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Department of the Treasury
Internal Revenue Service
2022

Instructions for Schedule H

(Form 990)

Hospitals

Section references are to the Internal Revenue Code unless
otherwise noted. Purpose of Schedule
Hospital organizations use Schedule H (Form 990) to provide
information on the activities and policies of, and community
Future Developments benefit provided by, its hospital facilities and other
non-hospital health care facilities that it operated during the tax
For the latest information about developments related to Form year. This includes facilities operated either directly or through
990 and its instructions, such as legislation enacted after they disregarded entities or joint ventures.
were published, go to IRS.gov/Form990.
Who Must File
General Instructions An organization that answered “Yes” on Form 990, Part IV,
Note. Terms in bold are defined in the Glossary of the line 20a, must complete and attach Schedule H to Form 990.
Instructions for Form 990. Schedule H (Form 990) must be completed by a hospital
Background. The Patient Protection and Affordable Care Act organization that operated at any time during the tax year at
(Affordable Care Act), enacted March 23, 2010, P.L. No. least one hospital facility. A hospital facility is one that is
111-148, added section 501(r) to the Code. Section 501(r) required to be licensed, registered, or similarly recognized by a
includes additional requirements a hospital organization must state as a hospital. A hospital organization may treat multiple
meet to qualify for tax exemption under section 501(c)(3) in tax buildings operated by a hospital organization under a single
years beginning after March 23, 2010. These additional state license as a single hospital facility.
requirements address a hospital organization's financial The organization must file a single Schedule H (Form 990)
assistance policy (FAP); policy relating to emergency medical that combines information from:
care; billing and collections; and charges for medical care. Also, 1. Hospital facilities directly operated by the organization.
for tax years beginning after March 23, 2012, the Affordable
Care Act requires hospital organizations to conduct community 2. Hospital facilities operated by disregarded entities of
health needs assessments. which the organization is the sole member.
Because section 501(r) requires a hospital organization to 3. Other health care facilities and programs of the hospital
meet these requirements for each of its hospital facilities, Part organization or any of the entities described in 1 or 2, even if
V, Facility Information, has been expanded to include a provided separately from the hospital's license.
Section A, Hospital Facilities. In this section, a hospital 4. Hospital facilities and other health care facilities and
organization must list its hospital facilities; that is, its facilities programs operated by any joint venture treated as a
that, at any time during the tax year, were required to be partnership, to the extent of the hospital organization's
licensed, registered, or similarly recognized as a hospital under proportionate share of the joint venture.
state law. Part V also includes Section B, Facility Policies and
Practices, for reporting of information on policies and practices “Proportionate share” is defined as the ending capital account
addressed in section 501(r). The hospital organization must percentage listed on the Schedule K-1 (Form 1065), Partner's
complete a separate Section B for each of its hospital facilities or Share of Income, Deductions, Credits, etc., Part II, line J, for the
facility reporting groups listed in Section A. partnership tax year ending in the organization's tax year being
Section 6033(b)(15)(B) also requires hospital organizations to reported on the organization's Form 990. If Schedule K-1 (Form
submit a copy of their audited financial statements to the IRS. 1065) isn't available, the organization can use other business
Accordingly, a hospital organization that is required to file Form records to make a reasonable estimate, including the most
990 must attach a copy of its most recent audited financial recently available Schedule K-1 (Form 1065), adjusted as
statements to its Form 990. If the organization was included in appropriate to reflect facts known to the organization, or
consolidated audited financial statements but not separate information used for purposes of determining its proportionate
audited financial statements for the tax year, then it must attach share of the venture for the organization's financial statements.
a copy of the consolidated financial statements, including details 5. In the case of a group return filed by the hospital
of consolidation. See the Instructions for Form 990, Part IV, organization, hospital facilities operated directly by members of
line 20b. the group exemption included in the group return, hospital
Part V, Section D, requires an organization to list all of its facilities operated by a disregarded entity of which a member
non-hospital health care facilities that it operated during the tax included in the group return is the sole member, hospital
year, whether or not such facilities were required to be licensed facilities operated by a joint venture treated as a partnership to
or registered under state law. The organization shouldn't the extent of the group member's proportionate share
complete Part V, Section B, for any of these non-hospital (determined in the manner described in 4, earlier), and other
facilities. health care facilities or programs of a member included in the
group return even if such programs are provided separately from
Sec. 501(r) final regulations are effective for tax years the hospital's license.
TIP beginning after 12/29/15.

Sep 20, 2022 Cat. No. 51526B

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Example.      The organization is the sole member of a                     Line 1. An FAP, sometimes referred to as a charity care policy, 
disregarded entity. The disregarded entity owns 50% of a joint             is a policy describing how the organization will provide financial 
venture treated as a partnership. The partnership in turn owns             assistance at its hospital(s) and other facilities, if any. Financial 
50% of another joint venture treated as a partnership that                 assistance includes free or discounted health services provided 
operates a hospital and a freestanding outpatient clinic that isn't        to persons who meet the organization's criteria for financial 
part of the hospital's license. (Assume the proportionate shares           assistance and are unable to pay for all or a portion of the 
of the partnerships based on capital account percentages listed            services. Financial assistance doesn't include: bad debt or 
on the partnerships' Schedule K-1 (Form 1065), Part II, line J,            uncollectible charges that the organization recorded as revenue 
are also 50%.) The organization would report 25% (50% of 50%)              but wrote off due to a patient's failure to pay, or the cost of 
of the hospital's and outpatient clinic's combined information on          providing such care to such patients; the difference between the 
Schedule H (Form 990).                                                     cost of care provided under Medicaid or other means-tested 
Note that while information from all the above sources is                  government programs or under Medicare and the revenue 
combined for purposes of Schedule H (Form 990), the                        derived therefrom; self-pay or prompt pay discounts; or 
organization is required to list and provide information regarding         contractual adjustments with any third-party payers.
each of its hospital facilities in Part V, Sections A, B, and C,           Line 2. Check only one of the three boxes. “Applied uniformly to 
whether operated directly by the organization or through a                 all hospitals” means that all of the organization's hospital 
disregarded entity or joint venture treated as a partnership. In           facilities use the same FAP. “Applied uniformly to most 
addition, the organization must list in Part V, Section D, each of         hospitals” means that the majority of the organization's hospital 
its other health care facilities (for example, rehabilitation clinics,     facilities use the same FAP. “Generally tailored to individual 
other outpatient clinics, diagnostic centers, skilled nursing              hospitals” means that the majority of the organization's hospital 
facilities) that it operated during the tax year, whether operated         facilities use different financial assistance policies. If the 
directly by the organization or through a disregarded entity or a          organization operates only one hospital facility, check “Applied 
joint venture treated as a partnership.                                    uniformly to all hospitals.”
Organizations aren't to enter information from hospitals                   Line 3. Answer lines 3a, 3b, and 3c, based on the financial 
located outside the United States in Parts I, II, III, or V.               assistance eligibility criteria that apply to (1) the largest number 
Information from foreign joint ventures and partnerships must be           of the organization's patients based on patient contacts or 
reported in Part IV, Management Companies and Joint                        encounters, or (2) if the organization doesn't operate its own 
Ventures. Information concerning foreign hospitals and facilities          hospital facility, the largest number of patients of a hospital 
may be described in Part VI.                                               facility operated by a joint venture in which the organization has 
Except as provided in Part IV, don't report on Schedule H                  an ownership interest. For example, if the organization has two 
(Form 990) information from an entity organized as a separate              hospital facilities, use the financial assistance eligibility criteria 
legal entity from the organization and treated as a corporation for        used by the hospital facility that has the most patient contacts or 
federal income tax purposes (except for members of a group                 encounters during the tax year.
exemption included in a group return filed by the organization),           Line 3a.  “Federal Poverty Guidelines” (FPG) are the Federal 
even if such entity is affiliated with or otherwise related to the         Poverty Guidelines published annually by the U.S. Department 
organization (for example, part of an affiliated health care               of Health and Human Services. If the organization has 
system).                                                                   established a family or household income threshold that a 
                                                                           patient must meet or fall below to qualify for free medical care, 
If an organization isn't required to file Form 990 but chooses             check the box in the “Yes” column and indicate the specific 
to do so, it must file a complete return and provide all of the            threshold by checking the appropriate box. For instance, if a 
information requested, including the required schedules.                   patient's family or household income must be less than or equal 
An organization that didn't operate one or more facilities                 to 250% of FPG for the patient to qualify for free care, then check 
during the tax year that satisfy the definition of hospital facility       the box marked “Other” and enter “250%.”
above shouldn't file Schedule H (Form 990).                                Line 3b.  If the organization has established a family or 
                                                                           household income threshold that a patient must meet or fall 
    The definition of “hospital” for Schedule A (Form 990),                below to qualify for discounted medical care, check the box in 
TIP Public Charity Status and Public Support, Part I, line 3,              the “Yes” column and indicate the specific threshold by checking 
    and the definition of “hospital” for Schedule H (Form                  the appropriate box.
990) aren't the same. Accordingly, an organization that checks             Line 3c.  If applicable, describe the other criteria used, such 
box 3 in Part I of Schedule A (Form 990) to enter that it is a             as asset test or other means test or threshold for free or 
hospital or cooperative hospital service organization must                 discounted care, on Part VI, line 1, of this schedule. An “asset 
complete and attach Schedule H to Form 990 only if it meets the            test” includes (i) a limit on the amount of total or liquid assets that 
definition of hospital facility for purposes of Schedule H (Form           a patient or the patient's family or household can own for the 
990), as explained above.                                                  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 
Specific Instructions                                                      their families or households own.
                                                                           Line 4. “Medically indigent” means persons whom the 
Part I. Financial Assistance and                                           organization has determined are unable to pay some or all of 
Certain Other Community Benefits at                                        their medical bills because their medical bills exceed a certain 
                                                                           percentage of their family or household income or assets (for 
Cost                                                                       example, due to catastrophic costs or conditions), even though 
Part I requires reporting of financial assistance policies, the            they have income or assets that otherwise exceed the generally 
availability of community benefit reports, and the cost of financial       applicable eligibility requirements for free or discounted care 
assistance and other community benefit activities and programs.            under the organization's FAP.
Worksheets and accompanying instructions are provided at the               Line 5. Answer lines 5a, 5b, and 5c based on the organization's 
end of the instructions to this schedule to assist in completing           budgeted amounts under its FAP.
the table in Part I, line 7.

                                                                       -2-                                  Instructions for Schedule H

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Line 5a. Answer “Yes” if the organization established or had If the organization included any bad debt expense on Form
in place at any time during the tax year an annual or periodic 990, Part IX, line 25, but subtracted this bad debt for purposes of
budgeted amount of free or discounted care to be provided calculating the amount entered on line 7, column (f), enter this
under its FAP. If “No,” skip to line 6a. bad debt expense on Part VI, line 1.
Line 5b. Answer “Yes” if the free or discounted care the The following are descriptions of the type of information
organization provided in the applicable period exceeded the reported in each column of the table.
budgeted amount of costs or charges for that period. If “No,” skip Column (a). “Number of activities or programs” means the
to line 6a. number of the organization's activities or programs conducted
Line 5c. Answer “Yes” if the organization denied financial during the year that involve the community benefit entered on
assistance to any patient eligible for free or discounted care the line. Enter each activity and program on only one line so that
under its FAP or under any of its hospital facilities' financial it isn't counted more than once. Entering in this column is
assistance policies because the organization's or the facility's optional.
financial assistance budget was exceeded. Column (b). “Persons served” means the number of patient
Line 6. Answer lines 6a and 6b based on the community benefit contacts or encounters in accordance with the filing
report that the organization prepared for the organization as a organization's records. Persons served can be entered in
whole during the tax year. multiple rows, as services across different categories may be
Line 6a. Answer “Yes” if the organization prepared a written provided to the same patient. Entering in this column is optional.
report during the tax year that describes the organization's Column (c). “Total community benefit expense” means the
programs and services that promote the health of the community total gross expense of the activity incurred during the year,
or communities served by the organization. If the organization's calculated by using the pertinent worksheets for each line item.
community benefit report is contained in a report prepared by a “Total community benefit expense” includes both “direct costs”
related organization, answer “Yes” and identify the related and “indirect costs.” “Direct costs” means salaries and benefits,
organization on Part VI, line 1. If “No,” skip to line 7. supplies, and other expenses directly related to the actual
Line 6b. Answer “Yes” if the organization made the conduct of each activity or program. “Indirect costs” means costs
community benefit report it prepared during the tax year that are shared by multiple activities or programs, such as
available to the public. facilities and administrative costs related to the organization's
infrastructure (space, utilities, custodial services, security,
Examples of how an organization can make its information systems, administration, materials management,
TIP community benefit report available to the public are to and others).
post the report on the organization's website and to Column (d). “Direct offsetting revenue” means revenue from
make a paper copy of the community health needs assessment the activity during the year that offsets the total community
(CHNA) report available for public inspection upon request and benefit expense of that activity, as calculated on the worksheets
without charge at the hospital facility. for each line item. “Direct offsetting revenue” includes any
revenue generated by the activity or program, such as payment
Lines 7a through 7k. Enter on the table (lines 7a through 7k), or reimbursement for services provided to program patients.
at cost, the organization's financial assistance (as defined in the
instructions for line 1) and certain other community benefits (as “Direct offsetting revenue” also includes restricted grants or
defined in the instructions to Worksheets 1-8). Enter on line 7i contributions that the organization uses to provide a community
contributions that the organization restricts, in writing, to one or benefit, such as a restricted grant to provide financial assistance
more of the community benefit activities listed on lines 7a or fund research. “Direct offsetting revenue” doesn't include
through 7h. Don't enter such contributions on lines 7a through unrestricted grants or contributions that the organization uses to
7h. To calculate the amounts to be entered on the table, use the provide a community benefit. Organizations may describe any
worksheets or other equivalent documentation that substantiates inconsistencies from reporting in prior years in Part VI.
the information entered consistent with the methodology used on Examples. The organization receives a restricted grant from
the worksheets. Don't include bad debt in these amounts. Bad an unrelated organization that must be used by the organization
debt will be entered in Part III. to provide financial assistance. The amount of the restricted
grant is entered as direct offsetting revenue on line 7a, column
If the organization completed worksheets other than on (d).
TIP a combined basis (for example, facility by facility, joint
venture by joint venture), the organization should The organization receives an unrestricted grant from an
combine all information from these worksheets for purposes of unrelated organization. The organization decides to use the
entering amounts on the table. Only the portion of each joint grant to increase the amount of financial assistance it provides.
venture or partnership that represents the organization's The amount of the unrestricted grant isn't entered as direct
proportionate share, based on capital interest, can be entered offsetting revenue on line 7a, column (d).
on lines 7a through 7k. See Purpose of Schedule for instructions Columns (e) and (f). Don't enter negative numbers. If the
on aggregation. net community benefit expense is less than $0, enter “0.”
Similarly, don't enter a negative percent in column (f), but enter
Use the organization's most accurate costing methodology “0.”
(cost accounting system, cost-to-charge ratio, or other) to
calculate the amounts entered on the table. If the organization Group return filers. The “total expense” denominator for
uses a cost-to-charge ratio, it can use Worksheet 2, Ratio of purposes of determining the percent of total expense for column
Patient Care Cost to Charges, for this purpose. See the (f) is the amount entered on Form 990, Part IX, line 25, column
instructions for Part VI, line 1, regarding an explanation of the (A), of the group return.
costing methodology used to calculate the amounts entered on Column (f) “percent of total expense” is based on
the table. TIP column (e) “net community benefit expense,” rather than
If the organization included any costs for a physician clinic as column (c) “total community benefit expense.”
subsidized health services on Part I, line 7g, enter these costs Organizations that enter amounts of direct offsetting revenue
on Part VI, line 1. might also wish to enter total community benefit expense (Part I,
line 7, column (c)) as a percentage of total expenses. Although

Instructions for Schedule H -3-

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this percentage cannot be entered on Part I, line 7, column(f), it        Line 2. “Economic development” can include, but isn't limited 
can be entered on Schedule H (Form 990), Part VI, line 1.                 to, assisting small business development in neighborhoods with 
                                                                          vulnerable populations and creating new employment 
Worksheets for Part I, Line 7                                             opportunities in areas with high rates of joblessness.
(Financial Assistance and Certain                                         Line 3. “Community support” can include, but isn't limited to, 
                                                                          child care and mentoring programs for vulnerable populations or 
Other Community Benefits at Cost)                                         neighborhoods, neighborhood support groups, violence 
Worksheets 1 through 8 give the definitions of community benefit          prevention programs, and disaster readiness and public health 
to be used in completing Schedule H (Form 990), Part I, lines 7a          emergency activities, such as community disease surveillance or 
through 7k. Use of the worksheets isn't required, and the                 readiness training beyond what is required by accrediting bodies 
organization can use alternative equivalent documentation,                or government entities.
provided that the methodology described in these instructions             Line 4. “Environmental improvements” include, but aren't 
(including the instructions to the worksheets) is followed.               limited to, activities to address environmental hazards that affect 
Regardless of whether the worksheets or alternative equivalent            community health, such as alleviation of water or air pollution, 
documentation is used to compile and enter the required                   safe removal or treatment of garbage or other waste products, 
information, such documentation should not be filed with Form             and other activities to protect the community from environmental 
990 but must be retained by the organization to substantiate the          hazards. The organization cannot include on this line or in this 
information entered on Schedule H (Form 990). The worksheets              part expenditures made to comply with environmental laws and 
or alternative equivalent documentation are to be completed               regulations that apply to activities of itself, its disregarded entity 
using the organization's most accurate costing methodology,               or entities, a joint venture in which it has an ownership interest, 
which can include a cost accounting system, cost-to-charge                or a member of a group exemption included in a group return 
ratios, a combination thereof, or some other method.                      of which the organization is also a member. Similarly, the 
 If the organization is filing a group return or has a disregarded        organization cannot include on this line or in this part 
entity or an ownership interest in one or more joint ventures,            expenditures made to reduce the environmental hazards caused 
the organization may find it helpful to complete the worksheets           by, or the environmental impact of, its own activities, or those of 
separately for the organization and for each disregarded entity,          its disregarded entities, joint ventures, or group exemption 
joint venture in which the organization had an ownership interest         members, unless the expenditures are for an environmental 
during the tax year, and group affiliate. In that case, the               improvement activity that (i) is provided for the primary purpose 
organization should combine all information from the worksheets           of improving community health; (ii) addresses an environmental 
for purposes of completing line 7. Complete the table by                  issue known to affect community health; and (iii) is subsidized by 
combining amounts from the organization's worksheets,                     the organization at a net loss. An expenditure may not be 
amounts from disregarded entities or group affiliates, and                entered on this line if the organization engages in the activity 
amounts from joint ventures that are attributable to the                  primarily for marketing purposes.
organization's proportionate share of each joint venture, under           Line 5. “Leadership development and training for community 
the aggregation instruction in Purpose of Schedule.                       members” includes, but isn't limited to, training in conflict 
 See Worksheets 1 through 8 and specific instructions for the             resolution; civic, cultural, or language skills; and medical 
worksheets later in these instructions.                                   interpreter skills for community residents.
                                                                          Line 6. “Coalition building” includes, but isn't limited to, 
Part II. Community Building Activities                                    participation in community coalitions and other collaborative 
Enter in this part the costs of the organization's activities that it     efforts with the community to address health and safety issues.
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        Line 7. “Community health improvement advocacy” includes, 
this schedule. Some community building activities may also                but isn't limited to, efforts to support policies and programs to 
meet the definition of a community health improvement service,            safeguard or improve public health, access to health care 
as defined in Worksheet 4. Don't enter in Part II community               services, housing, the environment, and transportation.
building costs that are entered on Part I, line 7e. An organization       Line 8. “Workforce development” includes, but isn't limited to, 
that enters information in this Part II must describe in Part VI how      recruitment of physicians and other health professionals to 
its community building activities promote the health of the               medical shortage areas or other areas designated as 
communities it serves.                                                    underserved, and collaboration with educational institutions to 
 If the filing organization makes a grant to an organization to           train and recruit health professionals needed in the community 
be used to accomplish one of the community building activities            (other than the health professions education activities entered 
listed in this part, then the organization should include the             on Part I, line 7f).
amount of the grant on the appropriate line in Part II. If the            Line 9. “Other” refers to community building activities that 
organization makes a grant to a joint venture in which it has an          protect or improve the community's health or safety that aren't 
ownership interest to be used to accomplish one of the                    described in the categories listed on lines 1 through 8 above. 
community building activities listed in this part, enter the grant on     Examples might include, but are not limited to, spending on food 
the appropriate line in Part II, but don't include in Part II the         security, nutrition, and other social determinants of health.
organization's proportionate share of the amount spent by the             Refer to the instructions to Part I, line 7, columns (a) through 
joint venture on such activities to avoid double counting.                (f), for descriptions of the types of information that should be 
Line 1. “Physical improvements and housing” include, but aren't           entered in each column of Part II.
limited to, the provision or rehabilitation of housing for vulnerable     If the organization is filing a group return or has a 
populations, such as removing building materials that harm the            disregarded entity or an ownership interest in one or more 
health of the residents, neighborhood improvement or                      joint ventures, the organization may find it helpful to complete 
revitalization projects, provision of housing for vulnerable              Part II separately for itself and for each disregarded entity, joint 
patients upon discharge from an inpatient facility, housing for           venture in which the organization had an ownership interest 
low-income seniors, and the development or maintenance of                 during the tax year, and group affiliate. The organization should 
parks and playgrounds to promote physical activity.

                                                                      -4-                                   Instructions for Schedule H

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combine the amounts from all such tables, according to the                the footnote or footnotes, or enter the page number(s) in which 
combined instructions in Purpose of Schedule, and include the             the footnote or footnotes appear in the attached audited financial 
combined information in Part II.                                          statements.
                                                                          If the organization's financial statements include a footnote on 
Part III. Bad Debt, Medicare, and                                         these issues that also includes other information, enter in Part VI 
Collection Practices                                                      only the relevant portions of the footnote. If the organization is a 
                                                                          member of a group with consolidated financial statements, the 
Section A                                                                 organization can summarize that portion, if any, of the footnote 
                                                                          or footnotes that apply. If the organization's financial statements 
In this section, (a) enter combined bad debt expense; (b) provide         don't include a footnote that discusses bad debt expense, 
an estimate of how much bad debt expense, if any, reasonably              “accounts receivable,” "allowance for doubtful accounts," or 
could be attributable to persons who likely would qualify for             similar designations, include a statement in Part VI that the 
financial assistance under the organization’s FAP; and (c)                organization's audited financial statements don't include a 
provide a rationale for what portion of bad debt, if any, the             footnote discussing these issues and explain how the 
organization believes is community benefit. In addition, the              organization's financial statements account for bad debt, if at all.
organization must enter whether it has adopted Healthcare 
Financial Management Association Statement No. 15, Valuation              Section B
and Financial Presentation of Charity Care, Implicit Price 
Concessions and Bad Debts by Institutional Healthcare                     In this section, (a) combine allowable costs to provide services 
Providers (“Statement 15”), and provide the text or page number           reimbursed by Medicare (don't include community benefit costs 
of its footnote, if applicable, to its audited financial statements       included on Part I, line 7I), (b) combine Medicare 
that describe the bad debt expense.                                       reimbursements attributable to such costs, and (c) combine 
                                                                          Medicare surplus or shortfall. Include in Section B only those 
Line 1. Indicate if the organization enters bad debt expense in           allowable costs and Medicare reimbursements that are reported 
accordance with Statement 15.                                             in the organization's Medicare Cost Report(s) for the year, 
                                                                          including its share of any such allowable costs and 
Note. Statement 15 hasn't been adopted by the American                    reimbursement from disregarded entities and joint ventures 
Institute of Certified Public Accountants (AICPA). The IRS                in which it has an ownership interest. Don't include any 
doesn't require organizations to adopt Statement 15 or use it to          Medicare-related expenses or revenue properly entered on Part 
determine bad debt expense or financial assistance costs. Some            I, line 7f or 7g.
organizations may rely on Statement 15 in reporting bad debt 
expense and financial assistance in their audited financial               In Part VI, the organization should describe what portion of its 
statements. Statement 15 provides instructions for                        Medicare shortfall, if any, it believes should constitute 
recordkeeping, valuation, and disclosure for bad debts.                   community benefit, and explain its rationale for its position. As 
                                                                          described below, the organization can also enter in Part VI the 
Line 2. Use the most accurate system and methodology                      amount of any Medicare revenues and costs not included in its 
available to the organization to enter bad debt expense. If only a        Medicare Cost Report(s) for the year, and can enter a 
portion of a patient’s bill for services is written off as a bad debt,    reconciliation of the amounts entered in Section B (including the 
include only the proportionate amount attributable to the bad             surplus or shortfall entered on line 7) and the total revenues and 
debt. Include the organization’s proportionate share of the bad           costs attributable to all of the organization's Medicare programs.
debt expense of joint ventures in which it had an ownership 
interest during the tax year.                                             Line 5. Enter all net patient service revenue (for Medicare fee 
                                                                          for service (FFS) patients) associated with the allowable costs 
Describe in Part VI the methodology used in determining the 
                                                                          the organization entered in its Medicare Cost Report(s) for the 
amount entered on line 2 as bad debt, including how the 
                                                                          year, including payments for indirect medical education (IME) 
organization accounted for discounts and payments on patient 
                                                                          (except for Medicare Advantage IME), Medicare 
accounts in determining bad debt expense.                                 disproportionate share hospital (DSH) revenue, coinsurance, 
Line 3. Provide an estimate of the amount of bad debt entered             patient deductible, outliers, capital, bad debt, and any other 
on line 2 that reasonably is attributable to patients who likely          amounts paid to the organization on the basis of its Medicare 
would qualify for financial assistance under the hospital's FAP           Cost Report. Don't include revenue related to subsidized health 
as entered on Part I, lines 1 through 4, but for whom insufficient        services as entered on Part I, line 7g (see Worksheet 6), 
information was obtained to determine their eligibility. Don't            research as entered on Part I, line 7h (see Worksheet 7), or 
include this amount in Part I, line 7. Organizations can use              direct graduate medical education (GME) as entered on Part I, 
any reasonable methodology to estimate this amount, such as               line 7f (see Worksheet 5). If the organization has more than one 
record reviews, an assessment of financial assistance                     Medicare provider number, combine the revenue attributable to 
applications that were denied due to incomplete documentation,            costs reported on the Medicare Cost Report(s) submitted under 
analysis of demographics, or other analytical methods.                    each provider number, and enter the combined revenues on 
Describe in Part VI the methodology used to determine the                 line 5.
amount entered on line 3 and the rationale, if any, for including         Line 6. Enter all Medicare allowable costs reported in the 
any portion of bad debt as community benefit.                             organization's Medicare Cost Report(s), except those already 
Line 4. In Part VI, provide the footnote from the organization's          entered on line 7g, Part I (subsidized health services), and costs 
audited financial statements on bad debt expense, if                      associated with direct GME already entered on line 7f, Part I 
applicable, or the footnotes related to “accounts receivable,”            (health professions education). This can be determined using 
“allowance for doubtful accounts,” or similar designations.               Worksheet A. If Worksheet A isn't used, the organization still 
Alternatively, enter the page number(s) on which the footnote or          must subtract the costs attributable to subsidized health services 
footnotes appear in the organization's most recent audited                and direct GME from the Medicare allowable costs it enters on 
financial statements, which must be attached to this return. If the       line 6. If the organization has more than one Medicare provider 
footnote or footnotes address only the filing organization's bad          number, it should combine the costs reported in the Medicare 
debt expense or “accounts receivable,” “allowance for doubtful            Cost Report(s) submitted under each provider number and enter 
accounts,” or similar designations, provide the exact wording of          the combined costs on line 6.

Instructions for Schedule H                                            -5-

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Worksheet A (Optional) or not such practices apply specifically to such patients or more
Complete Worksheets 5 and 6 before completing this Worksheet broadly to also cover other types of patients.
A.
Part IV. Management Companies and
Joint Ventures Owned 10% or More
1. Total Medicare allowable costs (from Medicare by Officers, Directors, Trustees, Key
Cost Report). . . . . . . . . . . . . . . . . . . . . . $
2. Total Medicare allowable costs (from line 1) Employees, and Physicians
included in Worksheet 6, line 3, col. (A) . . . . . . . $ List any management company, joint venture, or other
3. Total Medicare allowable costs (from line 1) separate entity (whether treated as a partnership or a
included in Worksheet 5, line 8 (direct GME) . . . . $ corporation), including joint ventures outside of the United
4. Total adjustments to Medicare allowable costs States, of which the organization is a partner or shareholder:
(add lines 2 and 3). . . . . . . . . . . . . . . . . . . $ 1. In which persons described in 1a and/or 1b below owned,
5. Total Medicare allowable costs (line 1 minus line 4). in the aggregate, more than 10% of the share of profits of such
Enter this value in Part III, line 6.. . . . . . . . . . . $
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
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 b. Physicians who were employed as physicians by, or had
number. staff privileges with, one or more of the organization's hospitals;
and
Lines 5, 6, and 7 don't include certain Medicare program 2. That either:
TIP revenues and costs, and thus cannot reflect all of the
organization's revenues and costs associated with its a. Provided management services used by the organization
participation in Medicare programs. The organization can in its provision of medical care, or
describe in Part VI the Medicare revenues and costs not b. Provided medical care, or owned or provided real
included in its Medicare Cost Report(s) for the year (for example, property, tangible personal property, or intangible property used
revenues and costs for freestanding ambulatory surgery centers, by the organization or by others to provide medical care.
physician services billed by the organization, clinical laboratory
services, and revenues and costs of Medicare Part C and Part D Examples of such joint ventures and management companies
programs). The organization can enter on Part VI, line 1, a include:
reconciliation of amounts entered in Section B (including the • An ancillary joint venture formed by the organization and its
officers or physicians to conduct an exempt or unrelated
surplus or shortfall entered on line 7) and all of the organization's
business activity,
total revenues and total expenses attributable to Medicare
programs. • A company owned by the organization and its officers or
physicians that owns and leases to the organization a hospital or
Line 8. Check the box that best describes the costing other medical care facility, and
methodology used to enter the Medicare allowable costs on • A company that owns and leases to entities other than the
line 6. Describe this methodology in Part VI. organization’s diagnostic equipment or intellectual property used
to provide medical care.
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, For purposes of Part IV, ownership interests can be direct or
as a community benefit. An organization's rationale must have a indirect. For example, if a joint venture reported in Part IV is
reasonable basis. Don't include this amount on Part I, line 7. owned, in part, by a physician group practice owned by staff
If the organization received any prior year settlements for physicians of the organization's hospital, report the physicians'
Medicare-related services in the current tax year, it can provide indirect ownership interest in the joint venture in proportion to
an explanation on Part VI, line 1. their ownership share of the physician group practice.
Note. Don't include publicly traded entities or entities whose
Section C sole income is passive investment income from interest or
In this section, enter the organization's written debt collection dividends.
policy.
For purposes of Part IV, the aggregate percentage share of
Line 9a. Answer “Yes” if the organization had a written debt profits or stock ownership percentage of officers, directors,
collection policy on the collection of amounts owed by patients trustees, key employees, and physicians who are employed as
during its tax year. physicians by, or have staff privileges with, one or more of the
For purposes of line 9a, a “written debt collection policy” organization's hospitals is measured as of the earlier of the close
includes a written billing and collections policy, or in the case of of the tax year of the organization or the last day the organization
an organization that doesn't have a separate written billing and was a member of the joint venture. All stock, whether common or
collections policy, a written FAP that includes the actions the preferred, is considered stock for purposes of determining the
organization may take in the event of non-payment, including stock ownership percentage. Provide all the information
collection actions and reporting to credit agencies. requested below for each such entity.
Line 9b. Answer “Yes” if the organization's written debt Column (a). Enter the full legal name of the entity.
collection policy that applied to the facilities that served the
Column (b). Describe the primary business activity or activities
largest number of the organization's patients during the tax year
conducted by the management company joint venture, , or
contained provisions for collecting amounts due from those
separate entity.
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

-6- Instructions for Schedule H

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Column (c). Enter the organization's percentage share of “Teaching hospital” is a hospital that provides training to
profits in the partnership or LLC, or stock in the entity that is medical students, interns, residents, fellows, nurses, or other
owned by the organization. health professionals and providers, provided that such
educational programs are accredited by the appropriate national
Column (d). Enter the percentage share of profits or stock in accrediting body.
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
Column (e). Enter the percentage share of profits or stock in Hospital Flexibility Program in accordance with Medicare rules.
the entity owned by all physicians who are employees
practicing as physicians or who have staff privileges with one or “Research facility” is a facility that conducts research.
more of the organization's hospitals. “ER—24 hours” refers to a facility that operates an
If a physician described above is also a current officer, emergency room 24 hours a day, 365 days a year.
director, trustee, or key employee of the organization, include
the physician’s profits or stock percentage in column (d). Don't “ER—other” refers to a facility that operates an emergency
include this in column (e). room for periods less than 24 hours a day, 365 days a year.
Part IV can be duplicated if more space is needed to list Complete the “Other (describe)” column for each hospital
additional management companies and joint ventures. facility that the organization operates that isn't described in the
other columns of Part V, Section A.
Part V. Facility Information In the upper left-hand corner of the Part V, Section A, table,
In Part V, the organization must list all of its hospital facilities in list the total number of hospital facilities that the organization
Section A, complete separate Sections B and C for each of its operated during the tax year.
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
Facility reporting groups. If the organization is able to check duplicate copies of Section A as needed, number each page,
the same checkboxes for all Part V, Section B, questions for and renumber the line numbers in the left-hand margin (an
more than one of its hospital facilities, it may file a single organization with 15 facilities should renumber lines 1–5 on the
Section B and Section C for all facilities in that facility reporting second page as lines 11–15).
group. For each of those facilities, the organization would assign
and list the facility reporting group letter in the “Facility reporting Section B
group” column in Section A. Assign letter A to the facility
reporting group with the greatest number of facilities, letter B to Section B requires reporting on a hospital facility by hospital
the group with the second greatest number of facilities, and so facility basis. The organization must complete a Section B for
forth. For instance, three hospital facilities with identical answers each of its hospital facilities or facility reporting groups listed in
to the Section B checkboxes would be assigned facility group Section A. At the top of each page of Section B, list the name of
letter A, while two other hospital facilities with identical answers the hospital facility or the facility reporting group letter. In the
would be assigned facility group letter B. space provided, list the line number of the hospital facility, or line
numbers of the hospital facilities in a facility reporting group
Section A (from Part V, Section A).
Complete Part V, Section A, by listing all of the organization's If the organization could check the same checkboxes for all
hospital facilities that it operated during the tax year. List Part V, Section B, questions for more than one of its hospital
these facilities in order of size from largest to smallest, measured facilities, it may file a single Section B for all facilities in that
by a reasonable method (for example, the number of patients facility reporting group.
served or total revenue per facility). “Hospital facilities” are References in these Section B instructions to a “hospital
facilities that, at any time during the tax year, were required to be facility” taking a certain action mean that the hospital
licensed, registered, or similarly recognized as a hospital under organization took action through or on behalf of the hospital
state law. A hospital facility is operated by an organization facility.
whether the facility is operated directly by the organization or
through a disregarded entity or joint venture treated as a Line 1. Answer “Yes” if the hospital facility was first licensed,
partnership. For each hospital facility, list its name, address, registered, or similarly recognized by a state as a hospital facility
primary website address, and state license number (and if a in the current tax year or the immediately preceding tax year.
group return, the name and employer identification number (EIN) Line 2. Answer “Yes” if the hospital facility was acquired or
of the subordinate hospital organization that operates the placed into service as a tax-exempt hospital in the current tax
hospital facility), and check the applicable column(s). year or the immediately preceding tax year. If “Yes,” provide
“Licensed hospital” is a facility licensed, registered, or details in Section C.
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
“General medical and surgical” refers to a hospital primarily community. To meet the requirements of section 501(r)(3), a
engaged in providing diagnostic and medical treatment (both CHNA must take into account input from persons who represent
surgical and nonsurgical) to inpatients with a wide variety of the broad interests of the community served by the hospital
medical conditions, and that may provide outpatient services, facility, including those with special knowledge of or expertise in
anatomical pathology services, diagnostic X-ray services, public health, and must be made widely available to the public.
clinical laboratory services, operating room services, and Each hospital facility must conduct a CHNA at least once
pharmacy services. every 3 years, and adopt an implementation strategy to meet the
“Children's hospital” is a center for provision of health care to community health needs identified through such CHNA.
children, and includes independent acute care children's Line 3. Answer “Yes” if the hospital facility conducted a CHNA
hospitals, children's hospitals within larger medical centers, and in the current tax year or in either of the 2 immediately preceding
independent children's specialty and rehabilitation hospitals. tax years. If “Yes,” indicate what the CHNA describes by
Instructions for Schedule H -7-

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checking all applicable boxes. If the CHNA describes Line 6a. Answer “Yes,” if the hospital facility's CHNA was
information that doesn't have a corresponding checkbox, check conducted with one or more other hospital facilities. “One or
line 3j, “Other,” and describe this information in Part V, more other hospital facilities” includes related and unrelated
Section C. If “No,” skip to line 12. hospital facilities. If “Yes,” list in Part V, Section C, the other
Note. Notice 2020-56 provided a postponement, until hospital facilities with which the hospital facility conducted its
December 31, 2020, of the deadline for performing any CHNA CHNA.
requirement due to be completed on or after April 1, 2020, and Line 6b. Answer “Yes,” if the hospital facility's CHNA was
before December 31, 2020. If you utilized this relief, treat the conducted with one or more organizations other than hospital
completed CHNA as having been completed in the tax year in facilities. If “Yes,” list in Part V, Section C, the other organizations
which it would have been due in the absence of any relief when with which the hospital facility conducted its CHNA.
answering line 3 and line 4.
Line 7. Answer “Yes,” if the hospital facility made its most
Line 3a. Check this box if the CHNA report defines the recently conducted CHNA widely available to the public. If “Yes,”
community served by the hospital facility and a description of indicate how the hospital facility made the CHNA widely
how the community was determined. available to the public by checking all applicable boxes. If the
Line 3c. Check this box if the CHNA report describes the hospital facility made the CHNA widely available to the public by
resources potentially available to address the significant health means other than those listed on lines 7a through 7c, check
needs identified through the CHNA, including existing health line 7d, “Other,” and describe these means in Part V, Section C.
care facilities and resources within the community that are Line 7a. Check this box if the CHNA was made available on the
available to respond to the health needs of the community. hospital facility’s website or the hospital organization’s website.
Line 3d. Check this box if the CHNA report describes the If line 7a is checked, list in the space provided the direct website
process and methods used to conduct the CHNA. address, or URL, where the CHNA can be accessed.
Line 3e. In Part V, Section C, indicate if the significant health Line 7b. Check this box if the CHNA was made available on a
needs are a prioritized description of the significant health needs website other than the hospital facility’s website or the hospital
of the community and identified through the CHNA. If not, organization’s website. If line 7b is checked, list in the space
explain how the health needs identified will be prioritized. provided the direct website address, or URL, where the CHNA
can be accessed.
Line 3g. Check this box if the CHNA report describes the
process and criteria used in identifying certain health needs as Line 7c. Check this box if a paper copy of the CHNA was made
significant and prioritizing those significant health needs. available for public inspection upon request and without charge
at the hospital facility.
Line 3h. Check this box if the CHNA report describes how the
hospital facility solicited and took into account input received Line 8. Answer “Yes” if the hospital facility adopted an
from persons who represent the broad interests of the implementation strategy to meet the significant health needs
community it serves. identified through its most recently conducted CHNA. If “No,”
skip to line 11.
Line 3i. Check this box if the CHNA report describes the
evaluation of the impact of any actions that were taken, since the Line 10. Answer “Yes” if the hospital facility’s most recently
hospital facility finished conducting its immediately preceding adopted implementation strategy is posted on a website. If
CHNA, to address the significant health needs identified in the “Yes,” answer line 10a. If “No,” skip to line 10b.
hospital facility’s prior CHNA(s). Line 10a. List in the space provided the direct website address,
Line 5. Answer “Yes” if the hospital facility took into account or URL, where the implementation strategy can be accessed
input from persons who represent the broad interests of the and skip to line 11.
community served by the hospital facility, including at least one Line 10b. Answer “Yes” if the hospital facility’s most recently
state, local, tribal, or regional governmental public health adopted implementation strategy is attached.
department (or equivalent department or agency), or a State
Office of Rural Health described in section 338J of the Public Line 11. Explain in Part V, Section C, how the hospital facility is
Health Service Act (42 U.S.C. 254r), with knowledge, addressing the significant needs identified in its most recently
information, or expertise relevant to the health needs of that conducted CHNA and any such needs that aren't being
community, members of medically underserved, low-income, addressed together with the reasons why such needs aren't
and minority populations in the community served by the hospital being addressed. For example, a hospital facility might identify
facility, or individuals or organizations serving or representing limited financial or other resources as reasons why it didn't take
the interests of such populations; and written comments action to address a need identified in its most recently
received on the hospital facility's most recently conducted CHNA conducted CHNA.
and most recently adopted implementation strategy. Line 12a. Answer “Yes” if the organization was liable, at any
If the organization checked “Yes,” summarize in Part V, time during the tax year, for the $50,000 excise tax incurred
Section C, in general terms, how and over what time period such under section 4959 for failure to conduct a CHNA and adopt an
input was provided (for example, whether through meetings, implementation strategy as required under section 501(r)(3).
focus groups, interviews, surveys, or written comments, and Section 501(r)(3) requires each hospital facility to conduct a
between what dates); the names of any organizations providing CHNA, in the tax year or in either of the immediately preceding 2
input; and describe the medically underserved, low-income, or tax years, that takes into account input from persons who
minority populations being represented by organizations or represent the broad interests of the community served by the
individuals that provided input. A CHNA report doesn't need to facility, including those with special knowledge of or expertise in
name or otherwise identify any specific individual providing input public health, and to make the CHNA widely available to the
on the CHNA. In the event a hospital facility solicits, but cannot public. Section 501(r)(3) also requires each hospital facility to
obtain, input from a source required by line 5, the hospital adopt an implementation strategy to meet the community health
facility's CHNA report must also describe the hospital facility's needs identified through its CHNA.
efforts to solicit input from such source.

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Line 12b. Answer “Yes” to line 12b if the organization answered other than those listed on lines 15a through 15d, check 15e,
“Yes” to line 12a and filed Form 4720, Return of Certain Excise “Other,” and explain the method(s) in Part V, Section C.
Taxes Under Chapters 41 and 42 of the Internal Revenue Code, Line 15a. Check this box if the hospital facility described all of
to report the section 4959 excise tax it incurred. Answer “Yes” if the information it may require an individual to provide as part of
the organization filed Form 4720 during the tax year or after the the application.
tax year but prior to the filing of this return.
Line 15b. Check this box if the hospital facility described all of
Line 12c. If line 12b is “Yes,” report the total amount of section the supporting documentation it may require an individual to
4959 excise tax the organization reported on Form 4720 for all of submit as part of the application.
its hospital facilities that incurred the tax.
Line 15c. Check this box if the hospital facility provided
Lines 13 through 16. See the instructions for Part I, line 1 of contact information of hospital facility staff that the hospital
Schedule H (Form 990), for the definition of “financial assistance facility has identified as an available source of assistance with
policy (FAP).” Answer “Yes” only if the FAP applies to all FAP applications.
emergency and other medically necessary care provided by the
hospital facility, including all such care provided in the hospital Line 15d. Check this box if the hospital facility provided the
facility by a substantially related entity. contact information of a nonprofit organization or government
agency that the hospital facility has identified as an available
Line 13. Answer “Yes,” if, during the tax year, the hospital source of assistance with FAP applications.
facility had a written FAP that explains eligibility criteria for
financial assistance, and whether such assistance includes free Line 16. Answer “Yes,” if, during the tax year, the FAP was
or discounted care. If “Yes,” indicate the eligibility criteria widely publicized within the community served by the hospital
explained in the FAP by checking all applicable boxes. If the facility. If “Yes,” indicate how the hospital facility publicized the
FAP describes information that doesn't have a corresponding policy by checking all applicable boxes. If the hospital facility
checkbox, check line 13h, “Other,” and describe this information publicized the policy within the community served by the hospital
in Part V, Section C. 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
Line 13a. See the instructions for Part I, line 3a of Schedule H was publicized within the community served by the hospital
(Form 990), for the definition of “Federal Poverty Guidelines” facility.
(FPG). Check this box if, during the tax year, the hospital
facility had a written FAP that used FPG for determining Line 16g. Check this box if individuals were notified about the
eligibility for free or discounted medical care. Show the specific FAP by being offered a paper copy of the plain language
threshold by writing in the percentage amount. If the hospital summary of the FAP, by receiving a conspicuous written notice
facility used FPG for determining eligibility for free or discounted about the FAP on their billing statements, and via conspicuous
medical care, but not both free and discounted medical care, public displays or other measures reasonably calculated to
enter “000” in the percentage amount for which FPG wasn't attract patients' attention.
used. Line 16i. Check this box if the FAP, FAP application form, and
Line 13b. Check this box if the hospital facility used an income plain language summary of the FAP were translated into the
level other than FPG and explain in Part V, Section C, what primary language(s) spoken by Limited English Proficient (LEP)
criteria the hospital facility used to determine eligibility for free or populations, such as by translating these documents into the
discounted care (including whether the hospital facility used the language(s) spoken by each LEP language group that
income level of patients, patients’ families, or patients’ constitutes the lesser of 1,000 individuals or 5% of the
guarantors as a factor). community served by the hospital facility or the population likely
to be affected or encountered by the hospital facility.
Line 13c. Check this box if the hospital facility used the asset
level of patients, patients' families, or patients' guarantors as a Line 16j. “Other” measures to publicize the policy within the
factor in determining eligibility for financial assistance. community served by the hospital facility may include, but
aren't limited to, having registration personnel refer uninsured
Line 13d. Check this box if the hospital facility considered and/or low-income patients to financial counselors to discuss the
whether patients were “medically indigent,” as defined in the policy. Check the box for line 16j if, instead of the detailed policy,
instructions for Part I, line 4 of Schedule H (Form 990), in the hospital facility provided a summary of the policy in a manner
determining eligibility for financial assistance. listed in lines 16a–16i.
Line 13e. Check this box if the hospital facility used the Line 17. Answer “Yes,” if, during the tax year, the hospital
insurance status of patients, patients' families, or patients' facility had either a separate written billing and collections
guarantors as a factor in determining eligibility for financial policy or a written FAP that described any actions that the
assistance. hospital facility (or other authorized party) may take related to
Line 13g. Check this box if the hospital facility considered obtaining payment of a bill for medical care, including, but not
residency as a factor in determining eligibility for financial limited to, any extraordinary collection actions (ECAs); the
assistance. process and time frames the hospital facility (or other authorized
party) uses in taking those actions (including, but not limited to,
Line 14. Answer “Yes,” if, during the tax year, the hospital the reasonable efforts it will make to determine whether an
facility had a written FAP that explained the basis for calculating individual is FAP-eligible before engaging in ECAs); and the
amounts charged to patients. office, department, committee, or other body with the final
Line 15. Answer “Yes,” if, during the tax year, the hospital authority or responsibility for determining that the hospital facility
facility had a written FAP that explained the method for applying has made reasonable efforts to determine whether an individual
for financial assistance. If “Yes,” indicate how the hospital is FAP-eligible and may therefore engage in ECAs against the
facility’s FAP or FAP application form (including the individual.
accompanying instructions) explained the method for applying Lines 18 and 19. “Other similar actions” don't include sending
for financial assistance by checking all applicable boxes. If the the patient a bill.
FAP explains a method(s) for applying for financial assistance

Instructions for Schedule H -9-

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Note. Section 501(r)(6) requires a hospital facility to forego          facility has referred the individual’s debt, or any substantially 
ECAs before the facility has made reasonable efforts to                 related entity.
determine the individual's eligibility under the facility's FAP.
                                                                        Line 19a. Check this box if the hospital facility reported adverse 
Line 18. Indicate what actions against an individual the                information about the individual to consumer credit reporting 
hospital facility was permitted to take during the tax year under       agencies or credit bureaus before making reasonable efforts to 
its policies before making reasonable efforts to determine the          determine the individual's eligibility under the facility's FAP.
individual's eligibility under the facility's FAP by checking all 
                                                                        Line 19b. Check this box if the hospital facility sold an 
applicable boxes.
                                                                        individual's debt to another party before making reasonable 
Line 18a.   Check this box if the FAP permitted reporting adverse       efforts to determine the individual's eligibility under the facility's 
information about the individual to consumer credit reporting           FAP. Don't check the box if, prior to the sale, the hospital facility 
agencies or credit bureaus.                                             entered into a legally binding written agreement with the 
                                                                        purchaser of the debt pursuant to which the purchaser is 
Line 18b.   Check this box if the FAP permitted selling an 
                                                                        prohibited from engaging in any ECAs to obtain payment for the 
individual's debt to another party. Don't check the box if, prior to 
                                                                        care; the purchaser is prohibited from charging interest on the 
the sale, the hospital facility entered into a legally binding written 
                                                                        debt in excess of the rate in effect under section 6621(a)(2) at 
agreement with the purchaser of the debt pursuant to which the 
                                                                        the time the debt is sold; the debt is returnable to or recallable by 
purchaser is prohibited from engaging in any ECAs to obtain 
                                                                        the hospital facility upon a determination by the hospital facility 
payment for the care; the purchaser is prohibited from charging 
                                                                        or the purchaser that the individual is FAP-eligible; and, if the 
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      individual is determined to be FAP-eligible and the debt isn't 
or recallable by the hospital facility upon a determination by the      returned to or recalled by the hospital facility, the purchaser is 
                                                                        required to adhere to procedures specified in the agreement that 
hospital facility or the purchaser that the individual is 
                                                                        ensure that the individual doesn't pay, and has no obligation to 
FAP-eligible; and, if the individual is determined to be 
                                                                        pay, the purchaser and the hospital facility together more than 
FAP-eligible and the debt isn't returned to or recalled by the 
                                                                        the individual is personally responsible for paying as an 
hospital facility, the purchaser is required to adhere to 
                                                                        FAP-eligible individual.
procedures specified in the agreement that ensure that the 
individual doesn't pay, and has no obligation to pay, the               Line 19c. Check this box if the hospital facility deferred or 
purchaser and the hospital facility together more than the              denied, or required a payment before providing, medically 
individual is personally responsible for paying as an FAP-eligible      necessary care because of an individual’s nonpayment of one or 
individual.                                                             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             Line 19d. Check this box if the hospital facility took legal action 
necessary care because of an individual’s nonpayment of one or          or pursued a judicial process, including but not limited to placing 
more bills for previously provided care covered under the               a lien on an individual's real property; attaching or seizing an 
hospital facility’s FAP.                                                individual's bank account or any other personal property; 
                                                                        commencing a civil action against an individual; causing an 
Line 18d.   Check this box if the FAP permitted actions that 
                                                                        individual's arrest; causing an individual to be subject to a writ of 
require a legal or judicial process, including but not limited to 
                                                                        body attachment; or garnishing an individual's wages. Don't 
placing a lien on an individual's real property; attaching or 
                                                                        include any liens that a hospital facility is entitled to assert under 
seizing an individual's bank account or any other personal 
                                                                        state law on the proceeds of a judgment settlement, or 
property; commencing a civil action against an individual; 
                                                                        compromise owed to an individual (or the individual’s 
causing an individual's arrest; causing an individual to be subject 
                                                                        representative) as a result of personal injuries for which the 
to a writ of body attachment; or garnishing an individual's wages. 
                                                                        hospital facility provided care and if it filed a claim in a 
Don't include any liens that a hospital facility is entitled to assert 
                                                                        bankruptcy proceeding.
under state law on the proceeds of a judgment, settlement, or 
compromise owed to an individual (or the individual’s                   Line 19e. If the hospital facility took an action or actions against 
representative) as a result of personal injuries for which the          an individual during the tax year similar to those listed in lines 
hospital facility provided care and if it files a claim in a            19a through 19d before making reasonable efforts to determine 
bankruptcy proceeding.                                                  the individual's eligibility under the facility's FAP, check line 19e, 
                                                                        “Other similar actions,” and describe those actions in Part V, 
Line 18e.   If a hospital facility's policies permitted the facility to 
                                                                        Section C.
take an action or actions against an individual during the tax year 
similar to those listed on lines 18a through 18d before making          Line 20. Indicate which efforts the hospital facility or other 
reasonable efforts to determine the individual's eligibility under      authorized party made before initiating any of the actions listed 
the facility's FAP, check line 18e, “Other similar actions,” and        (whether or not checked) on lines 19a through 19d or described 
describe those actions in Part V, Section C.                            in Part V, Section C (describing “other similar actions” checked 
                                                                        on line 18e or line 19e) by checking all applicable boxes on lines 
Line 18f. If the hospital facility was permitted to make no such 
                                                                        20a through 20d. If the hospital facility made efforts other than 
actions, check the box for line 18f, “None of these actions or 
                                                                        those listed on lines 20a through 20d before initiating any of the 
similar actions were permitted.”
                                                                        actions listed on lines 19a through 19d or described in Part V, 
Line 19. Indicate any of the actions against an individual that         Section C (describing "other similar actions" checked on line 18e 
the hospital facility took during the tax year before making            or line 19e), check the box for line 20e, “Other,” and describe in 
reasonable efforts to determine the individual's eligibility under      Part V, Section C.
the facility's FAP by checking all applicable boxes. For purposes            If the hospital facility made no such efforts before initiating 
of this question, actions against an individual include actions to      any of the actions listed (whether or not checked) on lines 19a 
obtain payment for the care against any other individual who has        through 19d or described in Part V, Section C (describing “other 
accepted or is required to accept responsibility for the                similar actions” checked on line 18e or line 19e), check the box 
individual’s hospital bill for the care, and actions of the hospital    for line 20f, “None of these efforts were made.”
facility include actions of any purchaser of the individual’s debt, 
any debt collection agency or other party to which the hospital 

                                                                        -10-                    Instructions for Schedule H

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Line 20a. Check this box if the hospital facility or other                1. That there is inadequate time to effect a safe transfer to 
authorized party provided individuals with a written notice that          another hospital before delivery, or
indicated financial assistance is available for eligible individuals,     2. That transfer may pose a threat to the health or safety of 
identified the ECA(s) that the hospital facility (or other authorized     the woman or the unborn child.
party) intended to initiate to obtain payment for the care, and 
stated a deadline after which such ECA(s) may be initiated that           Lines 22–24.   For purposes of lines 22–24, the term 
was no earlier than 30 days after the date that the written notice        “FAP-eligible” means eligible for assistance under the hospital 
was provided, along with a plain language summary of the FAP.             facility's FAP.
If not, describe in Section C.                                            Line 22. Indicate how the hospital facility determined, during the 
Line 20b. Check this box if the hospital facility or other                tax year, the maximum amounts that can be charged to 
authorized party made a reasonable effort to orally notify                FAP-eligible individuals for emergency or other medically 
individuals about the hospital facility’s FAP and about how the           necessary care by checking the appropriate box.
individual may obtain assistance with the FAP application 
process at least 30 days before initiating ECAs. If not, describe         Note. Under section 501(r)(5), the maximum amounts that can 
in Section C.                                                             be charged to FAP-eligible individuals for emergency or other 
                                                                          medically necessary care are the amounts generally billed to 
Line 20c. Check this box if (1) when an individual who                    individuals who have insurance covering such care.
submitted an incomplete FAP application during the application 
period, the hospital facility or other authorized party notified the      Line 23. Answer “Yes,” if, during the tax year, the hospital 
individual about how to complete the FAP application and gave             facility charged any FAP-eligible individual to whom the hospital 
the individual a reasonable opportunity to do so in accordance            facility provided emergency or other medically necessary 
with Regulations section 1.501(r)-6(c)(5); and (2) when an                services more than the amounts generally billed to individuals 
individual who submitted a complete FAP application during the            who had insurance covering such care. If “Yes,” explain in Part 
application period, the hospital facility or other authorized party       V, Section C, except as provided in the next paragraph.
determined whether the individual is FAP-eligible for the care            The hospital facility may check “No” if it charged more than 
and otherwise met the requirements described in Regulations               the amounts generally billed to individuals who had insurance 
section 1.501(r)-6(c)(6). If not, describe in Section C.                  covering such care to an individual if the charge in excess of 
Line 20d. Check this box if the hospital facility or other                amounts generally billed (AGB) wasn't made or requested as a 
authorized party made presumptive eligibility determinations in           pre-condition of providing medically necessary care to the 
accordance with Regulations section 1.501(r)-6(c)(2). If not,             FAP-eligible individual; as of the time of the charge, the 
describe in Section C.                                                    FAP-eligible individual hadn't submitted a complete FAP 
                                                                          application and hadn't otherwise been determined by the 
Line 21. Answer “Yes,” if, during the tax year, the hospital              hospital facility to be FAP-eligible for the care; and, if the 
facility had in place a written policy about emergency medical            individual subsequently submits a complete FAP application and 
care that required the hospital facility to provide, without              is determined to be FAP-eligible for the care, the hospital facility 
discrimination, care for emergency medical conditions to                  refunds any amount that exceeds the amount the individual is 
individuals without regard to their eligibility under the hospital        determined to be personally responsible for paying as an 
facility's FAP. A hospital facility's emergency medical care policy       FAP-eligible individual, unless such excess amount is less than 
doesn't meet this requirement unless it prohibits the hospital            $5.
facility from engaging in actions that discourage individuals from 
seeking emergency medical care, such as by demanding that                 Line 24. Answer “Yes,” if, during the tax year, the hospital 
emergency department patients pay before receiving treatment              facility charged any FAP-eligible individual an amount equal to 
for emergency medical conditions or by permitting debt                    the gross charge for any service provided to that individual, and 
collection activities that interfere with the provision, without          explain in Part V, Section C, the circumstances in which it used 
discrimination, of emergency medical care. If “No,” indicate the          gross charges. A bill that itemizes a reduction applied to a gross 
reasons why the hospital facility didn't have a written                   charge for a service doesn't need to be reported if the amount 
nondiscriminatory policy relating to emergency medical care by            charged to the individual for such service is less than the amount 
checking all applicable boxes. If the reason the hospital facility        of the gross charge.
didn't have a written nondiscriminatory policy relating to                The hospital facility may check “No” if it charged gross 
emergency medical care isn't listed in lines 21a through 21c,             charges for any medical care covered under the FAP if the 
check line 21d, “Other,” and describe the reason(s) in Part V,            charge in excess of AGB wasn't made or requested as a 
Section C.                                                                pre-condition of providing medically necessary care to the 
The hospital facility may check “Yes” if it had a written policy          FAP-eligible individual; as of the time of the charge, the 
that required compliance with 42 U.S.C. 1395dd (Emergency                 FAP-eligible individual hadn't submitted a complete FAP 
Medical Treatment and Active Labor Act (EMTALA)).                         application and hadn't otherwise been determined by the 
                                                                          hospital facility to be FAP-eligible for the care; and, if the 
For purposes of line 21, the term “emergency medical                      individual subsequently submits a complete FAP application and 
conditions” means:                                                        is determined to be FAP-eligible for the care, the hospital facility 
(a) A medical condition manifesting itself by acute symptoms              refunds any amount that exceeds the amount the individual is 
of sufficient severity (including severe pain) such that the              determined to be personally responsible for paying as an 
absence of immediate medical attention could reasonably be                FAP-eligible individual, unless such excess amount is less than 
expected to result in:                                                    $5.
1. Placing the health of the individual (or, for a pregnant 
woman, the health of the woman or the unborn child) in serious            Section C
jeopardy,                                                                 Use Section C to provide descriptions required for Part V, 
2. Serious impairment to bodily functions, or                             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 
3. Serious dysfunction of any bodily organ or part; or                    applicable. Complete a separate Section C for each hospital 
(b) For a pregnant woman who is having contractions:                      facility or facility reporting group for which the organization 

Instructions for Schedule H                                           -11-

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completed Section B; complete one Section C for each                   •    Line 20e: If the organization checked line 20e, describe the 
Section B.                                                             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 hospital facility limited who was eligible to receive care for 
the specific name and line number (from Schedule H (Form               emergency services.
990), Part V, Section A) of the hospital facility to which the         •    Line 21d: If the organization checked line 21d, describe the 
responses in Section C relate.                                         other reasons why the hospital facility didn't have a written 
  If completing Section C for a facility reporting group, list the     nondiscriminatory policy for emergency medical care.
reporting group letter, then list each hospital facility in that group •    Line 23: If the organization checked “Yes” to line 23, explain 
separately by name and line number (from Section A). For each          the circumstances in which the hospital facility charged any 
hospital facility, provide the descriptions required for Part V,       FAP-eligible individual more than the amounts generally billed to 
Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e,    individuals who had insurance covering such care.
19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable,     •    Line 24: If the organization answered “Yes” to line 24, explain 
provide separate descriptions for each hospital facility in a          the circumstances in which the hospital facility charged any 
facility reporting group, designated by facility reporting group       FAP-eligible individual an amount equal to the gross charge for 
letter and hospital facility line number from Part V, Section A (“A,   any service provided to that individual.
1,” “A, 4,” “B, 2,” “B, 3,” etc.), and name of hospital facility.
                                                                       Section D
• Line 2: If the organization checked “Yes,” provide details           Complete Part V, Section D, by listing all of the non-hospital 
regarding the hospital facility(ies) acquired or placed into           health care facilities that the organization operated during the 
service as a tax-exempt hospital in the current tax year or the        tax year. A facility is operated by an organization whether it is 
immediately preceding tax year.                                        operated directly by the organization or through a disregarded 
• Line 3j: If the organization checked line 3j, describe the other     entity or joint venture treated as a partnership. List each of 
content included in the hospital facility's CHNA report.               these facilities in order of size from largest to smallest, measured 
• Line 5: If the organization checked “Yes,” summarize, in             by a reasonable method (for example, the number of patients 
general terms, how and over what time period such input was            served or total revenue per facility). For each non-hospital health 
provided (for example, whether through meetings, focus groups,         care facility, list its name and address and describe the type of 
interviews, surveys, or written comments, and between what             facility. These types of facilities may include, but aren't limited to, 
dates); the names of any organizations providing input; and            rehabilitation and other outpatient clinics, diagnostic centers, 
describe the medically underserved, low-income, or minority            mobile clinics, and skilled nursing facilities.
populations being represented by organizations or individuals 
that provided input. A CHNA report doesn't need to name or                  List the total number of non-hospital health care facilities that 
otherwise identify any specific individual providing input on the      the organization operated during the tax year.
CHNA. In the event a hospital facility solicits, but cannot obtain, 
input from a source required by line 5, the hospital facility's             If the organization needs additional space to list all of its 
CHNA report must also describe the hospital facility's efforts to      non-hospital health care facilities, it should duplicate Section D 
solicit input from such source.                                        and use as many duplicate copies of Section D as needed, 
• Line 6a: If the organization checked “Yes,” list the other           number each page, and renumber the line numbers in the 
hospital facilities with which the hospital facility conducted its     left-hand margin (for example, an organization with 15 such 
CHNA.                                                                  facilities should renumber lines 1–5 on the 2nd page as lines 11–
• Line 6b: If the organization checked “Yes,” list the                 15).
organizations other than hospital facilities with which the hospital 
facility conducted its CHNA.                                           •    Line 2: If the organization checked “Yes,” provide details 
• Line 7d: If the organization checked line 7d, describe the           regarding the hospital facility(ies) acquired or placed into 
other means that the hospital facility used to make its CHNA           service as a tax-exempt hospital in the current tax year or the 
widely available.                                                      immediately preceding tax year.
• Line 11: Describe how the hospital facility is addressing the        •    Line 3j: If the organization checked line 3j, describe the other 
significant health needs identified in its most recently conducted     content included in the hospital facility's CHNA report.
CHNA and any such needs that aren't being addressed together           •    Line 5: If the organization checked “Yes,” summarize, in 
with the reasons why such needs aren't being addressed.                general terms, how and over what time period such input was 
• Line 13b: Describe the criteria the hospital facility used to        provided (for example, whether through meetings, focus groups, 
determine eligibility for free or discounted care (including           interviews, surveys, or written comments, and between what 
whether the hospital facility used the income level of patients,       dates); the names of any organizations providing input; and 
patients’ families, or patients’ guarantors as a factor).              describe the medically underserved, low-income, or minority 
• Line 13h: If the organization checked line 13h, describe the         populations being represented by organizations or individuals 
other eligibility criteria used.                                       that provided input. A CHNA report doesn't need to name or 
• Line 15e: If the organization checked line 15e, describe the         otherwise identify any specific individual providing input on the 
other methods for applying for financial assistance.                   CHNA. In the event a hospital facility solicits, but cannot obtain, 
• Line 16j: If the organization checked line 16j, describe other       input from a source required by line 5, the hospital facility's 
ways that the hospital facility publicized its FAP.                    CHNA report must also describe the hospital facility's efforts to 
• Line 18e: If the organization checked line 18e, describe the         solicit input from such source.
other similar actions that the hospital facility was permitted to      •    Line 6a: If the organization checked “Yes,” list the other 
take under its policies during the tax year before making              hospital facilities with which the hospital facility conducted its 
reasonable efforts to determine the individual's eligibility under     CHNA.
the facility's FAP.                                                    •    Line 6b: If the organization checked “Yes,” list the 
• Line 19e: If the organization checked line 19e, describe the         organizations other than hospital facilities with which the hospital 
other similar actions that the hospital facility was permitted to      facility conducted its CHNA.
take under its policies during the tax year before making              •    Line 7d: If the organization checked line 7d, describe the 
reasonable efforts to determine the individual's eligibility under     other means that the hospital facility used to make its CHNA 
the facility's FAP.                                                    widely available.

                                                                       -12-                           Instructions for Schedule H

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• Line 11: Describe how the hospital facility is addressing the Part I, line 7g. If applicable, describe if the organization
significant health needs identified in its most recently conducted included as subsidized health services any costs attributable to
CHNA and any such needs that aren't being addressed together a physician clinic, and enter such costs the organization
with the reasons why such needs aren't being addressed. included.
• Line 13b: Describe the criteria the hospital facility used to Part I, line 7, column (f). If applicable, enter the bad debt
determine eligibility for free or discounted care (including expense included in Form 990, Part IX, line 25, column (A) (but
whether the hospital facility used the income level of patients, subtracted for purposes of calculating the percentages in this
patients’ families, or patients’ guarantors as a factor). column).
• Line 13h: If the organization checked line 13h, describe the Part I, line 7. Provide an explanation of the costing
other eligibility criteria used. methodology used to calculate the amounts entered for each
• Line 15e: If the organization checked line 15e, describe the line in the table. If a cost accounting system was used, indicate
other methods for applying for financial assistance. whether the cost accounting system addresses all patient
• Line 16j: If the organization checked line 16j, describe other segments (for example, inpatient, outpatient, emergency room,
ways that the hospital facility publicized its FAP. private insurance, Medicaid, Medicare, uninsured, or self pay).
• Line 18e: If the organization checked line 18e, describe the Also, indicate if a cost-to-charge ratio was used for any of the
other similar actions that the hospital facility was permitted to figures in the table. Describe whether this cost-to-charge ratio
take under its policies during the tax year before making was derived from Worksheet 2, Ratio of Patient Care
reasonable efforts to determine the individual's eligibility under Cost-to-Charges, and, if not, what kind of cost-to-charge ratio
the facility's FAP. was used and how it was derived. If some other costing
• Line 19e: If the organization checked line 19e, describe the methodology was used besides a cost accounting system,
other similar actions that the hospital facility was permitted to cost-to-charge ratio, or a combination of the two, describe the
take under its policies during the tax year before making method used.
reasonable efforts to determine the individual's eligibility under Part II. Describe how the organization’s community building
the facility's FAP. activities, as reported in Part II, promote the health of the
• Line 20e: If the organization checked line 20e, describe the community or communities the organization serves.
other efforts that the hospital facility made. Part III, line 2. Describe the methodology used to determine
• Line 21c: If the organization checked line 21c, describe how the amount on Part III, line 2, including how the organization
the hospital facility limited who was eligible to receive care for accounts for discounts and payments on patient accounts in
emergency services. determining bad debt expense.
• Line 21d: If the organization checked line 21d, describe the
Part III, line 3. Describe the methodology used to determine
other reasons why the hospital facility didn't have a written
the amount entered on line 3. Also, describe the rationale, if any,
nondiscriminatory policy for emergency medical care.
for including any portion of bad debt as community benefit.
• Line 23: If the organization checked “Yes” to line 23, explain
the circumstances in which the hospital facility charged any Part III, line 4. Provide, if applicable, the text of the footnote
FAP-eligible individual more than the amounts generally billed to to the organization's financial statements that describes bad
individuals who had insurance covering such care. debt expense, or enter the page number(s) of the organization's
• Line 24: If the organization answered “Yes” to line 24, explain most recent audited financial statements on which the
the circumstances in which the hospital facility charged any footnote appears. If the organization's financial statements
FAP-eligible individual an amount equal to the gross charge for include a footnote on these issues that also includes other
any service provided to that individual. information, enter only the relevant portions of the footnote. If the
organization's financial statements don't contain such a footnote,
Part VI. Supplemental Information enter that the organization's financial statements don't include
such a footnote, and explain how the financial statements
Use Part VI to provide the narrative explanations required by account for bad debt, if at all.
the following questions, and to supplement responses to other Part III, line 8. Describe the costing methodology used to
questions on Schedule H (Form 990). In addition, use Part VI to determine the Medicare allowable costs entered on Part III,
make disclosures described in section 7 of Rev. Proc. 2015-21. line 6. Describe, if applicable, the extent to which any shortfall
Identify the specific part, section, and line number that the entered on Part III, line 7, should be treated as a community
response supports, in the order in which they appear on benefit, and the rationale for the organization's position.
Schedule H (Form 990). Part VI can be duplicated if more space Part III, line 9b. If the organization has a written debt
is needed. collection policy and answered “Yes,” to Part III, line 9b, describe
Rev. Proc. 2015-21, 2015-13 I.R.B. 817, provides guidance the collection practices in the policy that apply to patients who it
regarding correction and disclosure procedures for hospital knows qualify for financial assistance, whether the practices
organizations to follow so that certain failures to meet the apply specifically to such patients or also cover other types of
requirements of section 501(r) will be excused for purposes of patients.
sections 501(r)(1) and 501(r)(2)(B). Section 7 of the revenue Line 2. If applicable, describe whether and how the
procedure provides that certain information must be disclosed organization assesses the health care needs of the community
on the organization’s Form 990. Provide this information in Part or communities it serves, in addition to any CHNA entered in
VI. Part V, Section B.
Line 1. Provide the following supplemental information. Line 3. Describe how the organization informs and educates
Part I, line 3c. If applicable, describe the criteria used for patients and persons who are billed for patient care about their
determining eligibility for free or discounted care under the eligibility for assistance under federal, state, or local government
organization's FAP. Also, describe whether the organization programs or under the organization's FAP. For example, enter
uses an asset test or other threshold, regardless of income, to whether the organization posts its FAP, or a summary thereof,
determine eligibility for free or discounted care. applications for financial assistance, and financial assistance
Part I, line 6a. If the organization's community benefit report contact information in admissions areas, emergency rooms, and
is in a report prepared by a related organization, and not in a other areas of the organization's facilities where eligible patients
separate report prepared by the organization, identify the related are likely to be present; provides a copy of the policy, or a
organization and list its EIN. summary thereof, applications for financial assistance, and

Instructions for Schedule H -13-

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financial assistance contact information to patients as part of the  cost entered on Part I, line 7a. Refer to instructions for Part I, 
intake process; provides a copy of the policy, or a summary          line 1, for the definition of “financial assistance.”
thereof, applications for financial assistance, and financial 
                                                                     Line 1. Enter the gross patient charges written off to financial 
assistance contact information to patients with discharge 
                                                                     assistance pursuant to the organization's financial assistance 
materials; includes the policy, or a summary thereof, an 
                                                                     policies. “Gross patient charges” means the total charges at the 
application for financial assistance, and financial assistance 
                                                                     organization's full established rates for the provision of patient 
contact information, in patient bills; or discusses with the patient 
                                                                     care services before deductions from revenue are applied.
the availability of various government benefits, such as Medicaid 
or state programs, and assists the patient with qualification for    Line 3. Multiply line 1 by line 2, or enter estimated cost based 
such programs, where applicable.                                     on the organization's cost accounting methodology. 
                                                                     Organizations with a cost accounting system or a cost 
Line 4. Describe the community or communities the 
                                                                     accounting method more accurate than the ratio of patient care 
organization serves, taking into account the geographic service 
                                                                     cost to charges from Worksheet 2 can rely on that method to 
area(s) (urban, suburban, rural, etc.), the demographics of the 
                                                                     estimate financial assistance cost. An organization that doesn't 
community or communities (population, average income, 
                                                                     use Worksheet 2 to determine a ratio of patient care cost to 
percentages of community residents with incomes below the 
                                                                     charges should make any necessary adjustments for patient 
federal poverty guideline, percentage of the hospital's and 
                                                                     care charges and community benefit programs to avoid double 
community's patients who are uninsured or Medicaid recipients, 
                                                                     counting.
etc.), the number of other hospitals serving the community or 
communities, and whether one or more federally designated            Line 4. Enter the Medicaid/provider taxes, fees, and 
medically underserved areas or populations are present in the        assessments paid by the organization, if payments received 
community.                                                           from an uncompensated care pool or DSH program in the 
                                                                     organization's home state are intended primarily to offset the 
Line 5. Provide any other information important to describing 
                                                                     cost of financial assistance. If the payments are primarily 
how the organization's hospitals or other health care facilities 
                                                                     intended to offset the cost of Medicaid services, then enter this 
further its exempt purpose by promoting the health of the 
                                                                     amount in Worksheet 3, line 4, column (A). If the primary 
community or communities. Your response should include, but 
                                                                     purpose of the taxes or payments hasn't been made clear by 
need not be limited to, whether:
                                                                     state regulation or law, then the organization can allocate the 
• A majority of the organization's governing body is comprised 
                                                                     taxes or payments proportionately between Worksheet 1, line 4, 
of persons who reside in the organization's primary service area 
                                                                     and Worksheet 3, line 4, column (A), based on a reasonable 
who are neither employees nor independent contractors of 
                                                                     estimate of which portions are intended for financial assistance 
the organization, nor family members thereof;
                                                                     and Medicaid, respectively. “Medicaid provider taxes” means 
• The organization extends medical staff privileges to all 
                                                                     amounts paid or transferred by the organization to one or more 
qualified physicians in its community for some or all of its 
                                                                     states as a mechanism to generate federal Medicaid DSH funds 
departments or specialties; and
                                                                     (portions of the cost of the tax are generally promised back to 
• How the organization applies surplus funds to improvements 
                                                                     organizations either through an increase in the Medicaid 
in facilities and equipment, patient care, medical training, 
                                                                     reimbursement rate or through direct appropriation).
education, and research.
                                                                     Line 6. “Revenue from uncompensated care pools or 
Line 6. If the organization is part of an affiliated health care 
                                                                     programs” means payments received from a state, including 
system, describe the roles of the organization and its affiliates in 
                                                                     Upper Payment Limit (UPL) funding and Medicaid DSH funds, 
promoting the health of the communities served by the system. 
                                                                     as direct offsetting revenue for financial assistance or to 
For purposes of this question, an “affiliated health care system” 
                                                                     enhance Medicaid reimbursement rates. If such payments are 
is a system that includes affiliates under common governance or 
                                                                     primarily to offset the cost of Medicaid services, then enter this 
control, or that cooperate in providing health care services to 
                                                                     amount in Worksheet 3, line 7, column (A). If the primary 
their community or communities.
                                                                     purpose of the payments hasn't been made clear by state 
Line 7. Identify all states with which the organization files (or a  regulation or law, then the organization can allocate the 
related organization files on its behalf) a community benefit        payments proportionately between Worksheet 1, line 6, and 
report. Enter only those states in which the organization's own      Worksheet 3, line 7, column (A), based on a reasonable 
community benefit report is filed, either by the organization itself estimate of which portions are intended for financial assistance 
or by a related organization on the organization's behalf.           and Medicaid, respectively.
                                                                     Line 7. Include the amount of any other offsetting revenue, 
Worksheet 1. Financial Assistance at                                 including any restricted grants received by the organization.
Cost (Part I, Line 7a)
Worksheet 1 can be used to calculate the organization's 
financial assistance (sometimes referred to as “charity care”) at 

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Worksheet 1. Financial Assistance at Cost (Part I, line 7a)                                                                                                     Keep for Your Records
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.     Estimated cost (multiply line 1 by line 2, or obtain from cost accounting) . . . . . . . . . . . . . . . . .                                             3.   
4.     Medicaid provider taxes, fees, and assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                   4.   
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.     Other direct offsetting revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                    7.   
8. Total direct offsetting revenue (add lines 6 and 7; enter in Part I, line 7a, column 
       (d)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.   
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. Percent of total expense
       (divide line 9 by line 10; enter in Part I, line 7a, column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               11.                  %

                                                                      expenditure isn't double-counted when the ratio of patient care 
Worksheet 2. Ratio of Patient Care                                    cost to charges is applied.
Cost to Charges                                                       Line 4. Enter the sum of the total community benefit expenses 
Worksheet 2 can be used to calculate the organization's ratio of      included in “Total operating expense” on line 1 and entered in 
patient care cost to charges. An organization that doesn't use        Part I, lines 7e, 7f, 7h, and 7i, column (c), so these expenses 
Worksheet 2 to determine a ratio of patient care cost to charges      aren't double-counted when the ratio of patient care cost to 
should make any necessary adjustments for patient care                charges is applied.
charges and community benefit programs to avoid double                Also, include on line 4 the total community benefit expense 
counting.                                                             entered in Part I, lines 7a, 7b, 7c, and 7g, column (c), if the 
Line 1. Enter the organization's total operating expenses             organization hasn't relied on the ratio of patient care cost to 
(excluding bad debt expense) from its most recent audited             charges from this worksheet to determine these expenses, but 
financial statements.                                                 rather has relied on a cost accounting system or other cost 
                                                                      accounting method to estimate costs of financial assistance, 
Line 2. Enter the cost of nonpatient care activities. “Nonpatient     Medicaid or other means-tested government programs, or 
care activities” include health care operations that generate         subsidized health services.
“other operating revenue” such as nonpatient food sales, 
supplies sold to nonpatients, and medical records abstracting.        Line 5. Enter the gross expense of community building activities 
The cost of nonpatient care activities doesn't include any total      reported in Part II of Schedule H (Form 990).
community benefit expense entered on Worksheets 1 through 8.          Line 9. Enter the gross patient charges for any community 
If the organization is unable to establish the cost associated        benefit activities or programs for which the organization hasn't 
with nonpatient care activities, use other operating revenue from     relied on the ratio of patient care cost to charges from this 
its most recent audited financial statement as a proxy for these      worksheet to determine the expenses of such activities or 
costs. This proxy assumes no markup exists for other operating        programs. For example, if the organization uses a cost 
revenue compared to the cost of nonpatient care activities.           accounting system or another cost accounting method to 
Alternatively, if other operating revenue provides a markup           estimate total community benefit expense for Medicaid or any 
compared to the cost of nonpatient care activities, the               other means-tested government programs, enter gross charges 
organization can assume such a markup exists when completing          for those programs on line 9.
line 2.
Line 3. Enter the Medicaid provider taxes, fees, and 
assessments paid by the organization included on line 1 so this 

Instructions for Schedule H                                       -15-

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Worksheet 2.    Ratio of Patient Care Cost to Charges
                (can be used for other worksheets)                                                            Keep for Your Records
Patient care cost
  1.  Total operating expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    1 .  

Less adjustments
  2.  Nonpatient care activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.  
  3.  Medicaid provider taxes, fees, and assessments . . . . . . . . . . . . . . . . .                   3.   
  4.  Total community benefit expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        4.   
  5.  Total community building expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         5.   
  6.   Total adjustments (add lines 2 through 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             6.   
  7.  Adjusted patient care cost (subtract line 6 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   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.   %

                                                                 from their Medicaid reimbursements can enter SCHIP charges, 
Worksheet 3. Medicaid and Other                                  costs, and offsetting revenue under column (A).
Means-Tested Government Health                                   Line 1, column (B).                          Enter the amount of gross patient charges 
Programs (Part I, Lines 7b and 7c)                               for other means-tested government health programs.
Worksheet 3 can be used to report the cost of Medicaid and       Line 3, column (A).                          Enter the estimated cost for Medicaid 
other means-tested government health programs. A                 services. Multiply line 1, column (A), by line 2, column (A), or 
“means-tested government program” is a government health         enter estimated cost based on the organization's cost 
program for which eligibility depends on the recipient's income  accounting system or method. Organizations with a cost 
or asset level.                                                  accounting system or a cost accounting method more accurate 
                                                                 than the ratio of patient care cost to charges from Worksheet 2 
  “Medicaid” means the United States health program for          can rely on that system or method to estimate the cost of 
individuals and families with low incomes and resources. “Other  Medicaid services. Organizations relying on a cost accounting 
means-tested government programs” means                          system or method other than the ratio of patient care cost to 
government-sponsored health programs where eligibility for       charges from Worksheet 2 should use care not to double-count 
benefits or coverage is determined by income or assets.          community benefit expenses fully accounted for elsewhere on 
Examples include:                                                Schedule H (Form 990), Part I, line 7, such as the cost of health 
• The State Children's Health Insurance Program (SCHIP), a       professions education, community health improvement services, 
United States federal government program that gives funds to     community benefit operations, subsidized health services, and 
states in order to provide health insurance to families with     research.
children; and
• Other federal, state, or local health care programs.           Line 3, column (B).                          Enter the estimated cost for services 
                                                                 provided to patients who receive health benefits from other 
  Report Medicaid and other means-tested government 
                                                                 means-tested government health programs.
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 
Line 1, column (A). Enter the gross patient charges for 
                                                                 from an uncompensated care pool, UPL program, or Medicaid 
Medicaid services. Include gross patient charges for all 
                                                                 DSH program in the organization's home state are intended 
Medicaid recipients, including those enrolled in managed care 
                                                                 primarily to offset the cost of Medicaid services. If such 
plans. In certain states, SCHIP functions as an expansion of the 
                                                                 payments are primarily intended to offset the cost of financial 
Medicaid program, and reimbursements from SCHIP aren't 
                                                                 assistance, then enter this amount on Worksheet 1, line 4. If the 
distinguishable from regular Medicaid reimbursements. 
                                                                 primary purpose of such taxes or payments hasn't been made 
Hospitals that cannot distinguish their SCHIP reimbursements 
                                                                 clear by state regulation or law, then the organization can 

                                                                 -16-                                         Instructions for Schedule H

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allocate portions of such taxes or payments proportionately          way the Medicaid program that provides reimbursement 
between Worksheet 1, line 4, and Worksheet 3, line 4, column         classifies the funds.
(A), based on a reasonable estimate of which portions are 
                                                                     Line 7, column (A).                                               Enter revenue received from 
intended for financial assistance and Medicaid, respectively.
                                                                     uncompensated care pools or programs if payments received 
Line 6, column (A). Enter the net patient service revenue for        from an uncompensated care pool, UPL program, or Medicaid 
Medicaid services, including revenue associated with Medicaid        DSH program in the organization's home state are intended 
recipients enrolled in managed care plans. Don't include             primarily to offset the cost of Medicaid services. If such 
Medicaid reimbursement for direct graduate medical education         payments are primarily intended to offset the cost of charity care, 
(GME) costs, which should be entered on Worksheet 5, line 9.         then enter this amount on Worksheet 1, line 6. If the primary 
Include Medicaid reimbursement for indirect GME costs,               purpose of such payments hasn't been made clear by state 
including the indirect IME portion of children's health GME. The     regulation or law, then the organization can allocate the 
direct portion of children's health GME should be entered on         payments proportionately between Worksheet 1, line 6, and 
Worksheet 5, line 10. Also, include Medicaid DSH revenue and         Worksheet 3, line 7, column (A), based on a reasonable 
UPL funding. “Net patient service revenue” means payments            estimate of which portions are intended for financial assistance 
expected to be received from patients or third-party payers for      and Medicaid, respectively.
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 
                 Health Programs (Part I, lines 7b and 7c)                                                                                 Keep for Your Records
                                                                                                                                            (A)                    (B)
                                                                                                                                           Medicaid                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.          Cost (multiply line 1 by line 2, or obtain from cost accounting) . . . . . . . . . . . . . . . .                           3.
4.          Medicaid provider taxes, fees, and assessments . . . . . . . . . . . . . . . . . . . . . . . . . .                         4.
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.          Payments from uncompensated care pools or programs . . . . . . . . . . . . . . . . . . . .                                 7.
8.          Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        8.
9. Total direct offsetting revenue (add lines 6 through 8; enter amount from column 
            (A) in Part I, line 7b, column (d), and enter amount from column (B) in Part I, line 7c, 
            column (d)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      9.
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)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         10.
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))  . . . . . . . . . . . . .                              11.
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)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.      %                        %

Instructions for Schedule H                                      -17-

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Worksheet 4. Community Health Improvement Services and 
             Community Benefit Operations (Part I, line 7e)                                                             Keep for Your Records
                                                                                                                                     (C)
                                                                                                                                     Net 
                                                                                                                                     community 
                                                                                                                (A)                  benefit 
                                                                                                                Total     (B)        expense 
                                                                                                                community Direct     (subtract col. 
                                                                                                                benefit   offsetting (B) from col. (A) 
                                                                                                                expense   revenue    for lines 1–5)

1. Community health improvement services
   a.                                                                                                        1a.

   b.                                                                                                        1b.

   c.                                                                                                        1c.

   d.                                                                                                        1d.

   e.                                                                                                        1e.

   f.                                                                                                        1f.

   g.                                                                                                        1g.

   h.                                                                                                        1h.

   i.                                                                                                        1i.

   j.                                                                                                        1j.

2.  Worksheet subtotal (add lines 1a through 1j) . . . . . . . . . . . . . . . . . . .                       2.

3. Community benefit operations
   a.                                                                                                        3a.

   b.                                                                                                        3b.

   c.                                                                                                        3c.

   d.                                                                                                        3d.

4. Worksheet subtotal (add lines 3a through 3d) . . . . . . . . . . . . . . . . . . .                         4.

5. 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), 
   respectively) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5.

6. 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) . . . . . .                                   6.

7. 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 
Worksheet 4. Community Health                                       programs, subsidized by the health care organization, carried 
Improvement Services and                                            out or supported for the express purpose of improving 
                                                                    community health. Such services don't generate inpatient or 
Community Benefit Operations (Part                                  outpatient revenue, although there may be a nominal patient fee 
                                                                    or sliding scale fee for these services.
I, Line 7e)
Worksheet 4 can be used to report the net cost of community         “Community benefit operations” means:
health improvement services and community benefit operations.

                                                             -18-                                                         Instructions for Schedule H

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• Activities associated with conducting community health needs “Health professions education” means educational programs
assessments, that result in a degree, a certificate, or training necessary to be
• Community benefit program administration, and licensed to practice as a health professional, as required by
• The organization's activities associated with fundraising or state law, or continuing education necessary to retain state
grant writing for community benefit programs. license or certification by a board in the individual's health
Activities or programs cannot be reported if they are provided profession specialty. It doesn't include education or training
primarily for marketing purposes or if they are more beneficial to programs available exclusively to the organization's employees
the organization than to the community. For example, the activity and medical staff or scholarships provided to those individuals.
or program may not be reported if it is designed primarily to However, it does include education programs if the primary
increase referrals of patients with third-party coverage, required purpose of such programs is to educate health professionals in
for license or accreditation, or restricted to individuals affiliated the broader community. Costs for medical residents and interns
with the organization (employees and physicians of the can be included, even if they are considered “employees” for
organization). purposes of Form W-2, Wage and Tax Statement.
To be reported, community need for the activity or program Examples of health professions education activities or
must be established. Community need can be demonstrated programs that should and shouldn't be reported are as follows.
through the following.
• A CHNA conducted or accessed by the organization. Activity or Program Report Example Rationale
• Documentation that demonstrated community need or a
request from a public health agency or community group was the Scholarships for Yes More benefit to
basis for initiating or continuing the activity or program. community members community than
• The involvement of unrelated, collaborative tax-exempt or organization
government organizations as partners in the activity or program Scholarships for staff No More benefit to
carried out for the express purpose of improving community members organization than
health. community
Community benefit activities or programs also seek to Continuing medical Yes Accessible to all
achieve a community benefit objective, including improving education for community qualified physicians
access to health services, enhancing public health, advancing physicians
increased general knowledge, and relief of a government burden Continuing medical No Restricted to own
to improve health. This includes activities or programs that do education for own medical staff members
the following. medical staff
• Are available broadly to the public and serve low-income Nurse education if Yes More benefit to
consumers. graduates are free to community than
• Reduce geographic, financial, or cultural barriers to accessing seek employment at any organization
health services, and if they ceased would result in access organization
problems (for example, longer wait times or increased travel Nurse education if No Program designed
distances). graduates are required to primarily to benefit the
• Address federal, state, or local public health priorities such as become the organization
eliminating disparities in access to health care services or organization's employees
disparities in health status among different populations.
• Leverage or enhance public health department activities such
as childhood immunization efforts.
• Strengthen community health resilience by improving the Lines 1 through 6. Include both direct and indirect costs.
ability of a community to withstand and recover from public Direct costs of health professions education don't include costs
health emergencies. related to Ph.D. students and post-doctoral students, which are
• Otherwise would become the responsibility of government or to be entered on Worksheet 7, Research. See the instructions
another tax-exempt organization. for Part I, line 7, column (c), for the definition of “indirect costs.”
• Advance increased general knowledge through education or "Indirect costs" don't include the estimated cost of “indirect
research that benefits the public. medical education.”
Lines 1a through 1j, column (A). Enter the name of each Direct costs of health professions education include the
reported community health improvement activity or program and following.
total community benefit expense for each. Include both direct • Stipends, fringe benefits of interns, residents, and fellows in
costs and indirect costs in total community benefit expense. Use accredited graduate medical education programs.
additional worksheets if the organization reports more than 10 • Salaries and fringe benefits of faculty directly related to intern
community health improvement activities or programs. and resident education.
Lines 3a through 3d, column (A). Enter the name of each • Salaries and fringe benefits of faculty directly related to
reported community benefit operations activity or program and teaching:
total community benefit expense for each. Include both direct 1. Medical students;
costs and indirect costs in total community benefit expense. Use 2. Students enrolled in nursing programs that are licensed
additional worksheets if the organization enters more than four by state law or, if licensing isn't required, accredited by the
community benefit operations activities or programs. recognized national professional organization for the particular
Report total community benefit expense, direct offsetting activity;
revenue, and net community benefit expense for each line item. 3. Students enrolled in allied health professions education
programs, licensed by state law or, if licensing isn't required,
Worksheet 5. Health Professions accredited by the recognized national professional organization
Education (Part I, Line 7f) for the particular activity, including, but not limited to, programs
in pharmacy, occupational therapy, dietetics, and pastoral care;
Worksheet 5 can be used to report the net cost of health and
professions education.
Instructions for Schedule H -19-

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Worksheet 5. Health Professions Education (Part I, line 7f)
                                                                                                                                                             Keep for Your Records
                                                                                                                                                                  Totals
Total community benefit expense
  1.    Medical students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             1.   
  2.    Interns, residents, and fellows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  2.   
  3.    Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     3.   
  4.    Other allied health professions, students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          4.   
  5.    Continuing health professions education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            5.   
  6.    Other students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           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.    Medicaid reimbursement for direct GME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                              9.   
  10.   Continuing health professions education reimbursement/tuition . . . . . . . . . . . . . . . . . . . . . .                                            10.  
  11.   Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          11.  
  12. Total direct offsetting revenue (add lines 8 through 11; enter in Part I, line 7f, column 
        (d)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.  
  13. Net community benefit expense (line 7 minus line 12; enter in Part I, line 7f, column 
        (e)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.  
  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. Percent of total expense (line 13 divided by line 14; enter amount in Part I, line 7f, 
        column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      15.                  %

  4. Continuing health professions education open to all        that includes both direct and indirect payments, use reasonable 
qualified individuals in the community, including payment for   methods to estimate the portion of the lump sum that is direct 
development of online or other computer-based training          (for example, the percent of total Medicare GME payments that 
accepted as continuing health professions education by the      is direct).
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 
Line 8. Enter Medicare reimbursement for direct GME, 
                                                                education activities associated with expenses entered on 
reimbursement for approved nursing and allied health education 
                                                                Worksheet 5, line 7.
activities, and direct GME reimbursement received for services 
provided to Medicare Advantage patients. For a children's       Worksheet 6. Subsidized Health 
hospital that receives children's GME payments from Health 
Resources and Services Administration (HRSA), count that        Services (Part I, Line 7g)
portion of the payment equivalent to Medicare direct GME. Don't Worksheet 6 can be used to calculate the net cost of subsidized 
include indirect GME reimbursement provided by Medicare or      health services. Complete Worksheet 6 for each subsidized 
Medicaid.                                                       health service and enter in Part I the total for all subsidized 
Line 9. Enter Medicaid reimbursement for direct GME, including  health services combined.
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 
the organization from other Medicaid net patient revenue. Don't despite a financial loss to the organization. The financial loss is 
include indirect GME reimbursement provided by Medicaid,        measured after removing losses associated with bad debt, 
which is to be entered Worksheet 3, Unreimbursed Medicaid       financial assistance, Medicaid, and other means-tested 
and Other Means-Tested Government Programs. Include             government programs. Losses attributable to these items aren't 
Medicaid reimbursement for nursing and allied health education. included when determining which clinical services are 
If your state pays Medicaid GME reimbursement as a lump sum     subsidized health services because they are reported as 
                                                                community benefit elsewhere in Part I or as bad debt in Part III. 

                                                                -20-                                                                                         Instructions for Schedule H

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Losses attributable to these items are also excluded when                  The organization cannot include on Part I, line 7h, direct or 
measuring the losses generated by the subsidized health                    indirect costs of research funded by an individual or an 
services. In addition, in order to qualify as a subsidized health          organization that isn't a tax-exempt or government entity. 
service, the organization must provide the service because it              However, the organization can describe in Part VI any research it 
meets an identified community need. A service meets an                     conducts that isn't funded by tax-exempt or government entities, 
identified community need if it is reasonable to conclude that if          including the cost of such research, the identity of the funder, 
the organization no longer offered the service:                            how the results of such research are made available to the 
• The service would be unavailable in the community,                       public, if at all, and whether the results are made available to the 
• The community's capacity to provide the service would be                 public at no cost or nominal cost.
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, 
another tax-exempt organization.                                           salaries and benefits of researchers and staff, including stipends 
                                                                           for research trainees (Ph.D. candidates or fellows); facilities for 
  Subsidized health services can include qualifying inpatient              collection and storage of research, data, and samples; animal 
programs (for example, neonatal intensive care, addiction                  facilities; equipment; supplies; tests conducted for research 
recovery, and inpatient psychiatric units) and outpatient                  rather than patient care; statistical and computer support; 
programs (emergency and trauma services, satellite clinics                 compliance (for example, accreditation for human subjects 
designed to serve low-income communities, and home health                  protection, biosafety, Health Insurance Portability and 
programs). Subsidized health services generally exclude                    Accountability Act (HIPAA), etc.); and dissemination of research 
ancillary services that support inpatient and ambulatory                   results.
programs such as anesthesiology, radiology, and laboratory                 Line 1. Define direct costs under the guidelines and definitions 
departments. Subsidized health services include services or                published by the National Institutes of Health.
care provided at physician clinics and skilled nursing facilities if 
such clinics or facilities satisfy the general criteria for subsidized     Line 2. Define indirect costs under the guidelines and 
health services. An organization that includes any costs                   definitions published by the National Institutes of Health.
associated with stand-alone physician clinics (not other facilities        Line 4. Enter license fees and royalties the organization 
at which physicians provide services) as subsidized health                 received during the tax year that are directly associated with 
services on Part I, line 7g, must describe that it has done so and         research that the organization has (in any tax year) reported on 
enter on Part VI such costs included on Part I, line 7g.                   Schedule H as community benefit.
Note. The organization can report a physician clinic as a                  Line 5. An example of “other revenue” is Medicare 
subsidized health service only if the organization operated the            reimbursement associated with any research expense reported 
clinic and associated hospital services at a financial loss to the         as community benefit.
organization during the year.
Line 3, columns (A) through (D). Enter the estimated cost for              Worksheet 8. Cash and In-Kind 
each subsidized health service. For column (B), enter bad debt 
amounts attributable to the subsidized health service measured             Contributions for Community Benefit 
by cost. For column (C), enter amounts attributable to the                 (Part I, Line 7i)
subsidized health service for patients who are recipients of 
                                                                           Worksheet 8 can be used to report cash contributions or grants 
Medicaid and other means-tested government health programs. 
                                                                           and the cost of in-kind contributions that support financial 
For column (D), enter financial assistance amounts attributable 
                                                                           assistance, health professions education, and other community 
to the subsidized health service measured by cost. Multiply 
                                                                           benefit activities reportable on Part I, lines 7a through 7h. Report 
line 1 by line 2 or enter the estimated expense of each 
                                                                           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                 “Cash and in-kind contributions” means contributions made 
method more accurate than the ratio of patient care cost to                by the organization to health care organizations and other 
charges from Worksheet 2 can rely on that system or method to              community groups restricted, in writing, to one or more of the 
estimate the cost of each subsidized health service.                       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 
Worksheet 7. Research (Part I,                                             organization to the community while on the organization's 
Line 7h)                                                                   payroll, indirect cost of space donated to tax-exempt community 
Worksheet 7 can be used to report the cost of research                     groups (such as for meetings), and the financial value (generally 
conducted by the organization.                                             measured at cost) of donated food, equipment, and supplies.
                                                                           Don't report as cash or in-kind contributions any payments 
  Research means any study or investigation the goal of which              that the organization makes in exchange for a service, facility, or 
is to generate increased generalizable knowledge made                      product, or that the organization makes primarily to obtain an 
available to the public (for example, knowledge about underlying           economic or physical benefit; for example, payments made in 
biological mechanisms of health and disease, natural processes,            lieu of taxes that the organization makes to prevent or forestall 
or principles affecting health or illness; evaluation of safety and        local or state property tax assessments, and a teaching 
efficacy of interventions for disease such as clinical trials and          hospital's payments to its affiliated medical school for intern or 
studies of therapeutic protocols; laboratory-based studies;                resident supervision services by the school's faculty members.
epidemiology, health outcomes, and effectiveness; behavioral or 
sociological studies related to health, delivery of care, or               Report cash contributions and grants made by the 
prevention; studies related to changes in the health care delivery         organization to entities and community groups that share the 
system; and communication of findings and observations,                    organization's goals and mission. Don't report cash or in-kind 
including publication in a medical journal). The organization can          contributions contributed by employees, or emergency funds 
include the cost of internally funded research it conducts, as well        provided by the organization to the organization's employees; 
as the cost of research it conducts funded by a tax-exempt or              loans, advances, or contributions to the capital of another 
government entity.                                                         organization that are reportable in Part X of the core Form 990; 
Instructions for Schedule H                                            -21-

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Worksheet 6. Subsidized Health Services (Part I, line 7g)                                          Keep for Your Records
                                                                                                   (C)                      (E)
                                                                               (A)                 Medicaid and             Totals 
                                                                               Total               other means-             (subtract 
                                                                               subsidized          tested                  columns (B), 
                                                                               health              government   (D)        (C), and (D) 
                                                                               service    (B)      health       Financial  from column 
Program name: ______________________________                                   program    Bad debt programs     assistance  (A))
Gross patient charges 
1. Gross patient charges from program(s) . . . . . . . . .                  1.
Total community benefit expense
2. Ratio of patient care cost to charges (from 
Worksheet 2, if used) . . . . . . . . . . . . . . . . . . . . . .           2.         %      %             %             %
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)) . . . . . . . .                  3.
Direct offsetting revenue
4. Net patient service revenue . . . . . . . . . . . . . . . . .            4.
5. Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . .      5.
6. Total direct offsetting revenue (add lines 4 and 5; 
enter column (E) in Part I, line 7g, column 
(d)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.
7. Net community benefit expense (subtract line 6 
from line 3; enter column (E) in Part I, line 7g, 
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. Percent of total expense (line 7, column (E) 
divided by line 8; enter in Part I, line 7g, column 
(f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9.                                                        %

                                                                               -22-                           Instructions for Schedule H

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Worksheet 7.    Research (Part I, line 7h)                                                          Keep for Your Records
Total community benefit expense
   1. Direct costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    1.       
   2. Indirect costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      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. Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       5.       
   6. Total direct offsetting revenue (add lines 4 and 5; enter in Part I, line 7h, column (d)) . . . . . .                                                     6.       
   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. Percent of total expense
   (divide line 7 by line 8; enter in Part I, line 7h, column (f)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                              9.            %

Worksheet 8.    Cash and In-Kind Contributions for Community 
                Benefit
                (Part I, line 7i)                                                                   Keep for Your Records
                                                                                                                                                                (B)
                                                                                      (A)                                                                       In-kind 
                                                                                      Cash contrib-                 contrib-                                             (C)
                                                                                      utions                                                                    utions   Total

1. Total community benefit expense (enter amount from 
   column (C) in Part I, line 7i, column (c)) . . . . . . . . . . . . . .          1.
2. Direct offsetting revenue (enter amount from column 
   (C) in Part I, line 7i, column (d)) . . . . . . . . . . . . . . . . . . . . .   2.

3. Net community benefit expense (subtract line 2 from 
   line 1; enter on Part I, line 7i, column (e)) . . . . . . . . . . . . .         3.
4. 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. Percent of total expense (divide line 3 by line 4; enter 
   in Part I, line 7i, column (f)) . . . . . . . . . . . . . . . . . . . . . . . . 5.                                                                                         %

or unrestricted grants or gifts to another organization that can, at               interest to be used to accomplish one of the community benefit 
the discretion of the grantee organization, be used other than to                  activities reportable in the table, on Part I, line 7, enter the grant 
provide the type of community benefit described in the table on                    on line 7i, but don't include the organization's proportionate 
Part I, line 7.                                                                    share of the amount spent by the joint venture on such 
                                                                                   activities in any other part of the table, to avoid double counting.
Special rule for grants to joint ventures. If the organization 
makes a grant to a joint venture in which it has an ownership 

Instructions for Schedule H                                          -23-

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Index
 
                                      Financial Assistance Policy     9
B                                     Policy Relating to Emergency         S
Bad Debt, Medicare, & Collection      Medical Care          11             Supplemental Information 13
  Practices 5                         Hospital facilities 7
  Worksheet (optional) 6            Financial Assistance and Certain       W
                                      Other Community Benefits at 
                                      Cost 2                               Worksheets:
C                                                                           1-Financial Assistance at Cost               15
                                      Contributions for community benefit 3
Community Building Activities    4                                          2-Ratio of Patient Care Cost to 
  Disregarded entity 4              M                                       Charges    15
  Group return 4                                                            3-Unreimbursed Medicaid and Other 
                                    Management Companies and Joint          Means-Tested Government 
                                      Ventures  6
F                                                                           Programs   16
                                                                            4-Community Health Improvement 
Facility Information:               P                                       Services and Community Benefit 
  CHNA 7                            Patient Protection and Affordable       Operations   19
  Community Health Needs              Care Act:                             5-Health Professions Education               20
  Assessment     7                    Hospital facilities 1                 6-Subsidized Health Services                 20
  Facility Policies & Practices:      Section 501(r) of the Code 1          7-Research 21
  Billing and Collections 9                                                 8-Cash and In-Kind Contributions for 
  Charges for Medical Care       11                                         Community Benefit 23

                                                 -24-

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