Schedule H (Form 990) - Hospitals - 2012 Page 6
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Schedule H (Form 990) 2012
Page
Part V
Facility Information (continued)
18
Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
Notified individuals of the financial assistance policy on admission
b
Notified individuals of the financial assistance policy prior to discharge
c
Notified individuals of the financial assistance policy in communications with the patients regarding the patients' bills
d
Documented its determination of whether patients were eligible for financial assistance under the hospital facility's
financial assistance policy
e
Other (describe in Part VI)
Policy Relating to Emergency Medical Care
Yes
No
Did the hospital facility have in place during the tax year a written policy relating to emergency medical care
19
that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to
individuals regardless of their eligibility under the hospital facility's financial assistance policy?
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19
If “No,” indicate why:
a
The hospital facility did not provide care for any emergency medical conditions
b
The hospital facility's policy was not in writing
The hospital facility limited who was eligible to receive care for emergency medical conditions (describe
c
in Part VI)
d
Other (describe in Part VI)
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged
20
to FAP-eligible individuals for emergency or other medically necessary care.
The hospital facility used its lowest negotiated commercial insurance rate when calculating the
a
maximum amounts that can be charged
The hospital facility used the average of its three lowest negotiated commercial insurance rates when
b
calculating the maximum amounts that can be charged
The hospital facility used the Medicare rates when calculating the maximum amounts that can be
c
charged
d
Other (describe in Part VI)
21
During the tax year, did the hospital facility charge any of its FAP-eligible individuals, to whom the hospital
facility provided emergency or other medically necessary services, more than the amounts generally billed to
individuals who had insurance covering such care? .
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If “Yes,” explain in Part VI.
During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross
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charge for any service provided to that individual?
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If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
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