Form Rp-420-A/b-Org - Application For Real Property Tax Exemption For Nonprofit Organizations Page 14

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SCHEDULE A
14
RP-420-a/b-Org (1/95)
Part C – Hospital organizations
1a. Which general type(s) of service does or will the organization provide?
________Diagnosis and treatment of physical disabilities
________Diagnosis and treatment of mental disabilities
________Nursing home care
b. Describe the specialized service(s) provided or to be provided.
2a. Does or will the organization provide inpatient services?
_______Yes
_______No
If no, skip to Question 3. If yes:
b. Number of beds:
(1) Total
____________
(2) Physical treatment
____________
(3) Mental treatment
____________
(4) Nursing home
____________
c. Does or will the organization provide 24-hour patient services?
_______Yes
_______No
If no, please explain.
d. Does or will the organization have an organized medical staff of licensed doctors of medicine and licensed nurses?
________Yes
________No
If yes:
(1) Number of doctors________
(2) Number of nurses________
e. Does or will the organization have a courtesy medical staff (i.e. allow doctors who are not formally affiliated with the organization to
treat their patients in the organization’s facilities)?
________Yes
________No
If yes:
(1) Number of doctors on courtesy staff_________
(2) Does or will the courtesy staff include all the doctors in the community? _______Yes
_______No
If no, give the reasons why not, and explain how the courtesy staff is or will be selected.
f. Does or will the organization provide emergency services to the general public?
_______Yes
_______No
If yes:
(1) Does or will the organization maintain a full-time emergency room?
_______Yes
_______No
(2)What is the organization’s policy as to administering emergency services to persons without apparent means to pay?
g. Does or will the organization have any arrangements with police, fire and voluntary ambulance services as to the delivery or admission of
emergency cases?
_______Yes
_______No
If yes, please explain the arrangements.

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