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