Form Ag-Cbp-I Annual Non Profit Hospital Community Benefits Plan Report
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1
2Form AG-CBP-I
LISA MADIGAN
2/05
ATTORNEY GENERAL
Annual Non Profit Hospital Community Benefits Plan Report
Hospital or Hospital System: ______________________________________________________________________________________
Mailing Address: ________________________________________________________________________________________________
(Street Address/P.O. Box)
(City, State, Zip)
Physical Address (if different than mailing address):
________________________________________________________________________________________________________________
(Street Address/P.O. Box)
(City, State, Zip)
Reporting Period: _____/_____/_____ through _____/_____/_____ Taxpayer Number: ______________________________________
Month Day
Year
Month Day
Year
If filing a consolidated financial report for a health system, list below the Illinois hospitals included in the consolidated report.
Hospital Name
Address
FEIN #
_______________________________________
______________________________________
__________________
_______________________________________
______________________________________
__________________
_______________________________________
______________________________________
__________________
_______________________________________
______________________________________
__________________
_______________________________________
______________________________________
__________________
1.
ATTACH Mission Statement:
The reporting entity must provide an organizational mission statement that identifies the hospital's commitment to serving the
health care needs of the community and the date it was adopted.
2.
ATTACH Community Benefits Plan:
The reporting entity must provide it's most recent Community Benefits Plan and specify the date it was adopted. The plan should
be an operational plan for serving health care needs of the community. The plan must:
1.
Set out goals and objectives for providing community benefits including charity care and government-sponsored
indigent health care.
2.
Identify the populations and communities served by the hospital.
3.
Disclose health care needs that were considered in developing the plan.
3.
REPORT Charity Care:
Charity care is care for which the provider does not expect to receive payment from the patient or a third-party payer. Charity
care does not include bad debt. In reporting charity care, the reporting entity must report the actual cost of services provided,
based on the total cost to charge ratio derived from the hospital's Medicare cost report (CMS 2552-96 Worksheet C, Part 1, PPS
Inpatient Ratios), not the charges for the services.
Charity Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________
ATTACH Charity Care Policy:
Reporting entity must attach a copy of its current charity care policy and specify the date it was adopted.
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Parent category: Business