Provider, Hospital, And Surgical Center Taxes Instructions - Minnesota Department Of Revenue - 2017 Page 10
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10Worksheet for Filing Provider, Hospital, and Surgical Center Tax Returns
For your convenience, we have included this worksheet to record the amounts you will need to electronically file your
annual return. Keep this worksheet for your records. Do not mail or fax it to the Department of Revenue.
Record your annual gross receipts and exemption amounts below. Round all amounts to the nearest whole dollar.
Gross Receipts (All exemption amounts must be included in Gross Receipts.)
Total Gross Receipts. Enter the total amount received during the year for providing health care services.
See instructions for what to include as gross receipts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exemptions (Do not claim the same receipts on more than one line. See instructions.)
Medicare. Enter the amount received from Medicare, including deductibles, coinsurance, and copayments
from patients and/or Medicare supplemental plans for Medicare-covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Government Agencies. Enter the amount received from government agencies in connection with a
government program. Do not include payments received from Medical Assistance or MinnesotaCare . . . . . . . . . . . . . . .
FEHBA/TRICARE. Enter the amount received under the Federal Employees Health Benefit Act (FEHBA)
or TRICARE Program. Do not include deductibles, coinsurance, and copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Providers. Enter the amount received from other health care providers, hospitals, or surgical
centers who are liable for the MinnesotaCare tax on the services provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Care Research. Enter the amount received from sponsors of health care research
for services you provided through a formal program of health care research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Grants/Gifts/Donations/Home Health/Other. Enter the amounts received as grants, gifts, and donations
(that were not designated for a specific individual or group) and for home health services provided by a
registered home health care agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Legend Drugs. See instructions on how to calculate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The following amounts will be calculated for you when you file your return electronically. You may record the amounts here for
your records.
Total Exemptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Taxable Receipts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MinnesotaCare Tax Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How to File Your Return Electronically
You must file your return electronically either online or by phone. Go to and log in to e-Services, or call
1-800-570-3329 to file using our automated phone system.
You will receive a confirmation number if your return is filed successfully. If you file online, print the confirmation page for your records.
If you file by phone, you may record the following information, if applicable, for your records.
Amount Due (before penalty and interest) . . . . . . . . . . . . . . . . . . . . . . .
Confirmation Number
Additional Charge for Underpayment of Estimated Tax (ATC) . . . . . . . .
Date and Time
Penalty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TOTAL DUE or REFUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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