Annual Return Of Broad Based Health Care Related Taxes Page 2

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ANNUAL RETURN OF BROAD BASED HEALTH CARE RELATED TAXES
WV/HCP-3A
rtL080 v.10-Web
SCHEDULE A - COMPUTATION OF TAX FOR TAXABLE YEAR JANUARY 1 THRU DECEMBER 31
LINE
TAXABLE
COL 1
COL 2
COL 3
COL 4
COL 5
COL 6
CODE
SERVICE
TOTAL GROSS
BAD DEBT
CONTRACTUAL
TAXABLE GROSS
RATE
TAX DUE
PROCEEDS
ALLOWANCES
PROCEEDS
COL 4 X COL 5
COL 1 - COL 2 & 3
Ambulatory
1
.
.
.
.
.
Surgical
Independent
5
.
.
.
.
.
Lab/X-Ray
Inpatient
6
.
.
.
.
.
Hospital
Intermediate Care
7
.
.
.
.
.
Facility/MR
8
Nursing Facility
.
.
.
.
Outpatient
12
.
.
.
.
.
Hospital
SCHEDULE A TOTAL TAX DUE
.
(ADD COL 6 FOR ALL TAXABLE SERVICES) ENTER HERE AND ON SCHEDULE D LINE 1
SCHEDULE B - COMPUTATION OF TAX FOR TAXABLE PERIOD JANUARY 1 THRU JUNE 30
LINE
TAXABLE
COL 1
COL 2
COL 3
COL 4
COL 5
COL 6
CODE
SERVICE
TOTAL GROSS
BAD DEBT
CONTRACTUAL
TAXABLE GROSS
RATE
TAX DUE
PROCEEDS
ALLOWANCES
PROCEEDS
COL 4 X COL 5
COL 1 - COL 2 & 3
2
Chiropractic
.
.
.
.
.
3
Dental
.
.
.
.
.
Emergency
4
.
.
.
.
.
Ambulance
9
Nursing
.
.
.
.
.
10
Optician
.
.
.
.
.
11
Optometry
.
.
.
.
.
13
Physician
.
.
.
.
.
14
Podiatry
.
.
.
.
.
15
Psychological
.
.
.
.
.
16
Therapists
.
.
.
.
.
SCHEDULE B TOTAL TAX DUE
.
(ADD COL 6 FOR ALL TAXABLE SERVICES) ENTER HERE AND ON SCHEDULE D LINE 2
SEE INSTRUCTIONS ON PAGE 4
G
1
6
2
0
0
8
0
2
W
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