State of Rhode Island and Providence Plantations
Form HCP-64
13112499990101
Outpatient Health Care Facility Surcharge Return
Name
Federal employer identification number
Address
For the month ending:
MM/DD/YYYY
Address 2
City, town or post office
State
ZIP code
E-mail address
Calculation of Amount Due:
Net patient services revenue received.....................................................................................................
1
1
2
Outpatient health care facility surcharge. Multiply line 1 times 2% (0.02)..............................................
2
Interest calculated at 1.5% per month. See instructions..........................
3
3
4
Penalty calculated at 10%. See instructions ...........................................
4
Total interest and penalty amount. Add lines 3 and 4.............................................................................
5
5
TOTAL AMOUNT DUE. Add lines 2 and 5..............................................................................................
6
6
INSTRUCTIONS
Line 1: Net Patient Services Revenue Received - Enter the
Line 4: Penalty - If remitting after the due date, multiply line 2
amount of all monies and other consideration received
time 10% (0.10). Penalty is calculated at 10% of the
for patient care services for the month being reported
surcharge due.
on this return.
Line 5: Total Interest and Penalty Amount - Add lines 3 and 4.
Line 2: Outpatient Health Care Facility Surcharge - Multiply
line 1 times 2.0% (0.02)
Line 6: Total Amount Due - Add lines 2 and 5.
Line 3: Interest - If remitting after the due date, multiply line 2
times 1.5% (0.015) times the number of months late.
PAYMENTS MUST BE MADE BY ELECTRONIC FUNDS
Interest is calculated from the due date of the return to
TRANSFER (EFT).
the date of remittance at a rate of 18% per annum.
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Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Authorized officer signature
Print name
Date
Telephone number
Paid preparer signature
Print name
Date
Telephone number
Paid preparer address
City, town or post office
State
ZIP code
PTIN
May the Division of Taxation contact your preparer? YES