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Form 990sh: Hospitals

Use Tax Form 990sh: Hospitals as a stand alone tax form calculator to quickly calculate specific amounts for your 2017 tax return. Form 990sh: Hospitals is also integrated into our comprehensive US Tax Calculator where you can complete and save your calculations for later use. Alternatively you can use one of our Combined Federal and State Tax Estimator to quickly calculate your salary, tax and take home pay.

Hospitals
YesNo
1a1a
1b1b
2
3Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization’s patients during the tax year.
aDid the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care? If “Yes,” indicate which of the following was the FPG family income limit for eligibility for free care:
%
3a
bDid the organization use FPG as a factor in determining eligibility for providing discounted care? If “Yes,” indicate which of the following was the family income limit for eligibility for discounted care:
%
3b
cIf the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
44
5a5a
b5b
c5c
6a6a
b6b
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and Means-Tested Government Programs(a) Number of activities or programs (optional)(b) Persons served (optional)(c) Total community benefit expense(d) Direct offsetting revenue(e) Net community benefit expense(f) Percent of total expense
a
b
c
d
Other Benefits
e
f
g
h
i
j
k
Part II Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional)(b) Persons served (optional)(c) Total community benefit expense(d) Direct offsetting revenue(e) Net community benefit expense(f) Percent of total expense
1
2
3
4
5
6
7
8
9
10
Part III Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt ExpenseYesNo
11
22
33
4Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
55
66
77
8Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit. Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6. Check the box that describes the method used:
Section C. Collection Practices
9a9a
b9b
Part IV Management Companies and Joint Ventures (owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity(b) Description of primary activity of entity(c) Organization’s profit % or stock ownership %(d) Officers, directors, trustees, or key employees’ profit % or stock ownership %(e) Physicians’ profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Part V Facility Information
Section A. Hospital Facilities
(list in order of size, from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?
Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
Licensed hospitalGeneral medical & surgicalChildren’s hospitalTeaching hospitalCritical access hospitalResearch facilityER–24 hoursER–otherOther (describe) Facility reporting group
1  
2  
3  
4  
5  
6  
7  
8  
9  
10  
Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
YesNo
Community Health Needs Assessment
11
22
33
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4
55
6a6a
6b6b
77
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
88
9
1010
a
b10b
11Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a12a
b12b
c $
Financial Assistance Policy (FAP)
YesNo
Did the hospital facility have in place during the tax year a written financial assistance policy that:
1313
If “Yes,” indicate the eligibility criteria explained in the FAP:
a % %
b
c
d
e
f
g
h
1414
1515
If “Yes,” indicate how the hospital facility's FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
1616
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
h
i
j
Billing and Collections
YesNo
1717
18Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP:
a
b
c
d
e
f
1919
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19 (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
2121
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
YesNo
22Indicate 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.
a
b
c
d
2323
If “Yes,” explain in Section C.
2424
If “Yes,” explain in Section C.
Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest)
Name and addressType of Facility (describe)
1  
2  
3  
4  
5  
6  
7  
8  
9  
10  
Part VI Supplemental Information
Provide the following information.
1Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

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