheets) is followed.  
Regardless of whether the worksheets or alternative equivalent  
documentation is used to compile and enter the required  
information, such documentation should not be filed with Form  
990 but must be retained by the organization to substantiate the  
information entered on Schedule H (Form 990). The worksheets  
or alternative equivalent documentation are to be completed  
using the organization's most accurate costing methodology,  
which can include a cost accounting system, cost-to-charge  
ratios, a combination thereof, or some other method.  
Line 4. “Environmental improvements” include, but aren't limited  
to, activities to address environmental hazards that affect  
community health, such as alleviation of water or air pollution,  
safe removal or treatment of garbage or other waste products,  
and other activities to protect the community from environmental  
hazards. The organization can not include on this line or in this  
part expenditures made to comply with environmental laws and  
regulations that apply to activities of itself, its disregarded entity  
or entities, a joint venture in which it has an ownership interest,  
or a member of a group exemption included in a group return  
of which the organization is also a member. Similarly, the  
organization can not include on this line or in this part  
If the organization is filing a group return or has a disregarded  
entity or an ownership interest in one or more joint ventures,  
the organization may find it helpful to complete the worksheets  
separately for the organization and for each disregarded entity,  
joint venture in which the organization had an ownership interest  
during the tax year, and group affiliate. In that case, the  
organization should combine all information from the worksheets  
for purposes of completing line 7. Complete the table by  
combining amounts from the organization's worksheets,  
amounts from disregarded entities or group affiliates, and  
amounts from joint ventures that are attributable to the  
organization's proportionate share of each joint venture, under  
the aggregation instruction in Purpose of Schedule.  
expenditures made to reduce the environmental hazards caused  
by, or the environmental impact of, its own activities, or those of  
its disregarded entities, joint ventures, or group exemption  
members, unless the expenditures are for an environmental  
improvement activity that:  
1. Is provided for the primary purpose of improving  
community health,  
2. Addresses an environmental issue known to affect  
community health, and  
3. Is subsidized by the organization at a net loss.  
An expenditure may not be entered on this line if the organization  
engages in the activity primarily for marketing purposes.  
See Worksheets 1 through 8 and specific instructions for the  
worksheets later in these instructions.  
Line 5. “Leadership development and training for community  
members” includes, but isn't limited to, training in conflict  
resolution; civic, cultural, or language skills; and medical  
interpreter skills for community residents.  
Part II. Community Building Activities  
Enter in this part the costs of the organization's activities that it  
engaged in during the tax year to protect or improve the  
community's health or safety, and that aren't entered in Part I of  
this schedule. Some community building activities may also  
meet the definition of a community health improvement service,  
as defined in Worksheet 4. Don't enter in Part II community  
building costs that are entered on Part I, line 7e. An organization  
that enters information in this Part II must describe in Part VI how  
its community building activities promote the health of the  
communities it serves.  
Line 6. “Coalition building” includes, but isn't limited to,  
participation in community coalitions and other collaborative  
efforts with the community to address health and safety issues.  
Line 7. “Community health improvement advocacy” includes,  
but isn't limited to, efforts to support policies and programs to  
safeguard or improve public health, access to health care  
services, housing, the environment, and transportation.  
Line 8. “Workforce development” includes, but isn't limited to,  
recruitment of physicians and other health professionals to  
medical shortage areas or other areas designated as  
underserved, and collaboration with educational institutions to  
train and recruit health professionals needed in the community  
(other than the health professions education activities entered on  
Part I, line 7f).  
If the filing organization makes a grant to an organization to  
be used to accomplish one of the community building activities  
listed in this part, then the organization should include the  
amount of the grant on the appropriate line in Part II. If the  
organization makes a grant to a joint venture in which it has an  
ownership interest to be used to accomplish one of the  
community building activities listed in this part, enter the grant on  
the appropriate line in Part II, but don't include in Part II the  
organization's proportionate share of the amount spent by the  
joint venture on such activities to avoid double counting.  
Line 9. “Other” refers to community building activities that  
protect or improve the community's health or safety that aren't  
described in the categories listed on lines 1 through 8 above.  
Examples might include, but are not limited to, spending on food  
security, nutrition, and other social determinants of health.  
Refer to the instructions to Part I, line 7, columns (a) through  
(f), for descriptions of the types of information that should be  
entered in each column of Part II.  
Line 1. “Physical improvements and housing” include, but aren't  
limited to, the provision or rehabilitation of housing for vulnerable  
populations, such as removing building materials that harm the  
health of the residents, neighborhood improvement or  
revitalization projects, provision of housing for vulnerable  
patients upon discharge from an inpatient facility, housing for  
low-income seniors, and the development or maintenance of  
parks and playgrounds to promote physical activity.  
If the organization is filing a group return or has a  
disregarded entity or an ownership interest in one or more  
joint ventures, the organization may find it helpful to complete  
Part II separately for itself and for each disregarded entity, joint  
venture in which the organization had an ownership interest  
Line 2. “Economic development” can include, but isn't limited to,  
assisting small business development in neighborhoods with  
-4-  
Instructions for Schedule H  
   
during the tax year, and group affiliate. The organization should  
combine the amounts from all such tables, according to the  
combined instructions in Purpose of Schedule, and include the  
combined information in Part II.  
accounts,or similar designations, provide the exact wording of  
the footnote or footnotes, or enter the page number(s) in which  
the footnote or footnotes appear in the attached audited financial  
statements.  
If the organization's financial statements include a footnote on  
these issues that also includes other information, enter in Part VI  
only the relevant portions of the footnote. If the organization is a  
member of a group with consolidated financial statements, the  
organization can summarize that portion, if any, of the footnote or  
footnotes that apply. If the organization's financial statements  
don't include a footnote that discusses bad debt expense,  
“accounts receivable,"allowance for doubtful accounts," or  
similar designations, include a statement in Part VI that the  
organization's audited financial statements don't include a  
footnote discussing these issues and explain how the  
Part III. Bad Debt, Medicare, and  
Collection Practices  
Section A  
In this section, (a) enter combined bad debt expense; (b) provide  
an estimate of how much bad debt expense, if any, reasonably  
could be attributable to persons who likely would qualify for  
financial assistance under the organization’s FAP; and (c)  
provide a rationale for what portion of bad debt, if any, the  
organization believes is community benefit. In addition, the  
organization must enter whether it has adopted Healthcare  
Financial Management Association Statement No. 15, Valuation  
and Financial Presentation of Charity Care, Implicit Price  
Concessions and Bad Debts by Institutional Healthcare  
Providers (“Statement 15”), and provide the text or page number  
of its footnote, if applicable, to its audited financial statements  
that describe the bad debt expense.  
organization's financial statements account for bad debt, if at all.  
Section B  
In this section, (a) combine allowable costs to provide services  
reimbursed by Medicare (don't include community benefit costs  
included on Part I, line 7), (b) combine Medicare  
reimbursements attributable to such costs, and(c) combine  
Medicare surplus or shortfall. Include in Section B only those  
allowable costs and Medicare reimbursements that are reported  
in the organization's Medicare Cost Report(s) for the year,  
including its share of any such allowable costs and  
reimbursement from disregarded entities and joint ventures  
in which it has an ownership interest. Don't include any  
Medicare-related expenses or revenue properly entered on Part  
I, line 7f or 7g.  
Line 1. Indicate if the organization enters bad debt expense in  
accordance with Statement 15.  
Note. Statement 15 hasn't been adopted by the American  
Institute of Certified Public Accountants (AICPA). The IRS  
doesn't require organizations to adopt Statement 15 or use it to  
determine bad debt expense or financial assistance costs. Some  
organizations may rely on Statement 15 in reporting bad debt  
expense and financial assistance in their audited financial  
statements. Statement 15 provides instructions for  
In Part VI, the organization should describe what portion of its  
Medicare shortfall, if any, it believes should constitute community  
benefit, and explain its rationale for its position. As described  
below, the organization can also enter in Part VI the amount of  
any Medicare revenues and costs not included in its Medicare  
Cost Report(s) for the year, and can enter a reconciliation of the  
amounts entered in Section B (including the surplus or shortfall  
entered on line 7) and the total revenues and costs attributable  
to all of the organization's Medicare programs.  
recordkeeping, valuation, and disclosure for bad debts.  
Line 2. Use the most accurate system and methodology  
available to the organization to enter bad debt expense. If only a  
portion of a patient’s bill for services is written off as a bad debt,  
include only the proportionate amount attributable to the bad  
debt. Include the organization’s proportionate share of the bad  
debt expense of joint ventures in which it had an ownership  
interest during the tax year.  
Describe in Part VI the methodology used in determining the  
amount entered on line 2 as bad debt, including how the  
organization accounted for discounts and payments on patient  
accounts in determining bad debt expense.  
Line 5. Enter all net patient service revenue (for Medicare fee  
for service (FFS) patients) associated with the allowable costs  
the organization entered in its Medicare Cost Report(s) for the  
year, including payments for indirect medical education (IME)  
(except for Medicare Advantage IME), Medicare  
disproportionate share hospital (DSH) revenue, coinsurance,  
patient deductible, outliers, capital, bad debt, and any other  
amounts paid to the organization on the basis of its Medicare  
Cost Report. Don't include revenue related to subsidized health  
services as entered on Part I, line 7g (see Worksheet 6),  
research as entered on Part I, line 7h (see Worksheet 7), or  
direct graduate medical education (GME) as entered on Part I,  
line 7f (see Worksheet 5). If the organization has more than one  
Medicare provider number, combine the revenue attributable to  
costs reported on the Medicare Cost Report(s) submitted under  
each provider number, and enter the combined revenues on  
line 5.  
Line 3. Provide an estimate of the amount of bad debt entered  
on line 2 that reasonably is attributable to patients who likely  
would qualify for financial assistance under the hospital's FAP  
as entered on Part I, lines 1 through 4, but for whom insufficient  
information was obtained to determine their eligibility. Don't  
include this amount in Part I, line 7. Organizations can use  
any reasonable methodology to estimate this amount, such as  
record reviews, an assessment of financial assistance  
applications that were denied due to incomplete documentation,  
analysis of demographics, or other analytical methods.  
Describe in Part VI the methodology used to determine the  
amount entered on line 3 and the rationale, if any, for including  
any portion of bad debt as community benefit.  
Line 6. Enter all Medicare allowable costs reported in the  
organization's Medicare Cost Report(s), except those already  
entered on line 7g, Part I (subsidized health services), and costs  
associated with direct GME already entered on line 7f, Part I  
(health professions education). This can be determined using  
Worksheet A. If Worksheet A isn't used, the organization still  
must subtract the costs attributable to subsidized health services  
and direct GME from the Medicare allowable costs it enters on  
line 6. If the organization has more than one Medicare provider  
number, it should combine the costs reported in the Medicare  
Cost Report(s) submitted under each provider number and enter  
the combined costs on line 6.  
Line 4. In Part VI, provide the footnote from the organization's  
audited financial statements on bad debt expense, if  
applicable, or the footnotes related to “accounts receivable,”  
“allowance for doubtful accounts,or similar designations.  
Alternatively, enter the page number(s) on which the footnote or  
footnotes appear in the organization's most recent audited  
financial statements, which must be attached to this return. If the  
footnote or footnotes address only the filing organization's bad  
debt expense or “accounts receivable,allowance for doubtful  
-5-  
Instructions for Schedule H  
 
or not such practices apply specifically to such patients or more  
broadly to also cover other types of patients.  
Worksheet A (Optional)  
Complete Worksheets 5 and 6 before completing this Worksheet  
A.  
Part IV. Management Companies and  
Joint Ventures Owned 10% or More  
by Officers, Directors, Trustees, Key  
Employees, and Physicians  
1.  
2.  
3.  
4.  
5.  
Total Medicare allowable costs (from Medicare  
$
$
$
$
$
Cost Report)  
Total Medicare allowable costs (from line 1)  
included in Worksheet 6, line 3, col. (A)  
Total Medicare allowable costs (from line 1)  
included in Worksheet 5, line 8 (direct GME)  
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
List any management company, joint venture, or other  
separate entity (whether treated as a partnership or a  
corporation), including joint ventures outside of the United  
States, of which the organization is a partner or shareholder:  
.
.
.
Total adjustments to Medicare allowable costs (add  
lines 2 and 3) .  
Total Medicare allowable costs (line 1 minus line 4).  
Enter this value in Part III, line 6.  
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1. In which persons described in 1a and/or 1b below owned,  
in the aggregate, more than 10% of the share of profits of such  
partnership or LLC interest, or stock of the corporation:  
.
.
.
.
.
.
.
.
.
.
.
a. Persons who were officers, directors, trustees, or key  
employees of the organization at any time during the  
organization's tax year, and/or  
b. Physicians who were employed as physicians by, or had  
staff privileges with, one or more of the organization's hospitals;  
and  
Line 7. Subtract line 6 from the amount on line 5. If line 6  
exceeds line 5, enter the surplus (the shortfall) as a negative  
number.  
Lines 5, 6, and 7 don't include certain Medicare program  
2. That either:  
revenues and costs, and thus cannot reflect all of the  
organization's revenues and costs associated with its  
TIP  
a. Provided management services used by the organization  
in its provision of medical care, or  
participation in Medicare programs. The organization can  
describe in Part VI the Medicare revenues and costs not  
included in its Medicare Cost Report(s) for the year (for example,  
revenues and costs for freestanding ambulatory surgery centers,  
physician services billed by the organization, clinical laboratory  
services, and revenues and costs of Medicare Part C and Part D  
programs). The organization can enter on Part VI, line 1, a  
reconciliation of amounts entered in Section B (including the  
surplus or shortfall entered on line 7) and all of the organization's  
total revenues and total expenses attributable to Medicare  
programs.  
b. Provided medical care, or owned or provided real  
property, tangible personal property, or intangible property used  
by the organization or by others to provide medical care.  
Examples of such joint ventures and management companies  
include:  
An ancillary joint venture formed by the organization and its  
officers or physicians to conduct an exempt or unrelated  
business activity,  
A company owned by the organization and its officers or  
physicians that owns and leases to the organization a hospital or  
other medical care facility, and  
Line 8. Check the box that best describes the costing  
methodology used to enter the Medicare allowable costs on  
line 6. Describe this methodology in Part VI.  
The organization must also describe in Part VI its rationale for  
treating the amount entered on Part III, line 7, or any portion of it,  
as a community benefit. An organization's rationale must have a  
reasonable basis. Don't include this amount on Part I, line 7.  
If the organization received any prior year settlements for  
Medicare-related services in the current tax year, it can provide  
an explanation on Part VI, line 1.  
A company that owns and leases to entities other than the  
organization’s diagnostic equipment or intellectual property used  
to provide medical care.  
For purposes of Part IV, ownership interests can be direct or  
indirect. For example, if a joint venture reported in Part IV is  
owned, in part, by a physician group practice owned by staff  
physicians of the organization's hospital, report the physicians'  
indirect ownership interest in the joint venture in proportion to  
their ownership share of the physician group practice.  
Note. Don't include publicly traded entities or entities whose  
sole income is passive investment income from interest or  
dividends.  
Section C  
In this section, enter the organization's written debt collection  
policy.  
For purposes of Part IV, the aggregate percentage share of  
profits or stock ownership percentage of officers, directors,  
trustees, key employees, and physicians who are employed as  
physicians by, or have staff privileges with, one or more of the  
organization's hospitals is measured as of the earlier of the close  
of the tax year of the organization or the last day the organization  
was a member of the joint venture. All stock, whether common or  
preferred, is considered stock for purposes of determining the  
stock ownership percentage. Provide all the information  
requested below for each such entity.  
Line 9a. Answer “Yes” if the organization had a written debt  
collection policy on the collection of amounts owed by patients  
during its tax year.  
For purposes of line 9a, a “written debt collection policy”  
includes a written billing and collections policy, or in the case of  
an organization that doesn't have a separate written billing and  
collections policy, a written FAP that includes the actions the  
organization may take in the event of non-payment, including  
collection actions and reporting to credit agencies.  
Line 9b. Answer “Yes” if the organization's written debt  
collection policy that applied to the facilities that served the  
largest number of the organization's patients during the tax year  
contained provisions for collecting amounts due from those  
patients who the organization knows qualify for financial  
assistance. If the organization answers “Yes,describe in Part VI  
the collection practices that it follows for such patients, whether  
Column (a). Enter the full legal name of the entity.  
Column (b). Describe the primary business activity or activities  
conducted by the management company, joint venture, or  
separate entity.  
-6-  
Instructions for Schedule H  
   
Teaching hospital” is a hospital that provides training to  
medical students, interns, residents, fellows, nurses, or other  
health professionals and providers, provided that such  
educational programs are accredited by the appropriate national  
accrediting body.  
Column (c). Enter the organization's percentage share of  
profits in the partnership or LLC, or stock in the entity that is  
owned by the organization.  
Column (d). Enter the percentage share of profits or stock in  
the entity owned by all of the organization's current officers,  
directors, trustees, or key employees.  
“Critical access hospital” (CAH) is a hospital designated as a  
CAH by a state that has established a State Medicare Rural  
Hospital Flexibility Program in accordance with Medicare rules.  
Column (e). Enter the percentage share of profits or stock in  
the entity owned by all physicians who are employees practicing  
as physicians or who have staff privileges with one or more of the  
organization's hospitals.  
If a physician described above is also a current officer,  
director, trustee, or key employee of the organization, include the  
physician’s profits or stock percentage in column (d). Don't  
include this in column (e).  
“Research facility” is a facility that conducts research.  
“ER—24 hours” refers to a facility that operates an  
emergency room 24 hours a day, 365 days a year.  
“ER—other” refers to a facility that operates an emergency  
room for periods less than 24 hours a day, 365 days a year.  
Complete the “Other (describe)” column for each hospital  
facility that the organization operates that isn't described in the  
other columns of Part V, Section A.  
Part IV can be duplicated if more space is needed to list  
additional management companies and joint ventures.  
Part V. Facility Information  
In the upper left-hand corner of the Part V, Section A, table,  
list the total number of hospital facilities that the organization  
operated during the tax year.  
In Part V, the organization must list all of its hospital facilities in  
Section A, complete separate Sections B and C for each of its  
hospital facilities or facility reporting groups listed in Section A,  
and list its non-hospital health care facilities in Section D.  
If the organization needs additional space to list all of its  
hospital facilities, it should duplicate Section A and use as many  
duplicate copies of Section A as needed, number each page,  
and renumber the line numbers in the left-hand margin (an  
organization with 15 facilities should renumber lines 1–5 on the  
second page as lines 11–15).  
Facility reporting groups. If the organization is able to check  
the same checkboxes for all Part V, Section B, questions for  
more than one of its hospital facilities, it may file a single  
Section B and Section C for all facilities in that facility reporting  
group. For each of those facilities, the organization would assign  
and list the facility reporting group letter in the “Facility reporting  
group” column in Section A. Assign letter A to the facility  
reporting group with the greatest number of facilities, letter B to  
the group with the second greatest number of facilities, and so  
forth. For instance, three hospital facilities with identical answers  
to the Section B checkboxes would be assigned facility group  
letter A, while two other hospital facilities with identical answers  
would be assigned facility group letter B.  
Section B  
Section B requires reporting on a hospital facility by hospital  
facility basis. The organization must complete a Section B for  
each of its hospital facilities or facility reporting groups listed in  
Section A. At the top of each page of Section B, list the name of  
the hospital facility or the facility reporting group letter. In the  
space provided, list the line number of the hospital facility, or line  
numbers of the hospital facilities in a facility reporting group  
(from Part V, Section A).  
Section A  
If the organization could check the same checkboxes for all  
Part V, Section B, questions for more than one of its hospital  
facilities, it may file a single Section B for all facilities in that  
facility reporting group.  
Complete Part V, Section A, by listing all of the organization's  
hospital facilities that it operated during the tax year. List  
these facilities in order of size from largest to smallest, measured  
by a reasonable method (for example, the number of patients  
served or total revenue per facility). “Hospital facilities” are  
facilities that, at any time during the tax year, were required to be  
licensed, registered, or similarly recognized as a hospital under  
state law. A hospital facility is operated by an organization  
whether the facility is operated directly by the organization or  
through a disregarded entity or joint venture treated as a  
partnership. For each hospital facility, list its name, address,  
primary website address, and state license number (and if a  
group return, the name and employer identification number (EIN)  
of the subordinate hospital organization that operates the  
hospital facility), and check the applicable column(s).  
References in these Section B instructions to a “hospital  
facility” taking a certain action mean that the hospital  
organization took action through or on behalf of the hospital  
facility.  
Line 1. Answer “Yes” if the hospital facility was first licensed,  
registered, or similarly recognized by a state as a hospital facility  
in the current tax year or the immediately preceding tax year.  
Line 2. Answer “Yes” if the hospital facility was acquired or  
placed into service as a tax-exempt hospital in the current tax  
year or the immediately preceding tax year. If “Yes,provide  
details in Section C.  
“Licensed hospital” is a facility licensed, registered, or  
similarly recognized by a state as a hospital.  
Lines 3 through 12c. A community health needs assessment  
(CHNA) is an assessment of the significant health needs of the  
community. To meet the requirements of section 501(r)(3), a  
CHNA must take into account input from persons who represent  
the broad interests of the community served by the hospital  
facility, including those with special knowledge of or expertise in  
public health, and must be made widely available to the public.  
Each hospital facility must conduct a CHNA at least once  
every 3 years, and adopt an implementation strategy to meet the  
community health needs identified through such CHNA.  
“General medical and surgical” refers to a hospital primarily  
engaged in providing diagnostic and medical treatment (both  
surgical and nonsurgical) to inpatients with a wide variety of  
medical conditions, and that may provide outpatient services,  
anatomical pathology services, diagnostic X-ray services,  
clinical laboratory services, operating room services, and  
pharmacy services.  
“Children's hospital” is a center for provision of health care to  
children, and includes independent acute care children's  
hospitals, children's hospitals within larger medical centers, and  
independent children's specialty and rehabilitation hospitals.  
Line 3. Answer “Yes” if the hospital facility conducted a CHNA  
in the current tax year or in either of the 2 immediately preceding  
tax years. If “Yes,indicate what the CHNA describes by  
-7-  
Instructions for Schedule H  
   
checking all applicable boxes. If the CHNA describes information  
that doesn't have a corresponding checkbox, check line 3j,  
“Other,and describe this information in Part V, Section C. If “No,”  
skip to line 12.  
input; and describe the medically underserved, low-income, or  
minority populations being represented by organizations or  
individuals that provided input. A CHNA report doesn't need to  
name or otherwise identify any specific individual providing input  
on the CHNA. In the event a hospital facility solicits, but cannot  
obtain, input from a source required by line 5, the hospital  
facility's CHNA report must also describe the hospital facility's  
efforts to solicit input from such source.  
Note. Notice 2020-56 provided a postponement, until  
December 31, 2020, of the deadline for performing any CHNA  
requirement due to be completed on or after April 1, 2020, and  
before December 31, 2020. If you utilized this relief, treat the  
completed CHNA as having been completed in the tax year in  
which it would have been due in the absence of any relief when  
answering line 3 and line 4.  
Notice 2022-36 provides relief for certain taxpayers from  
certain failure to file penalties and certain international  
information return (IIR) penalties with respect to tax returns for  
taxable years 2019 and 2020 that are filed on or before  
September 30, 2022. This notice also provides relief from certain  
information return penalties with respect to taxable year 2019  
returns that were filed on or before August 1, 2020, and with  
respect to taxable year 2020 returns that were filed on or before  
August 1, 2021.  
Line 6a. Answer “Yes” if the hospital facility's CHNA was  
conducted with one or more other hospital facilities. “One or  
more other hospital facilities” includes related and unrelated  
hospital facilities. If “Yes,list in Part V, Section C, the other  
hospital facilities with which the hospital facility conducted its  
CHNA.  
Line 6b. Answer “Yes” if the hospital facility's CHNA was  
conducted with one or more organizations other than hospital  
facilities. If “Yes,list in Part V, Section C, the other organizations  
with which the hospital facility conducted its CHNA.  
Line 7. Answer “Yes” if the hospital facility made its most  
recently conducted CHNA widely available to the public. If “Yes,”  
indicate how the hospital facility made the CHNA widely  
available to the public by checking all applicable boxes. If the  
hospital facility made the CHNA widely available to the public by  
means other than those listed on lines 7a through 7c, check  
line 7d, “Other,and describe these means in Part V, Section C.  
Line 3a. Check this box if the CHNA report defines the  
community served by the hospital facility and a description of  
how the community was determined.  
Line 3c. Check this box if the CHNA report describes the  
resources potentially available to address the significant health  
needs identified through the CHNA, including existing health  
care facilities and resources within the community that are  
available to respond to the health needs of the community.  
Line 7a. Check this box if the CHNA was made available on the  
hospital facility’s website or the hospital organization’s website. If  
line 7a is checked, list in the space provided the direct website  
address, or URL, where the CHNA can be accessed.  
Line 3d. Check this box if the CHNA report describes the  
process and methods used to conduct the CHNA.  
Line 7b. Check this box if the CHNA was made available on a  
website other than the hospital facility’s website or the hospital  
organization’s website. If line 7b is checked, list in the space  
provided the direct website address, or URL, where the CHNA  
can be accessed.  
Line 3e. In Part V, Section C, indicate if the significant health  
needs are a prioritized description of the significant health needs  
of the community and identified through the CHNA. If not,  
explain how the health needs identified will be prioritized.  
Line 7c. Check this box if a paper copy of the CHNA was made  
available for public inspection upon request and without charge  
at the hospital facility.  
Line 3g. Check this box if the CHNA report describes the  
process and criteria used in identifying certain health needs as  
significant and prioritizing those significant health needs.  
Line 8. Answer “Yes” if the hospital facility adopted an  
implementation strategy to meet the significant health needs  
identified through its most recently conducted CHNA. If “No,”  
skip to line 11.  
Line 3h. Check this box if the CHNA report describes how the  
hospital facility solicited and took into account input received  
from persons who represent the broad interests of the  
community it serves.  
Line 10. Answer “Yes” if the hospital facility’s most recently  
adopted implementation strategy is posted on a website. If “Yes,”  
answer line 10a. If “No,skip to line 10b.  
Line 3i. Check this box if the CHNA report describes the  
evaluation of the impact of any actions that were taken, since the  
hospital facility finished conducting its immediately preceding  
CHNA, to address the significant health needs identified in the  
hospital facility’s prior CHNA(s).  
Line 10a. List in the space provided the direct website address,  
or URL, where the implementation strategy can be accessed  
and skip to line 11.  
Line 5. Answer “Yes” if the hospital facility took into account  
input from persons who represent the broad interests of the  
community served by the hospital facility, including at least one  
state, local, tribal, or regional governmental public health  
department (or equivalent department or agency), or a State  
Office of Rural Health described in section 338J of the Public  
Health Service Act (section 254r), with knowledge, information,  
or expertise relevant to the health needs of that community,  
members of medically underserved, low-income, and minority  
populations in the community served by the hospital facility, or  
individuals or organizations serving or representing the interests  
of such populations; and written comments received on the  
hospital facility's most recently conducted CHNA and most  
recently adopted implementation strategy.  
Line 10b. Answer “Yes” if the hospital facility’s most recently  
adopted implementation strategy is attached.  
Line 11. Explain in Part V, Section C, how the hospital facility is  
addressing the significant needs identified in its most recently  
conducted CHNA and any such needs that aren't being  
addressed together with the reasons why such needs aren't  
being addressed. For example, a hospital facility might identify  
limited financial or other resources as reasons why it didn't take  
action to address a need identified in its most recently  
conducted CHNA.  
Line 12a. Answer “Yes” if the organization was liable, at any  
time during the tax year, for the $50,000 excise tax incurred  
under section 4959 for failure to conduct a CHNA and adopt an  
implementation strategy as required under section 501(r)(3).  
Section 501(r)(3) requires each hospital facility to conduct a  
CHNA, in the tax year or in either of the immediately preceding 2  
tax years, that takes into account input from persons who  
If the organization checked “Yes,summarize in Part V,  
Section C, in general terms, how and over what time period such  
input was provided (for example, whether through meetings,  
focus groups, interviews, surveys, or written comments, and  
between what dates); the names of any organizations providing  
-8-  
Instructions for Schedule H  
represent the broad interests of the community served by the  
facility, including those with special knowledge of or expertise in  
public health, and to make the CHNA widely available to the  
public. Section 501(r)(3) also requires each hospital facility to  
adopt an implementation strategy to meet the community health  
needs identified through its CHNA.  
for financial assistance. If “Yes,indicate how the hospital  
facility’s FAP or FAP application form (including the  
accompanying instructions) explained the method for applying  
for financial assistance by checking all applicable boxes. If the  
FAP explains a method(s) for applying for financial assistance  
other than those listed on lines 15a through 15d, check 15e,  
“Other,and explain the method(s) in Part V, Section C.  
Line 12b. Answer “Yes” to line 12b if the organization answered  
Yes” to line 12a and filed Form 4720, Return of Certain Excise  
Taxes Under Chapters 41 and 42 of the Internal Revenue Code,  
to report the section 4959 excise tax it incurred. Answer “Yes” if  
the organization filed Form 4720 during the tax year or after the  
tax year but prior to the filing of this return.  
Line 15a. Check this box if the hospital facility described all of  
the information it may require an individual to provide as part of  
the application.  
Line 15b. Check this box if the hospital facility described all of  
the supporting documentation it may require an individual to  
submit as part of the application.  
Line 12c. If line 12b is “Yes,” report the total amount of section  
4959 excise tax the organization reported on Form 4720 for all of  
its hospital facilities that incurred the tax.  
Line 15c. Check this box if the hospital facility provided  
contact information of hospital facility staff that the hospital  
facility has identified as an available source of assistance with  
FAP applications.  
Lines 13 through 16. See the instructions for Part I, line 1, of  
Schedule H (Form 990) for the definition of “financial assistance  
policy ” (FAP). Answer “Yes” only if the FAP applies to all  
emergency and other medically necessary care provided by the  
hospital facility, including all such care provided in the hospital  
facility by a substantially related entity.  
Line 15d. Check this box if the hospital facility provided the  
contact information of a nonprofit organization or government  
agency that the hospital facility has identified as an available  
source of assistance with FAP applications.  
Line 13. Answer “Yes” if, during the tax year, the hospital  
facility had a written FAP that explains eligibility criteria for  
financial assistance, and whether such assistance includes free  
or discounted care. If “Yes,indicate the eligibility criteria  
explained in the FAP by checking all applicable boxes. If the FAP  
describes information that doesn't have a corresponding  
checkbox, check line 13h, “Other,and describe this information  
in Part V, Section C.  
Line 16. Answer “Yes” if, during the tax year, the FAP was  
widely publicized within the community served by the hospital  
facility. If “Yes,indicate how the hospital facility publicized the  
policy by checking all applicable boxes. If the hospital facility  
publicized the policy within the community served by the hospital  
facility by means that aren't listed on lines 16a–16i, check  
line 16j, “Other,and describe in Part V, Section C, how the FAP  
was publicized within the community served by the hospital  
facility.  
Line 13a. See the instructions for Part I, line 3a, of Schedule H  
(Form 990) for the definition of “Federal Poverty Guidelines”  
(FPG). Check this box if, during the tax year, the hospital  
facility had a written FAP that used FPG for determining  
eligibility for free or discounted medical care. Show the specific  
threshold by writing in the percentage amount. If the hospital  
facility used FPG for determining eligibility for free or discounted  
medical care, but not both free and discounted medical care,  
enter “000” in the percentage amount for which FPG wasn't  
used.  
Line 16g. Check this box if individuals were notified about the  
FAP by being offered a paper copy of the plain language  
summary of the FAP, by receiving a conspicuous written notice  
about the FAP on their billing statements, and via conspicuous  
public displays or other measures reasonably calculated to  
attract patients' attention.  
Line 16i. Check this box if the FAP, FAP application form, and  
plain language summary of the FAP were translated into the  
primary language(s) spoken by Limited English Proficient (LEP)  
populations, such as by translating these documents into the  
language(s) spoken by each LEP language group that  
constitutes the lesser of 1,000 individuals or 5% of the  
community served by the hospital facility or the population likely  
to be affected or encountered by the hospital facility.  
Line 13b. Check this box if the hospital facility used an income  
level other than FPG and explain in Part V, Section C, what  
criteria the hospital facility used to determine eligibility for free or  
discounted care (including whether the hospital facility used the  
income level of patients, patients’ families, or patients’  
guarantors as a factor).  
Line 16j. “Other” measures to publicize the policy within the  
community served by the hospital facility may include, but  
aren't limited to, having registration personnel refer uninsured  
and/or low-income patients to financial counselors to discuss the  
policy. Check the box for line 16j if, instead of the detailed policy,  
the hospital facility provided a summary of the policy in a manner  
listed in lines 16a–16i.  
Line 13c. Check this box if the hospital facility used the asset  
level of patients, patients' families, or patients' guarantors as a  
factor in determining eligibility for financial assistance.  
Line 13d. Check this box if the hospital facility considered  
whether patients were “medically indigent,as defined in the  
instructions for Part I, line 4, of Schedule H (Form 990), in  
determining eligibility for financial assistance.  
Line 17. Answer “Yes” if, during the tax year, the hospital  
facility had either a separate written billing and collections  
policy or a written FAP that described any actions that the  
hospital facility (or other authorized party) may take related to  
obtaining payment of a bill for medical care, including, but not  
limited to, any extraordinary collection actions (ECAs); the  
process and time frames the hospital facility (or other authorized  
party) uses in taking those actions (including, but not limited to,  
the reasonable efforts it will make to determine whether an  
individual is FAP-eligible before engaging in ECAs); and the  
office, department, committee, or other body with the final  
authority or responsibility for determining that the hospital facility  
has made reasonable efforts to determine whether an individual  
Line 13e. Check this box if the hospital facility used the  
insurance status of patients, patients' families, or patients'  
guarantors as a factor in determining eligibility for financial  
assistance.  
Line 13g. Check this box if the hospital facility considered  
residency as a factor in determining eligibility for financial  
assistance.  
Line 14. Answer “Yes” if, during the tax year, the hospital  
facility had a written FAP that explained the basis for calculating  
amounts charged to patients.  
Line 15. Answer “Yes” if, during the tax year, the hospital  
facility had a written FAP that explained the method for applying  
-9-  
Instructions for Schedule H  
   
is FAP-eligible and may therefore engage in ECAs against the  
individual.  
of this question, actions against an individual include actions to  
obtain payment for the care against any other individual who has  
accepted or is required to accept responsibility for the  
individual’s hospital bill for the care, and actions of the hospital  
facility include actions of any purchaser of the individual’s debt,  
any debt collection agency or other party to which the hospital  
facility has referred the individual’s debt, or any substantially  
related entity.  
Lines 18 and 19. “Other similar actions” don't include sending  
the patient a bill.  
Note. Section 501(r)(6) requires a hospital facility to forego  
ECAs before the facility has made reasonable efforts to  
determine the individual's eligibility under the facility's FAP.  
Line 19a. Check this box if the hospital facility reported adverse  
information about the individual to consumer credit reporting  
agencies or credit bureaus before making reasonable efforts to  
determine the individual's eligibility under the facility's FAP.  
Line 18. Indicate what actions against an individual the  
hospital facility was permitted to take during the tax year under  
its policies before making reasonable efforts to determine the  
individual's eligibility under the facility's FAP by checking all  
applicable boxes.  
Line 19b. Check this box if the hospital facility sold an  
individual's debt to another party before making reasonable  
efforts to determine the individual's eligibility under the facility's  
FAP. Don't check the box if, prior to the sale, the hospital facility  
entered into a legally binding written agreement with the  
purchaser of the debt pursuant to which the purchaser is  
prohibited from engaging in any ECAs to obtain payment for the  
care; the purchaser is prohibited from charging interest on the  
debt in excess of the rate in effect under section 6621(a)(2) at  
the time the debt is sold; the debt is returnable to or recallable by  
the hospital facility upon a determination by the hospital facility  
or the purchaser that the individual is FAP-eligible; and, if the  
individual is determined to be FAP-eligible and the debt isn't  
returned to or recalled by the hospital facility, the purchaser is  
required to adhere to procedures specified in the agreement that  
ensure that the individual doesn't pay, and has no obligation to  
pay, the purchaser and the hospital facility together more than  
the individual is personally responsible for paying as an  
FAP-eligible individual.  
Line 18a. Check this box if the FAP permitted reporting adverse  
information about the individual to consumer credit reporting  
agencies or credit bureaus.  
Line 18b. Check this box if the FAP permitted selling an  
individual's debt to another party. Don't check the box if, prior to  
the sale, the hospital facility entered into a legally binding written  
agreement with the purchaser of the debt pursuant to which the  
purchaser is prohibited from engaging in any ECAs to obtain  
payment for the care; the purchaser is prohibited from charging  
interest on the debt in excess of the rate in effect under section  
6621(a)(2) at the time the debt is sold; the debt is returnable to  
or recallable by the hospital facility upon a determination by the  
hospital facility or the purchaser that the individual is  
FAP-eligible; and, if the individual is determined to be  
FAP-eligible and the debt isn't returned to or recalled by the  
hospital facility, the purchaser is required to adhere to  
procedures specified in the agreement that ensure that the  
individual doesn't pay, and has no obligation to pay, the  
purchaser and the hospital facility together more than the  
individual is personally responsible for paying as an FAP-eligible  
individual.  
Line 19c. Check this box if the hospital facility deferred or  
denied, or required a payment before providing, medically  
necessary care because of an individual’s nonpayment of one or  
more bills for previously provided care covered under the  
hospital facility’s FAP.  
Line 18c. Check this box if the FAP permitted deferring or  
denying, or requiring a payment before providing, medically  
necessary care because of an individual’s nonpayment of one or  
more bills for previously provided care covered under the  
hospital facility’s FAP.  
Line 19d. Check this box if the hospital facility took legal action  
or pursued a judicial process, including but not limited to placing  
a lien on an individual's real property; attaching or seizing an  
individual's bank account or any other personal property;  
commencing a civil action against an individual; causing an  
individual's arrest; causing an individual to be subject to a writ of  
body attachment; or garnishing an individual's wages. Don't  
include any liens that a hospital facility is entitled to assert under  
state law on the proceeds of a judgment settlement, or  
compromise owed to an individual (or the individual’s  
representative) as a result of personal injuries for which the  
hospital facility provided care and if it filed a claim in a  
bankruptcy proceeding.  
Line 18d. Check this box if the FAP permitted actions that  
require a legal or judicial process, including but not limited to  
placing a lien on an individual's real property; attaching or  
seizing an individual's bank account or any other personal  
property; commencing a civil action against an individual;  
causing an individual's arrest; causing an individual to be subject  
to a writ of body attachment; or garnishing an individual's wages.  
Don't include any liens that a hospital facility is entitled to assert  
under state law on the proceeds of a judgment, settlement, or  
compromise owed to an individual (or the individual’s  
representative) as a result of personal injuries for which the  
hospital facility provided care and if it files a claim in a  
bankruptcy proceeding.  
Line 19e. If the hospital facility took an action or actions against  
an individual during the tax year similar to those listed in lines  
19a through 19d before making reasonable efforts to determine  
the individual's eligibility under the facility's FAP, check line 19e,  
“Other similar actions,and describe those actions in Part V,  
Section C.  
Line 18e. If a hospital facility's policies permitted the facility to  
take an action or actions against an individual during the tax year  
similar to those listed on lines 18a through 18d before making  
reasonable efforts to determine the individual's eligibility under  
the facility's FAP, check line 18e, “Other similar actions,and  
describe those actions in Part V, Section C.  
Line 20. Indicate which efforts the hospital facility or other  
authorized party made before initiating any of the actions listed  
(whether or not checked) on lines 19a through 19d or described  
in Part V, Section C (describing “other similar actions” checked  
on line 18e or line 19e), by checking all applicable boxes on lines  
20a through 20d. If the hospital facility made efforts other than  
those listed on lines 20a through 20d before initiating any of the  
actions listed on lines 19a through 19d or described in Part V,  
Section C (describing "other similar actions" checked on line 18e  
or line 19e), check the box for line 20e, “Other,and describe in  
Part V, Section C.  
Line 18f. If the hospital facility was permitted to make no such  
actions, check the box for line 18f, “None of these actions or  
similar actions were permitted.”  
Line 19. Indicate any of the actions against an individual that  
the hospital facility took during the tax year before making  
reasonable efforts to determine the individual's eligibility under  
the facility's FAP by checking all applicable boxes. For purposes  
-10-  
Instructions for Schedule H  
If the hospital facility made no such efforts before initiating  
any of the actions listed (whether or not checked) on lines 19a  
through 19d or described in Part V, Section C (describing “other  
similar actions” checked on line 18e or line 19e), check the box  
for line 20f, “None of these efforts were made.”  
1. Placing the health of the individual (or, for a pregnant  
woman, the health of the woman or the unborn child) in serious  
jeopardy,  
2. Serious impairment to bodily functions, or  
3. Serious dysfunction of any bodily organ or part; or  
Line 20a. Check this box if the hospital facility or other  
authorized party provided individuals with a written notice that  
indicated financial assistance is available for eligible individuals,  
identified the ECA(s) that the hospital facility (or other authorized  
party) intended to initiate to obtain payment for the care, and  
stated a deadline after which such ECA(s) may be initiated that  
was no earlier than 30 days after the date that the written notice  
was provided, along with a plain language summary of the FAP. If  
not, describe in Section C.  
(b) For a pregnant woman who is having contractions:  
1. That there is inadequate time to effect a safe transfer to  
another hospital before delivery, or  
2. That transfer may pose a threat to the health or safety of  
the woman or the unborn child.  
Lines 22–24. For purposes of lines 22–24, the term  
“FAP-eligible” means eligible for assistance under the hospital  
facility's FAP.  
Line 20b. Check this box if the hospital facility or other  
authorized party made a reasonable effort to orally notify  
individuals about the hospital facility’s FAP and about how the  
individual may obtain assistance with the FAP application  
process at least 30 days before initiating ECAs. If not, describe in  
Section C.  
Line 22. Indicate how the hospital facility determined, during the  
tax year, the maximum amounts that can be charged to  
FAP-eligible individuals for emergency or other medically  
necessary care by checking the appropriate box.  
Note. Under section 501(r)(5), the maximum amounts that can  
be charged to FAP-eligible individuals for emergency or other  
medically necessary care are the amounts generally billed to  
individuals who have insurance covering such care.  
Line 20c. Check this box if (1) when an individual who  
submitted an incomplete FAP application during the application  
period, the hospital facility or other authorized party notified the  
individual about how to complete the FAP application and gave  
the individual a reasonable opportunity to do so in accordance  
with Regulations section 1.501(r)-6(c)(5); and (2) when an  
individual who submitted a complete FAP application during the  
application period, the hospital facility or other authorized party  
determined whether the individual is FAP-eligible for the care  
and otherwise met the requirements described in Regulations  
section 1.501(r)-6(c)(6). If not, describe in Section C.  
Line 23. Answer “Yes” if, during the tax year, the hospital  
facility charged any FAP-eligible individual to whom the hospital  
facility provided emergency or other medically necessary  
services more than the amounts generally billed to individuals  
who had insurance covering such care. If “Yes,” explain in Part V,  
Section C, except as provided in the next paragraph.  
The hospital facility may check “No” if it charged more than  
the amounts generally billed to individuals who had insurance  
covering such care to an individual if the charge in excess of  
amounts generally billed (AGB) wasn't made or requested as a  
pre-condition of providing medically necessary care to the  
FAP-eligible individual; as of the time of the charge, the  
FAP-eligible individual hadn't submitted a complete FAP  
application and hadn't otherwise been determined by the  
hospital facility to be FAP-eligible for the care; and, if the  
individual subsequently submits a complete FAP application and  
is determined to be FAP-eligible for the care, the hospital facility  
refunds any amount that exceeds the amount the individual is  
determined to be personally responsible for paying as an  
FAP-eligible individual, unless such excess amount is less than  
$5.  
Line 20d. Check this box if the hospital facility or other  
authorized party made presumptive eligibility determinations in  
accordance with Regulations section 1.501(r)-6(c)(2). If not,  
describe in Section C.  
Line 21. Answer “Yes” if, during the tax year, the hospital  
facility had in place a written policy about emergency medical  
care that required the hospital facility to provide, without  
discrimination, care for emergency medical conditions to  
individuals without regard to their eligibility under the hospital  
facility's FAP. A hospital facility's emergency medical care policy  
doesn't meet this requirement unless it prohibits the hospital  
facility from engaging in actions that discourage individuals from  
seeking emergency medical care, such as by demanding that  
emergency department patients pay before receiving treatment  
for emergency medical conditions or by permitting debt  
collection activities that interfere with the provision, without  
discrimination, of emergency medical care. If “No,indicate the  
reasons why the hospital facility didn't have a written  
nondiscriminatory policy relating to emergency medical care by  
checking all applicable boxes. If the reason the hospital facility  
didn't have a written nondiscriminatory policy relating to  
emergency medical care isn't listed in lines 21a through 21c,  
check line 21d, “Other,and describe the reason(s) in Part V,  
Section C.  
Line 24. Answer “Yes” if, during the tax year, the hospital  
facility charged any FAP-eligible individual an amount equal to  
the gross charge for any service provided to that individual, and  
explain in Part V, Section C, the circumstances in which it used  
gross charges. A bill that itemizes a reduction applied to a gross  
charge for a service doesn't need to be reported if the amount  
charged to the individual for such service is less than the amount  
of the gross charge.  
The hospital facility may check “No” if it charged gross  
charges for any medical care covered under the FAP if the  
charge in excess of AGB wasn't made or requested as a  
pre-condition of providing medically necessary care to the  
FAP-eligible individual; as of the time of the charge, the  
FAP-eligible individual hadn't submitted a complete FAP  
application and hadn't otherwise been determined by the  
hospital facility to be FAP-eligible for the care; and, if the  
individual subsequently submits a complete FAP application and  
is determined to be FAP-eligible for the care, the hospital facility  
refunds any amount that exceeds the amount the individual is  
determined to be personally responsible for paying as a  
FAP-eligible individual, unless such excess amount is less than  
$5.  
The hospital facility may check “Yes” if it had a written policy  
that required compliance with 42 U.S.C. 1395dd (Emergency  
Medical Treatment and Active Labor Act (EMTALA)).  
For purposes of line 21, the term “emergency medical  
conditions” means:  
(a) A medical condition manifesting itself by acute symptoms  
of sufficient severity (including severe pain) such that the  
absence of immediate medical attention could reasonably be  
expected to result in:  
-11-  
Instructions for Schedule H  
   
reasonable efforts to determine the individual's eligibility under  
the facility's FAP.  
Section C  
Use Section C to provide descriptions required for Part V,  
Section B, lines 2, 3e, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j,  
18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24, as  
applicable. Complete a separate Section C for each hospital  
facility or facility reporting group for which the organization  
completed Section B; complete one Section C for each  
Section B.  
Line 19e: If the organization checked line 19e, describe the  
other similar actions that the hospital facility was permitted to  
take under its policies during the tax year before making  
reasonable efforts to determine the individual's eligibility under  
the facility's FAP.  
Line 20e: If the organization checked line 20e, describe the  
other efforts that the hospital facility made.  
Line 21c: If the organization checked line 21c, describe how  
If completing Section C for a single hospital facility, identify  
the specific name and line number (from Schedule H (Form  
990), Part V, Section A) of the hospital facility to which the  
responses in Section C relate.  
the hospital facility limited who was eligible to receive care for  
emergency services.  
Line 21d: If the organization checked line 21d, describe the  
other reasons why the hospital facility didn't have a written  
nondiscriminatory policy for emergency medical care.  
If completing Section C for a facility reporting group, list the  
reporting group letter, then list each hospital facility in that group  
separately by name and line number (from Section A). For each  
hospital facility, provide the descriptions required for Part V,  
Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e,  
19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable,  
provide separate descriptions for each hospital facility in a facility  
reporting group, designated by facility reporting group letter and  
hospital facility line number from Part V, Section A (“A, 1,” “A, 4,”  
“B, 2,B, 3,etc.), and name of hospital facility.  
Line 23: If the organization checked “Yes” to line 23, explain  
the circumstances in which the hospital facility charged any  
FAP-eligible individual more than the amounts generally billed to  
individuals who had insurance covering such care.  
Line 24: If the organization answered “Yes” to line 24, explain  
the circumstances in which the hospital facility charged any  
FAP-eligible individual an amount equal to the gross charge for  
any service provided to that individual.  
Section D  
Line 2: If the organization checked “Yes,provide details  
Complete Part V, Section D, by listing all of the non-hospital  
health care facilities that the organization operated during the  
tax year. A facility is operated by an organization whether it is  
operated directly by the organization or through a disregarded  
entity or joint venture treated as a partnership. List each of  
these facilities in order of size from largest to smallest, measured  
by a reasonable method (for example, the number of patients  
served or total revenue per facility). For each non-hospital health  
care facility, list its name and address and describe the type of  
facility. These types of facilities may include, but aren't limited to,  
rehabilitation and other outpatient clinics, diagnostic centers,  
mobile clinics, and skilled nursing facilities.  
regarding the hospital facility(ies) acquired or placed into  
service as a tax-exempt hospital in the current tax year or the  
immediately preceding tax year.  
Line 3j: If the organization checked line 3j, describe the other  
content included in the hospital facility's CHNA report.  
Line 5: If the organization checked “Yes,summarize, in  
general terms, how and over what time period such input was  
provided (for example, whether through meetings, focus groups,  
interviews, surveys, or written comments, and between what  
dates); the names of any organizations providing input; and  
describe the medically underserved, low-income, or minority  
populations being represented by organizations or individuals  
that provided input. A CHNA report doesn't need to name or  
otherwise identify any specific individual providing input on the  
CHNA. In the event a hospital facility solicits, but cannot obtain,  
input from a source required by line 5, the hospital facility's  
CHNA report must also describe the hospital facility's efforts to  
solicit input from such source.  
List the total number of non-hospital health care facilities that  
the organization operated during the tax year.  
If the organization needs additional space to list all of its  
non-hospital health care facilities, it should duplicate Section D  
and use as many duplicate copies of Section D as needed,  
number each page, and renumber the line numbers in the  
left-hand margin (for example, an organization with 15 such  
facilities should renumber lines 1–5 on the 2nd page as lines 11–  
15).  
Line 6a: If the organization checked “Yes,list the other  
hospital facilities with which the hospital facility conducted its  
CHNA.  
Line 6b: If the organization checked “Yes,list the  
organizations other than hospital facilities with which the hospital  
facility conducted its CHNA.  
Line 2: If the organization checked “Yes,provide details  
regarding the hospital facility(ies) acquired or placed into  
service as a tax-exempt hospital in the current tax year or the  
immediately preceding tax year.  
Line 7d: If the organization checked line 7d, describe the other  
means that the hospital facility used to make its CHNA widely  
available.  
Line 3j: If the organization checked line 3j, describe the other  
Line 11: Describe how the hospital facility is addressing the  
content included in the hospital facility's CHNA report.  
Line 5: If the organization checked “Yes,summarize, in  
significant health needs identified in its most recently conducted  
CHNA and any such needs that aren't being addressed together  
with the reasons why such needs aren't being addressed.  
general terms, how and over what time period such input was  
provided (for example, whether through meetings, focus groups,  
interviews, surveys, or written comments, and between what  
dates); the names of any organizations providing input; and  
describe the medically underserved, low-income, or minority  
populations being represented by organizations or individuals  
that provided input. A CHNA report doesn't need to name or  
otherwise identify any specific individual providing input on the  
CHNA. In the event a hospital facility solicits, but cannot obtain,  
input from a source required by line 5, the hospital facility's  
CHNA report must also describe the hospital facility's efforts to  
solicit input from such source.  
Line 13b: Describe the criteria the hospital facility used to  
determine eligibility for free or discounted care (including  
whether the hospital facility used the income level of patients,  
patients’ families, or patients’ guarantors as a factor).  
Line 13h: If the organization checked line 13h, describe the  
other eligibility criteria used.  
Line 15e: If the organization checked line 15e, describe the  
other methods for applying for financial assistance.  
Line 16j: If the organization checked line 16j, describe other  
ways that the hospital facility publicized its FAP.  
Line 18e: If the organization checked line 18e, describe the  
Line 6a: If the organization checked “Yes,list the other  
other similar actions that the hospital facility was permitted to  
take under its policies during the tax year before making  
hospital facilities with which the hospital facility conducted its  
CHNA.  
-12-  
Instructions for Schedule H  
Line 6b: If the organization checked “Yes,list the  
an asset test or other threshold, regardless of income, to  
determine eligibility for free or discounted care.  
Part I, line 6a. If the organization's community benefit report  
is in a report prepared by a related organization, and not in a  
separate report prepared by the organization, identify the related  
organization and list its EIN.  
Part I, line 7g. If applicable, describe if the organization  
included as subsidized health services any costs attributable to  
a physician clinic, and enter such costs the organization  
included.  
Part I, line 7, column (f). If applicable, enter the bad debt  
expense included in Form 990, Part IX, line 25, column (A) (but  
subtracted for purposes of calculating the percentages in this  
column).  
organizations other than hospital facilities with which the hospital  
facility conducted its CHNA.  
Line 7d: If the organization checked line 7d, describe the other  
means that the hospital facility used to make its CHNA widely  
available.  
Line 11: Describe how the hospital facility is addressing the  
significant health needs identified in its most recently conducted  
CHNA and any such needs that aren't being addressed together  
with the reasons why such needs aren't being addressed.  
Line 13b: Describe the criteria the hospital facility used to  
determine eligibility for free or discounted care (including  
whether the hospital facility used the income level of patients,  
patients’ families, or patients’ guarantors as a factor).  
Line 13h: If the organization checked line 13h, describe the  
Part I, line 7. Provide an explanation of the costing  
methodology used to calculate the amounts entered for each line  
in the table. If a cost accounting system was used, indicate  
whether the cost accounting system addresses all patient  
segments (for example, inpatient, outpatient, emergency room,  
private insurance, Medicaid, Medicare, uninsured, or self pay).  
Also, indicate if a cost-to-charge ratio was used for any of the  
figures in the table. Describe whether this cost-to-charge ratio  
was derived from Worksheet 2, Ratio of Patient Care  
Cost-to-Charges, and, if not, what kind of cost-to-charge ratio  
was used and how it was derived. If some other costing  
methodology was used besides a cost accounting system,  
cost-to-charge ratio, or a combination of the two, describe the  
method used.  
Part II. Describe how the organization’s community building  
activities, as reported in Part II, promote the health of the  
community or communities the organization serves.  
Part III, line 2. Describe the methodology used to determine  
the amount on Part III, line 2, including how the organization  
accounts for discounts and payments on patient accounts in  
determining bad debt expense.  
Part III, line 3. Describe the methodology used to determine  
the amount entered on line 3. Also, describe the rationale, if any,  
for including any portion of bad debt as community benefit.  
Part III, line 4. Provide, if applicable, the text of the footnote  
to the organization's financial statements that describes bad  
debt expense, or enter the page number(s) of the organization's  
most recent audited financial statements on which the  
footnote appears. If the organization's financial statements  
include a footnote on these issues that also includes other  
information, enter only the relevant portions of the footnote. If the  
organization's financial statements don't contain such a footnote,  
enter that the organization's financial statements don't include  
such a footnote, and explain how the financial statements  
account for bad debt, if at all.  
Part III, line 8. Describe the costing methodology used to  
determine the Medicare allowable costs entered on Part III,  
line 6. Describe, if applicable, the extent to which any shortfall  
entered on Part III, line 7, should be treated as a community  
benefit, and the rationale for the organization's position.  
Part III, line 9b. If the organization has a written debt  
collection policy and answered “Yes” to Part III, line 9b, describe  
the collection practices in the policy that apply to patients who it  
knows qualify for financial assistance, whether the practices  
apply specifically to such patients or also cover other types of  
patients.  
other eligibility criteria used.  
Line 15e: If the organization checked line 15e, describe the  
other methods for applying for financial assistance.  
Line 16j: If the organization checked line 16j, describe other  
ways that the hospital facility publicized its FAP.  
Line 18e: If the organization checked line 18e, describe the  
other similar actions that the hospital facility was permitted to  
take under its policies during the tax year before making  
reasonable efforts to determine the individual's eligibility under  
the facility's FAP.  
Line 19e: If the organization checked line 19e, describe the  
other similar actions that the hospital facility was permitted to  
take under its policies during the tax year before making  
reasonable efforts to determine the individual's eligibility under  
the facility's FAP.  
Line 20e: If the organization checked line 20e, describe the  
other efforts that the hospital facility made.  
Line 21c: If the organization checked line 21c, describe how  
the hospital facility limited who was eligible to receive care for  
emergency services.  
Line 21d: If the organization checked line 21d, describe the  
other reasons why the hospital facility didn't have a written  
nondiscriminatory policy for emergency medical care.  
Line 23: If the organization checked “Yes” to line 23, explain  
the circumstances in which the hospital facility charged any  
FAP-eligible individual more than the amounts generally billed to  
individuals who had insurance covering such care.  
Line 24: If the organization answered “Yes” to line 24, explain  
the circumstances in which the hospital facility charged any  
FAP-eligible individual an amount equal to the gross charge for  
any service provided to that individual.  
Part VI. Supplemental Information  
Use Part VI to provide the narrative explanations required by  
the following questions, and to supplement responses to other  
questions on Schedule H (Form 990). In addition, use Part VI to  
make disclosures described in section 7 of Rev. Proc. 2015-21.  
Identify the specific part, section, and line number that the  
response supports, in the order in which they appear on  
Schedule H (Form 990). Part VI can be duplicated if more space  
is needed.  
Rev. Proc. 2015-21, 2015-13 I.R.B. 817, provides guidance  
regarding correction and disclosure procedures for hospital  
organizations to follow so that certain failures to meet the  
requirements of section 501(r) will be excused for purposes of  
sections 501(r)(1) and 501(r)(2)(B). Section 7 of the revenue  
procedure provides that certain information must be disclosed  
on the organization’s Form 990. Provide this information in Part  
VI.  
Line 2. If applicable, describe whether and how the organization  
assesses the health care needs of the community or  
communities it serves, in addition to any CHNA entered in Part V,  
Section B.  
Line 1. Provide the following supplemental information.  
Part I, line 3c. If applicable, describe the criteria used for  
determining eligibility for free or discounted care under the  
organization's FAP. Also, describe whether the organization uses  
Line 3. Describe how the organization informs and educates  
patients and persons who are billed for patient care about their  
eligibility for assistance under federal, state, or local government  
programs or under the organization's FAP. For example, enter  
-13-  
Instructions for Schedule H  
 
whether the organization posts its FAP, or a summary thereof,  
applications for financial assistance, and financial assistance  
contact information in admissions areas, emergency rooms, and  
other areas of the organization's facilities where eligible patients  
are likely to be present; provides a copy of the policy, or a  
summary thereof, applications for financial assistance, and  
financial assistance contact information to patients as part of the  
intake process; provides a copy of the policy, or a summary  
thereof, applications for financial assistance, and financial  
assistance contact information to patients with discharge  
materials; includes the policy, or a summary thereof, an  
application for financial assistance, and financial assistance  
contact information, in patient bills; or discusses with the patient  
the availability of various government benefits, such as Medicaid  
or state programs, and assists the patient with qualification for  
such programs, where applicable.  
Worksheet 1. Financial Assistance at  
Cost (Part I, Line 7a)  
Worksheet 1 can be used to calculate the organization's financial  
assistance (sometimes referred to as “charity care”) at cost  
entered on Part I, line 7a. Refer to instructions for Part I, line 1,  
for the definition of “financial assistance.”  
Line 1. Enter the gross patient charges written off to financial  
assistance pursuant to the organization's financial assistance  
policies. “Gross patient charges” means the total charges at the  
organization's full established rates for the provision of patient  
care services before deductions from revenue are applied.  
Line 3. Multiply line 1 by line 2, or enter estimated cost based  
on the organization's cost accounting methodology.  
Organizations with a cost accounting system or a cost  
accounting method more accurate than the ratio of patient care  
cost to charges from Worksheet 2 can rely on that method to  
estimate financial assistance cost. An organization that doesn't  
use Worksheet 2 to determine a ratio of patient care cost to  
charges should make any necessary adjustments for patient  
care charges and community benefit programs to avoid double  
counting.  
Line 4. Describe the community or communities the  
organization serves, taking into account the geographic service  
area(s) (urban, suburban, rural, etc.), the demographics of the  
community or communities (population, average income,  
percentages of community residents with incomes below the  
federal poverty guideline, percentage of the hospital's and  
community's patients who are uninsured or Medicaid recipients,  
etc.), the number of other hospitals serving the community or  
communities, and whether one or more federally designated  
medically underserved areas or populations are present in the  
community.  
Line 4. Enter the Medicaid/provider taxes, fees, and  
assessments paid by the organization, if payments received from  
an uncompensated care pool or DSH program in the  
organization's home state are intended primarily to offset the  
cost of financial assistance. If the payments are primarily  
intended to offset the cost of Medicaid services, then enter this  
amount in Worksheet 3, line 4, column (A). If the primary  
purpose of the taxes or payments hasn't been made clear by  
state regulation or law, then the organization can allocate the  
taxes or payments proportionately between Worksheet 1, line 4,  
and Worksheet 3, line 4, column (A), based on a reasonable  
estimate of which portions are intended for financial assistance  
and Medicaid, respectively. Medicaid provider taxes” means  
amounts paid or transferred by the organization to one or more  
states as a mechanism to generate federal Medicaid DSH funds  
(portions of the cost of the tax are generally promised back to  
organizations either through an increase in the Medicaid  
reimbursement rate or through direct appropriation).  
Line 5. Provide any other information important to describing  
how the organization's hospitals or other health care facilities  
further its exempt purpose by promoting the health of the  
community or communities. Your response should include, but  
need not be limited to, whether:  
A majority of the organization's governing body is comprised  
of persons who reside in the organization's primary service area  
who are neither employees nor independent contractors of  
the organization, nor family members thereof;  
The organization extends medical staff privileges to all  
qualified physicians in its community for some or all of its  
departments or specialties; and  
How the organization applies surplus funds to improvements  
in facilities and equipment, patient care, medical training,  
education, and research.  
Line 6. “Revenue from uncompensated care pools or programs”  
means payments received from a state, including Upper  
Payment Limit (UPL) funding and Medicaid DSH funds, as direct  
offsetting revenue for financial assistance or to enhance  
Medicaid reimbursement rates. If such payments are primarily to  
offset the cost of Medicaid services, then enter this amount in  
Worksheet 3, line 7, column (A). If the primary purpose of the  
payments hasn't been made clear by state regulation or law, then  
the organization can allocate the payments proportionately  
between Worksheet 1, line 6, and Worksheet 3, line 7, column  
(A), based on a reasonable estimate of which portions are  
intended for financial assistance and Medicaid, respectively.  
Line 6. If the organization is part of an affiliated health care  
system, describe the roles of the organization and its affiliates in  
promoting the health of the communities served by the system.  
For purposes of this question, an “affiliated health care system”  
is a system that includes affiliates under common governance or  
control, or that cooperate in providing health care services to  
their community or communities.  
Line 7. Identify all states with which the organization files (or a  
related organization files on its behalf) a community benefit  
report. Enter only those states in which the organization's own  
community benefit report is filed, either by the organization itself  
or by a related organization on the organization's behalf.  
Line 7. Include the amount of any other offsetting revenue,  
including any restricted grants received by the organization.  
-14-  
Instructions for Schedule H  
Keep for Your Records  
Worksheet 1. Financial Assistance at Cost (Part I, line 7a)  
Gross patient charges  
1. Amount of gross patient charges written off under financial assistance policies . . . . . . . . . . . .  
1.  
Total community benefit expense  
2. Ratio of patient care cost to charges (from Worksheet 2, if used) . . . . . . . . . . . . . . . . . . . . . . .  
2.  
3.  
4.  
3. Estimated cost (multiply line 1 by line 2, or obtain from cost accounting) . . . . . . . . . . . . . . . . .  
4. Medicaid provider taxes, fees, and assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5. Total community benefit expense (add lines 3 and 4; enter in Part I, line 7a, column  
(c)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5.  
Direct offsetting revenue  
6. Revenue from uncompensated care pools or programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6.  
7.  
8.  
7. Other direct offsetting revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
8. Total direct offsetting revenue (add lines 6 and 7; enter in Part I, line 7a, column (d)) . . . . .  
9. Net community benefit expense (subtract line 8 from line 5; enter in Part I, line 7a,  
column (e)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
9.  
10. Total expense (enter amount from Form 990, Part IX, line 25, column (A), including the  
organization's share of joint venture expenses, and excluding any bad debt expense included  
on Part IX, line 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
10.  
11.  
11. Percent of total expense  
%
(divide line 9 by line 10; enter in Part I, line 7a, column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
expenditure isn't double-counted when the ratio of patient care  
cost to charges is applied.  
Worksheet 2. Ratio of Patient Care  
Cost to Charges  
Line 4. Enter the sum of the total community benefit expenses  
included in “Total operating expense” on line 1 and entered in  
Part I, lines 7e, 7f, 7h, and 7i, column (c), so these expenses  
aren't double-counted when the ratio of patient care cost to  
charges is applied.  
Also, include on line 4 the total community benefit expense  
entered in Part I, lines 7a, 7b, 7c, and 7g, column (c), if the  
organization hasn't relied on the ratio of patient care cost to  
charges from this worksheet to determine these expenses, but  
rather has relied on a cost accounting system or other cost  
accounting method to estimate costs of financial assistance,  
Medicaid or other means-tested government programs, or  
subsidized health services.  
Worksheet 2 can be used to calculate the organization's ratio of  
patient care cost to charges. An organization that doesn't use  
Worksheet 2 to determine a ratio of patient care cost to charges  
should make any necessary adjustments for patient care  
charges and community benefit programs to avoid double  
counting.  
Line 1. Enter the organization's total operating expenses  
(excluding bad debt expense) from its most recent audited  
financial statements.  
Line 2. Enter the cost of nonpatient care activities. “Nonpatient  
care activities” include health care operations that generate  
“other operating revenue” such as nonpatient food sales,  
supplies sold to nonpatients, and medical records abstracting.  
The cost of nonpatient care activities doesn't include any total  
community benefit expense entered on Worksheets 1 through 8.  
If the organization is unable to establish the cost associated  
with nonpatient care activities, use other operating revenue from  
its most recent audited financial statement as a proxy for these  
costs. This proxy assumes no markup exists for other operating  
revenue compared to the cost of nonpatient care activities.  
Alternatively, if other operating revenue provides a markup  
compared to the cost of nonpatient care activities, the  
organization can assume such a markup exists when completing  
line 2.  
Line 5. Enter the gross expense of community building activities  
reported in Part II of Schedule H (Form 990).  
Line 9. Enter the gross patient charges for any community  
benefit activities or programs for which the organization hasn't  
relied on the ratio of patient care cost to charges from this  
worksheet to determine the expenses of such activities or  
programs. For example, if the organization uses a cost  
accounting system or another cost accounting method to  
estimate total community benefit expense for Medicaid or any  
other means-tested government programs, enter gross charges  
for those programs on line 9.  
Line 3. Enter the Medicaid provider taxes, fees, and  
assessments paid by the organization included on line 1 so this  
-15-  
Instructions for Schedule H  
   
Worksheet 2. Ratio of Patient Care Cost to Charges  
Keep for Your Records  
(can be used for other worksheets)  
Patient care cost  
1. Total operating expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
1.  
Less adjustments  
2. Nonpatient care activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
3. Medicaid provider taxes, fees, and assessments . . . . . . . . . . . . . . . . .  
4. Total community benefit expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5. Total community building expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
2.  
3.  
4.  
5.  
6. Total adjustments (add lines 2 through 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
7. Adjusted patient care cost (subtract line 6 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6.  
7.  
Patient care charges  
8. Gross patient charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
8.  
Less: adjustments  
9. Gross charges for community benefit programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
9.  
10. Adjusted patient care charges (subtract line 9 from line 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
10.  
Calculation of ratio of patient care cost to charges  
11. Ratio of patient care cost to charges (divide line 7 by line 10; enter on the applicable lines of  
%
Worksheets 1, 3, or 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
11.  
reimbursements can enter SCHIP charges, costs, and offsetting  
revenue under column (A).  
Worksheet 3. Medicaid and Other  
Means-Tested Government Health  
Programs (Part I, Lines 7b and 7c)  
Line 1, column (B). Enter the amount of gross patient charges  
for other means-tested government health programs.  
Line 3, column (A). Enter the estimated cost for Medicaid  
services. Multiply line 1, column (A), by line 2, column (A), or  
enter estimated cost based on the organization's cost  
accounting system or method. Organizations with a cost  
accounting system or a cost accounting method more accurate  
than the ratio of patient care cost to charges from Worksheet 2  
can rely on that system or method to estimate the cost of  
Medicaid services. Organizations relying on a cost accounting  
system or method other than the ratio of patient care cost to  
charges from Worksheet 2 should use care not to double-count  
community benefit expenses fully accounted for elsewhere on  
Schedule H (Form 990), Part I, line 7, such as the cost of health  
professions education, community health improvement services,  
community benefit operations, subsidized health services, and  
research.  
Worksheet 3 can be used to report the cost of Medicaid and  
other means-tested government health programs. A  
“means-tested government program” is a government health  
program for which eligibility depends on the recipient's income or  
asset level.  
“Medicaid” means the United States health program for  
individuals and families with low incomes and resources. “Other  
means-tested government programs” means  
government-sponsored health programs where eligibility for  
benefits or coverage is determined by income or assets.  
Examples include:  
The State Children's Health Insurance Program (SCHIP), a  
United States federal government program that gives funds to  
states in order to provide health insurance to families with  
children; and  
Line 3, column (B). Enter the estimated cost for services  
provided to patients who receive health benefits from other  
means-tested government health programs.  
Other federal, state, or local health care programs.  
Report Medicaid and other means-tested government  
program revenues and expenses from all states, not just from the  
organization's home state.  
Line 4, column (A). Enter the Medicaid provider taxes, fees,  
and assessments paid by the organization if payments received  
from an uncompensated care pool, UPL program, or Medicaid  
DSH program in the organization's home state are intended  
primarily to offset the cost of Medicaid services. If such  
Line 1, column (A). Enter the gross patient charges for  
Medicaid services. Include gross patient charges for all Medicaid  
recipients, including those enrolled in managed care plans. In  
certain states, SCHIP functions as an expansion of the Medicaid  
program, and reimbursements from SCHIP aren't distinguishable  
from regular Medicaid reimbursements. Hospitals that cannot  
distinguish their SCHIP reimbursements from their Medicaid  
payments are primarily intended to offset the cost of financial  
assistance, then enter this amount on Worksheet 1, line 4. If the  
primary purpose of such taxes or payments hasn't been made  
clear by state regulation or law, then the organization can  
-16-  
Instructions for Schedule H  
 
allocate portions of such taxes or payments proportionately  
between Worksheet 1, line 4, and Worksheet 3, line 4, column  
(A), based on a reasonable estimate of which portions are  
intended for financial assistance and Medicaid, respectively.  
way the Medicaid program that provides reimbursement  
classifies the funds.  
Line 7, column (A). Enter revenue received from  
uncompensated care pools or programs if payments received  
from an uncompensated care pool, UPL program, or Medicaid  
DSH program in the organization's home state are intended  
primarily to offset the cost of Medicaid services. If such  
payments are primarily intended to offset the cost of charity care,  
then enter this amount on Worksheet 1, line 6. If the primary  
purpose of such payments hasn't been made clear by state  
regulation or law, then the organization can allocate the  
payments proportionately between Worksheet 1, line 6, and  
Worksheet 3, line 7, column (A), based on a reasonable estimate  
of which portions are intended for financial assistance and  
Medicaid, respectively.  
Line 6, column (A). Enter the net patient service revenue for  
Medicaid services, including revenue associated with Medicaid  
recipients enrolled in managed care plans. Don't include  
Medicaid reimbursement for direct graduate medical education  
(GME) costs, which should be entered on Worksheet 5, line 9.  
Include Medicaid reimbursement for indirect GME costs,  
including the indirect IME portion of children's health GME. The  
direct portion of children's health GME should be entered on  
Worksheet 5, line 10. Also, include Medicaid DSH revenue and  
UPL funding. “Net patient service revenue” means payments  
expected to be received from patients or third-party payers for  
patient services performed during the year. “Net patient service  
revenue” also includes revenue for services performed during  
prior years.  
Organizations can describe in Part VI the amount of prior year  
Medicaid revenue included on Part I, line 7b.  
Amounts received from a Medicaid program as  
“reimbursement for direct GME” or IME should be treated the  
Worksheet 3. Medicaid and Other Means-Tested Government  
Keep for Your Records  
Health Programs (Part I, lines 7b and 7c)  
(A)  
Medicaid  
(B)  
Other  
means-tested  
government health  
programs  
Gross patient charges  
1. Gross patient charges from the programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
1.  
Total community benefit expense  
2. Ratio of patient care cost to charges (from Worksheet 2, if used) . . . . . . . . . . . . . .  
2.  
3.  
4.  
%
%
3. Cost (multiply line 1 by line 2, or obtain from cost accounting) . . . . . . . . . . . . . . . .  
4. Medicaid provider taxes, fees, and assessments . . . . . . . . . . . . . . . . . . . . . . . . . .  
5. Total community benefit expense Total community benefit expense (add lines 3  
and 4; enter amount from column (A) in Part I, line 7b, column (c); and enter amount  
from column (B) in Part I, line 7c, column (c)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5.  
Direct offsetting revenue  
6. Net patient service revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6.  
7.  
8.  
7. Payments from uncompensated care pools or programs . . . . . . . . . . . . . . . . . . . .  
8. Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
9. Total direct offsetting revenue (add lines 6 through 8; enter amount from column  
(A) in Part I, line 7b, column (d), and enter amount from column (B) in Part I, line 7c,  
column (d)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
9.  
10.  
11.  
12.  
10. Net community benefit expense (subtract line 9 from line 5; enter amount from  
column (A) in Part I, line 7b, column (e); enter amount from column (B) in Part I,  
line 7c, column (e)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
11. Total expense (enter amount from Form 990, Part IX, line 25, column (A), including  
the organization's share of joint venture expenses, and excluding any bad debt  
expense included in Part IX, line 25, in both columns (A) and (B)) . . . . . . . . . . . . .  
12. Percent of total expense (line 10 divided by line 11; enter amount from column (A)  
in Part I, line 7b, column (f); enter amount from column (B) in Part I, line 7c, column  
(f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
%
%
-17-  
Instructions for Schedule H  
Worksheet 4. Community Health Improvement Services and  
Keep for Your Records  
Community Benefit Operations (Part I, line 7e)  
(C)  
Net  
community  
(A)  
Total  
benefit  
expense  
(B)  
community  
benefit  
Direct  
(subtract col.  
offsetting (B) from col. (A)  
expense  
revenue  
for lines 1–5)  
1.  
Community health improvement services  
a.  
1a.  
1b.  
1c.  
1d.  
1e.  
1f.  
b.  
c.  
d.  
e.  
f.  
g.  
h.  
i.  
1g.  
1h.  
1i.  
j.  
1j.  
2.  
3.  
Worksheet subtotal (add lines 1a through 1j) . . . . . . . . . . . . . . . . . . . 2.  
Community benefit operations  
a.  
b.  
c.  
d.  
3a.  
3b.  
3c.  
3d.  
4.  
5.  
Worksheet subtotal (add lines 3a through 3d) . . . . . . . . . . . . . . . . . . . 4.  
Worksheet total (add lines 2 and 4; enter amounts from columns  
(A), (B), and (C) in Part I, line 7e, columns (c), (d), and (e),  
5.  
6.  
respectively) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6.  
7.  
Total expense (enter amount from Form 990, Part IX, line 25, column  
(A), including the organization's share of joint venture expenses, and  
excluding any bad debt expense included on Part IX, line 25) . . . . . .  
Percent of total expense (line 5, column (C) divided by line 6; enter  
amount in Part I, line 7e, column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.  
“Community health improvement services” means activities or  
programs, subsidized by the health care organization, carried out  
or supported for the express purpose of improving community  
health. Such services don't generate inpatient or outpatient  
revenue, although there may be a nominal patient fee or sliding  
scale fee for these services.  
Worksheet 4. Community Health  
Improvement Services and  
Community Benefit Operations (Part I,  
Line 7e)  
“Community benefit operations” means:  
Worksheet 4 can be used to report the net cost of community  
health improvement services and community benefit operations.  
-18-  
Instructions for Schedule H  
Activities associated with conducting community health needs  
Worksheet 5. Health Professions  
Education (Part I, Line 7f)  
assessments,  
Community benefit program administration, and  
The organization's activities associated with fundraising or  
Worksheet 5 can be used to report the net cost of health  
professions education.  
grant writing for community benefit programs.  
Activities or programs cannot be reported if they are provided  
primarily for marketing purposes or if they are more beneficial to  
the organization than to the community. For example, the activity  
or program may not be reported if it is: designed primarily to  
increase referrals of patients with third-party coverage; required  
for license or accreditation, except when responding to a  
community health need, enhancing public health, or relieving the  
burden of government to improve health; or restricted to  
individuals affiliated with the organization (employees and  
physicians of the organization).  
“Health professions education” means educational programs  
that result in a degree, a certificate, or training necessary to be  
licensed to practice as a health professional, as required by state  
law, or continuing education necessary to retain state license or  
certification by a board in the individual's health profession  
specialty. It doesn't include education or training programs  
available exclusively to the organization's employees and  
medical staff or scholarships provided to those individuals.  
However, it does include education programs if the primary  
purpose of such programs is to educate health professionals in  
the broader community. Costs for medical residents and interns  
can be included, even if they are considered “employees” for  
purposes of Form W-2, Wage and Tax Statement.  
To be reported, community need for the activity or program  
must be established. Community need can be demonstrated  
through the following.  
A CHNA conducted or accessed by the organization.  
Documentation that demonstrated community need or a  
Examples of health professions education activities or  
request from a public health agency or community group was the  
basis for initiating or continuing the activity or program.  
programs that should and shouldn't be reported are as follows.  
The involvement of unrelated, collaborative tax-exempt or  
Activity or Program  
Report  
Example Rationale  
government organizations as partners in the activity or program  
carried out for the express purpose of improving community  
health.  
Scholarships for  
community members  
Yes  
More benefit to  
community than  
organization  
Community benefit activities or programs also seek to  
achieve a community benefit objective, including improving  
access to health services, enhancing public health, advancing  
increased general knowledge, and relief of a government burden  
to improve health. This includes activities or programs that do  
the following.  
Scholarships for staff  
members  
No  
Yes  
No  
More benefit to  
organization than  
community  
Continuing medical  
education for community  
physicians  
Accessible to all  
qualified physicians  
Are available broadly to the public and serve low-income  
Continuing medical  
education for own  
medical staff  
Restricted to own  
medical staff members  
consumers.  
Reduce geographic, financial, or cultural barriers to accessing  
health services, and if they ceased would result in access  
problems (for example, longer wait times or increased travel  
distances).  
Nurse education if  
graduates are free to  
seek employment at any  
organization  
Yes  
More benefit to  
community than  
organization  
Address federal, state, or local public health priorities such as  
eliminating disparities in access to health care services or  
disparities in health status among different populations.  
Nurse education if  
No  
Program designed  
primarily to benefit the  
organization  
Leverage or enhance public health department activities such  
graduates are required to  
become the  
as childhood immunization efforts.  
organization's employees  
Strengthen community health resilience by improving the  
ability of a community to withstand and recover from public  
health emergencies.  
Otherwise would become the responsibility of government or  
another tax-exempt organization.  
Lines 1 through 6. Include both direct and indirect costs. Direct  
costs of health professions education don't include costs related  
to Ph.D. students and post-doctoral students, which are to be  
entered on Worksheet 7, Research. See the instructions for Part  
I, line 7, column (c), for the definition of “indirect costs."Indirect  
costs" don't include the estimated cost of “indirect medical  
education.”  
Advance increased general knowledge through education or  
research that benefits the public.  
Lines 1a through 1j, column (A). Enter the name of each  
reported community health improvement activity or program and  
total community benefit expense for each. Include both direct  
costs and indirect costs in total community benefit expense. Use  
additional worksheets if the organization reports more than 10  
community health improvement activities or programs.  
Direct costs of health professions education include the  
following.  
Stipends, fringe benefits of interns, residents, and fellows in  
Lines 3a through 3d, column (A). Enter the name of each  
reported community benefit operations activity or program and  
total community benefit expense for each. Include both direct  
costs and indirect costs in total community benefit expense. Use  
additional worksheets if the organization enters more than four  
community benefit operations activities or programs.  
accredited graduate medical education programs.  
Salaries and fringe benefits of faculty directly related to intern  
and resident education.  
Salaries and fringe benefits of faculty directly related to  
teaching:  
1. Medical students;  
Report total community benefit expense, direct offsetting  
2. Students enrolled in nursing programs that are licensed  
by state law or, if licensing isn't required, accredited by the  
recognized national professional organization for the particular  
activity;  
revenue, and net community benefit expense for each line item.  
-19-  
Instructions for Schedule H  
 
Worksheet 5. Health Professions Education (Part I, line 7f)  
Keep for Your Records  
Totals  
Total community benefit expense  
1. Medical students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
1.  
2.  
3.  
4.  
2. Interns, residents, and fellows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
3. Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
4. Other allied health professions, students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5. Continuing health professions education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6. Other students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5.  
6.  
7. Total community benefit expense (add lines 1 through 6; enter in Part I, line 7f,  
column (c)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
7.  
Direct offsetting revenue  
8. Medicare reimbursement for direct GME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
8.  
9.  
9. Medicaid reimbursement for direct GME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
10. Continuing health professions education reimbursement/tuition . . . . . . . . . . . . . . . . . . . . . .  
11. Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
10.  
11.  
12. Total direct offsetting revenue (add lines 8 through 11; enter in Part I, line 7f, column  
(d)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
12.  
13.  
13. Net community benefit expense (line 7 minus line 12; enter in Part I, line 7f, column  
(e)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
14. Total expense (enter amount from Form 990, Part IX, line 25, column (A), including the  
organization's share of joint venture expenses, and excluding any bad debt expense  
included on Part IX, line 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
14.  
15.  
15. Percent of total expense (line 13 divided by line 14; enter amount in Part I, line 7f,  
%
column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
3. Students enrolled in allied health professions education  
programs, licensed by state law or, if licensing isn't required,  
accredited by the recognized national professional organization  
for the particular activity, including, but not limited to, programs in  
pharmacy, occupational therapy, dietetics, and pastoral care;  
and  
the organization from other Medicaid net patient revenue. Don't  
include indirect GME reimbursement provided by Medicaid,  
which is to be entered in Worksheet 3, Unreimbursed Medicaid  
and Other Means-Tested Government Programs. Include  
Medicaid reimbursement for nursing and allied health education.  
If your state pays Medicaid GME reimbursement as a lump sum  
that includes both direct and indirect payments, use reasonable  
methods to estimate the portion of the lump sum that is direct  
(for example, the percent of total Medicare GME payments that  
is direct).  
4. Continuing health professions education open to all  
qualified individuals in the community, including payment for  
development of online or other computer-based training  
accepted as continuing health professions education by the  
relevant professional organization.  
Line 10. Enter revenue received for continuing health  
Scholarships provided by the organization to community  
professions education reimbursement or tuition.  
members.  
Line 11. Enter other revenue received for health professions  
education activities associated with expenses entered on  
Worksheet 5, line 7.  
Line 8. Enter Medicare reimbursement for direct GME,  
reimbursement for approved nursing and allied health education  
activities, and direct GME reimbursement received for services  
provided to Medicare Advantage patients. For a children's  
hospital that receives children's GME payments from Health  
Resources and Services Administration (HRSA), count that  
portion of the payment equivalent to Medicare direct GME. Don't  
include indirect GME reimbursement provided by Medicare or  
Medicaid.  
Worksheet 6. Subsidized Health  
Services (Part I, Line 7g)  
Worksheet 6 can be used to calculate the net cost of subsidized  
health services. Complete Worksheet 6 for each subsidized  
health service and enter in Part I the total for all subsidized  
health services combined.  
Line 9. Enter Medicaid reimbursement for direct GME, including  
only that portion of Medicaid GME payment equivalent to  
Medicare direct GME and that can be explicitly segregated by  
“Subsidized health services” means clinical services provided  
despite a financial loss to the organization. The financial loss is  
-20-  
Instructions for Schedule H  
   
measured after removing losses associated with bad debt,  
financial assistance, Medicaid, and other means-tested  
government programs. Losses attributable to these items aren't  
included when determining which clinical services are  
subsidized health services because they are reported as  
community benefit elsewhere in Part I or as bad debt in Part III.  
Losses attributable to these items are also excluded when  
measuring the losses generated by the subsidized health  
services. In addition, in order to qualify as a subsidized health  
service, the organization must provide the service because it  
meets an identified community need. A service meets an  
identified community need if it is reasonable to conclude that if  
the organization no longer offered the service:  
prevention; studies related to changes in the health care delivery  
system; and communication of findings and observations,  
including publication in a medical journal). The organization can  
include the cost of internally funded research it conducts, as well  
as the cost of research it conducts funded by a tax-exempt or  
government entity.  
The organization cannot include on Part I, line 7h, direct or  
indirect costs of research funded by an individual or an  
organization that isn't a tax-exempt or government entity.  
However, the organization can describe in Part VI any research it  
conducts that isn't funded by tax-exempt or government entities,  
including the cost of such research, the identity of the funder,  
how the results of such research are made available to the  
public, if at all, and whether the results are made available to the  
public at no cost or nominal cost.  
The service would be unavailable in the community,  
The community's capacity to provide the service would be  
below the community's need, or  
The service would become the responsibility of government or  
Examples of costs of research include, but aren't limited to,  
salaries and benefits of researchers and staff, including stipends  
for research trainees (Ph.D. candidates or fellows); facilities for  
collection and storage of research, data, and samples; animal  
facilities; equipment; supplies; tests conducted for research  
rather than patient care; statistical and computer support;  
compliance (for example, accreditation for human subjects  
protection, biosafety, Health Insurance Portability and  
Accountability Act (HIPAA), etc.); and dissemination of research  
results.  
another tax-exempt organization.  
Subsidized health services can include qualifying inpatient  
programs (for example, neonatal intensive care, addiction  
recovery, and inpatient psychiatric units) and outpatient  
programs (emergency and trauma services, satellite clinics  
designed to serve low-income communities, and home health  
programs). Subsidized health services generally exclude  
ancillary services that support inpatient and ambulatory  
programs such as anesthesiology, radiology, and laboratory  
departments. Subsidized health services include services or  
care provided at physician clinics and skilled nursing facilities if  
such clinics or facilities satisfy the general criteria for subsidized  
health services. An organization that includes any costs  
associated with stand-alone physician clinics (not other facilities  
at which physicians provide services) as subsidized health  
services on Part I, line 7g, must describe that it has done so and  
enter on Part VI such costs included on Part I, line 7g.  
Line 1. Define direct costs under the guidelines and definitions  
published by the National Institutes of Health.  
Line 2. Define indirect costs under the guidelines and  
definitions published by the National Institutes of Health.  
Line 4. Enter license fees and royalties the organization  
received during the tax year that are directly associated with  
research that the organization has (in any tax year) reported on  
Schedule H as community benefit.  
Note. The organization can report a physician clinic as a  
subsidized health service only if the organization operated the  
clinic and associated hospital services at a financial loss to the  
organization during the year.  
Line 5. An example of “other revenue” is Medicare  
reimbursement associated with any research expense reported  
as community benefit.  
Line 3, columns (A) through (D). Enter the estimated cost for  
each subsidized health service. For column (B), enter bad debt  
amounts attributable to the subsidized health service measured  
by cost. For column (C), enter amounts attributable to the  
subsidized health service for patients who are recipients of  
Medicaid and other means-tested government health programs.  
For column (D), enter financial assistance amounts attributable  
to the subsidized health service measured by cost. Multiply  
line 1 by line 2 or enter the estimated expense of each  
Worksheet 8. Cash and In-Kind  
Contributions for Community Benefit  
(Part I, Line 7i)  
Worksheet 8 can be used to report cash contributions or grants  
and the cost of in-kind contributions that support financial  
assistance, health professions education, and other community  
benefit activities reportable on Part I, lines 7a through 7h. Report  
such contributions on line 7i, and not on lines 7a through 7h.  
subsidized health service based on the organization's cost  
accounting. Organizations with a cost accounting system or  
method more accurate than the ratio of patient care cost to  
charges from Worksheet 2 can rely on that system or method to  
estimate the cost of each subsidized health service.  
“Cash and in-kind contributions” means contributions made  
by the organization to health care organizations and other  
community groups restricted, in writing, to one or more of the  
community benefit activities described in the table on Part I,  
line 7 (and the related worksheets and instructions). “In-kind  
contributions” include the cost of staff hours donated by the  
organization to the community while on the organization's  
payroll, indirect cost of space donated to tax-exempt community  
groups (such as for meetings), and the financial value (generally  
measured at cost) of donated food, equipment, and supplies.  
Worksheet 7. Research (Part I,  
Line 7h)  
Worksheet 7 can be used to report the cost of research  
conducted by the organization.  
Research means any study or investigation the goal of which  
is to generate increased generalizable knowledge made  
available to the public (for example, knowledge about underlying  
biological mechanisms of health and disease, natural processes,  
or principles affecting health or illness; evaluation of safety and  
efficacy of interventions for disease such as clinical trials and  
studies of therapeutic protocols; laboratory-based studies;  
epidemiology, health outcomes, and effectiveness; behavioral or  
sociological studies related to health, delivery of care, or  
Don't report as cash or in-kind contributions any payments  
that the organization makes in exchange for a service, facility, or  
product, or that the organization makes primarily to obtain an  
economic or physical benefit; for example, payments made in  
lieu of taxes that the organization makes to prevent or forestall  
local or state property tax assessments, and a teaching  
hospital's payments to its affiliated medical school for intern or  
resident supervision services by the school's faculty members.  
-21-  
Instructions for Schedule H  
 
Keep for Your Records  
Worksheet 6. Subsidized Health Services (Part I, line 7g)  
(C)  
(E)  
(A)  
Medicaid and  
other means-  
tested  
Totals  
Total  
(subtract  
columns (B),  
(C), and (D)  
from column  
(A))  
subsidized  
health  
service  
program  
government  
health  
programs  
(D)  
Financial  
assistance  
(B)  
Bad debt  
Program name: ______________________________  
Gross patient charges  
1. Gross patient charges from program(s) . . . . . . . . .  
1.  
2.  
3.  
Total community benefit expense  
2. Ratio of patient care cost to charges (from  
Worksheet 2, if used) . . . . . . . . . . . . . . . . . . . . . .  
%
%
%
%
3. Total community benefit expense (multiply line 1  
by line 2, or obtain from cost accounting; enter  
column (E) in Part I, line 7g, column (c)) . . . . . . . .  
Direct offsetting revenue  
4. Net patient service revenue . . . . . . . . . . . . . . . . .  
4.  
5.  
5. Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6. Total direct offsetting revenue (add lines 4 and 5;  
enter column (E) in Part I, line 7g, column  
6.  
7.  
(d)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
7. Net community benefit expense (subtract line 6  
from line 3; enter column (E) in Part I, line 7g, column  
(e)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
8. Total expense (enter amount from Form 990, Part IX,  
line 25, column (A), including the organization's  
share of joint venture expenses, and excluding any  
bad debt expense included on Part IX,  
8.  
9.  
$
line 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
9. Percent of total expense (line 7, column (E)  
divided by line 8; enter in Part I, line 7g, column  
(f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
%
-22-  
Instructions for Schedule H  
Keep for Your Records  
Worksheet 7. Research (Part I, line 7h)  
Total community benefit expense  
1. Direct costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
2. Indirect costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
1.  
2.  
3. Total community benefit expense (add lines 1 and 2; enter in Part I, line 7h, column  
(c)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
3.  
Direct offsetting revenue  
4. License fees and royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
4.  
5.  
6.  
5. Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6. Total direct offsetting revenue (add lines 4 and 5; enter in Part I, line 7h, column (d)) . . . . . . .  
7. Net community benefit expense (subtract line 6 from line 3; enter in Part I, line 7h, column  
(e)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
7.  
8. Total expense (enter amount from Form 990, Part IX, line 25, column (A), including the  
organization's share of joint venture expenses, and excluding any bad debt expense included on  
Part IX, line 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
8.  
9.  
9. Percent of total expense  
%
(divide line 7 by line 8; enter in Part I, line 7h, column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Worksheet 8. Cash and In-Kind Contributions for Community  
Benefit  
(Part I, line 7i)  
Keep for Your Records  
(B)  
(A)  
In-kind  
Cash contrib-  
utions  
contrib-  
utions  
(C)  
Total  
1.  
2.  
Total community benefit expense (enter amount from  
1.  
2.  
column (C) in Part I, line 7i, column (c)) . . . . . . . . . . . . . .  
Direct offsetting revenue (enter amount from column  
(C) in Part I, line 7i, column (d)) . . . . . . . . . . . . . . . . . . . . .  
3.  
4.  
Net community benefit expense (subtract line 2 from  
3.  
line 1; enter on Part I, line 7i, column (e)) . . . . . . . . . . . . .  
Total expense (enter amount from Form 990, Part IX,  
line 25, column (A), including the organization's share of  
joint venture expenses, and excluding any bad debt  
expense included on Part IX, line 25) . . . . . . . . . . . . . . . .  
4.  
5.  
5.  
Percent of total expense (divide line 3 by line 4; enter in  
Part I, line 7i, column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . .  
%
Report cash contributions and grants made by the  
Special rule for grants to joint ventures. If the organization  
makes a grant to a joint venture in which it has an ownership  
interest to be used to accomplish one of the community benefit  
activities reportable in the table, on Part I, line 7, enter the grant  
on line 7i, but don't include the organization's proportionate  
share of the amount spent by the joint venture on such  
activities in any other part of the table, to avoid double counting.  
organization to entities and community groups that share the  
organization's goals and mission. Don't report cash or in-kind  
contributions contributed by employees, or emergency funds  
provided by the organization to the organization's employees;  
loans, advances, or contributions to the capital of another  
organization that are reportable in Part X of the core Form 990;  
or unrestricted grants or gifts to another organization that can, at  
the discretion of the grantee organization, be used other than to  
provide the type of community benefit described in the table on  
Part I, line 7.  
-23-  
Instructions for Schedule H  
 
Index  
B
Financial Assistance Policy 9  
S
Policy Relating to Emergency  
Medical Care 11  
Bad Debt, Medicare, & Collection  
Supplemental Information 13  
Hospital facilities 7  
Practices 5  
Financial Assistance and Certain  
Other Community Benefits at  
Cost 2  
Worksheet (optional) 6  
W
Worksheets:  
C
1-Financial Assistance at Cost 15  
Contributions for community benefit 3  
Community Building Activities 4  
Disregarded entity 4  
2-Ratio of Patient Care Cost to  
Charges 15  
M
Group return 4  
3-Unreimbursed Medicaid and Other  
Means-Tested Government  
Programs 16  
Management Companies and Joint  
Ventures 6  
F
4-Community Health Improvement  
Services and Community Benefit  
Operations 19  
Facility Information:  
P
CHNA 7  
Patient Protection and Affordable  
Community Health Needs  
Assessment 7  
Care Act:  
5-Health Professions Education 20  
6-Subsidized Health Services 20  
7-Research 21  
Hospital facilities 1  
Facility Policies & Practices:  
Billing and Collections 9  
Section 501(r) of the Code 1  
8-Cash and In-Kind Contributions for  
Community Benefit 23  
Charges for Medical Care 11  
-24-