Form Hcp-2 - Rhode Island Health Care Provider Tax Return
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1HCP-2
State of Rhode Island and Providence Plantations
Department of Revenue - Division of Taxation
NURSING
FACILITIES
HEALTH CARE PROVIDER TAX RETURN
RETURN
Due on or before the 25th day of the following month
NAME
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
FEDERAL IDENTIFICATION NUMBER:
LICENSE NUMBER:
RETURN FOR THE PERIOD OF:
MONTH
YEAR
S
P
S
01/01/2008
ERVICES
ROVIDED
ERVICES
T
D
OTAL
UE
P
01/01/2008
T
RIOR TO
AND
HEREAFTER
L
1: G
P
R
INE
ROSS
ATIENT
EVENUE
L
2: R
:
6.00%
5.50%
INE
ATE
L
3: P
A
D
INE
ROVIDER
SSESSMENT
UE
(L
1
L
2)
INE
TIMES
INE
L
4: I
INE
NTEREST
L
5: P
INE
ENALTY
L
6: T
D
INE
OTAL
UE
(A
L
3, 4
5)
DD
INES
AND
INSTRUCTIONS
Line 1: Gross Patient Revenue - Enter the gross amount
Line 3: Provider Assessment Due - Multiple Line 1 times Line 2.
received on a cash basis by the provider from all patient
care services provided on June 1, 1992 and thereafter.
Line 4: Interest - Interest is calculated from the due date of the
Charitable contributions, donated goods and services,
return to the date of remittance at a rate of 18% per
fund raising proceeds, endowment support, income from
annum. If remitting after the due date, multiply Line 3
meals on wheels, income from investments and such
times 1.5% (0.015) times the number of months late.
other nonpatient revenues defined by the Tax
Administrator upon the recommendation of the
Line 5: Penalty - If remitting after the due date, multiply Line 3
Department of Human Services shall not be considered
times 10% (0.10). Penalty is calculated at 10% of the
“gross patient revenue”.
provider assessment due.
Line 2: Rate - The applicable rate for a Nursing Facility is 6.00%
Line 6: Total Amount Due - Add lines 3, 4 and 5.
for services provided prior to 1/1/2008 and 5.50% for
services provided 1/1/2008 and thereafter.
Under penalties of perjury, I hereby certify that I have personal knowledge of the statements and other information constituting this return, that the same are true,
correct and complete to the best of my knowledge and belief.
Date
Signature of authorized officer
Title
Date
Signature of preparer
Address of preparer
MAY THE DIVISION CONTACT YOUR PREPARER ABOUT THIS RETURN? YES
NO
Phone number
MAILING ADDRESS: RHODE ISLAND DIVISION OF TAXATION, ONE CAPITOL HILL, PROVIDENCE, RI 02908-5811
#23
revised 2/6/2009
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