State of Rhode Island and Providence Plantations
Form HCP-4
13112399990101
Hospital Licensing Fee Report
Name
Federal employer identification number
June
Report
Address
For the period ending:
October 1, 2011 through September 30, 2012
July
Remittance
Address 2
City, town or post office
State
ZIP code
E-mail address
Calculation of Amount Due:
Gross patient services revenue. See instructions....................................
1
1
2
Amount of Charity Care, Bad Debts Expense and Contract Allowances...
2
Net patient services revenue. Subtract line 2 from line 1.......................................................................
3
3
4
Net licensing fee due. Multiply line 3 by 5.418% (0.05418)....................................................................
4
Discount for hospitals located in Washington County ONLY. Multiply line 4 by 37% (0.3700)...............
5
5
AMOUNT DUE. Subtract line 5 from line 4.............................................................................................
6
6
Interest calculated at 1.5% per month. See instructions.........................................................................
7
7
Penalty calculated at 10%. See instructions ..........................................................................................
8
8
TOTAL AMOUNT DUE. Add lines 6, 7 and 8..........................................................................................
9
9
INSTRUCTIONS
NOTE: AS OUTLINED IN RIGL 23-17-38.1, THIS RETURN IS DUE BY
Line 5: Discount for Washington County hospitals. Pursuant to RIGL
JUNE 16, 2014 EVEN THOUGH THE REMITTANCE IS NOT DUE UNTIL
23-17-38.1, hospitals located in Washington County, Rhode Island shall
JULY 14, 2014.
receive a discount of 37% on the hospital license fee of 5.418%.
Check the applicable box regarding which filing this return covers.
Line 6: Amount Due. Subtract line 5 from line 4.
Line 1: Gross Patient Services Revenue. Enter the amount reported on
line 1 of Worksheet G3, Medicare Hospital and Hospital Health Care Com-
Line 7: Interest. If remitting after July 14, 2014, multiply line 6 by 1.5%
(0.015) times the number of months late. Interest is calculated from
plex Cost Report for the Hospital Fiscal Year ending September 30, 2012.
July 14, 2014 to the date of remittance at a rate of 18% per annum.
Line 2: Deductions. Enter the amount of Charity Care, Bad Debts Ex-
pense and Contract Allowances.
Line 8: Penalty. If remitting after July 14, 2014, multiply line 6 by 10%
(0.10). Penalty is calculated at 10% of the net licensing fee due.
Line 3: Net Patient Services Revenue. Subtract line 2 from line 1.
Line 9: Total Amount Due. Add lines 6, 7 and 8.
Line 4: Net Licensing Fee Due. Multiply line 3 by 5.418% (0.05418).
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