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Step 1: Identify the property

or subsidized goods, supplies, or services needed by low-income or

underserved individuals because of their medical condition; and pre-

Line 4 — Write the dimensions (square footage) or acreage of this

natal or childbirth outreach to low-income or underserved persons.

property. Attach a plot plan of each building’s location and use

Attach a list of identifying activities or services provided.

of the property.

Line 14 — Subsidy of state or local governments — Direct or

Line 5 — Write the date on which ownership began. Attach a copy

indirect financial or in-kind subsidies of state or local governments

of proof of ownership (deed, contract for deed, or title insurance

by the Relevant Hospital Entity that pay for or subsidize activities

policy, etc.).

or programs related to health care for low-income or underserved

Line 6 — Check the relevant hospital entity—hospital owner, hospital

individuals.

affiliate, or hospital system. If you check “hospital affiliate” or “hos-

Line 15 — Support for state health care programs for low-

pital system”, describe the type of entity (e.g., corporation, partner-

income individuals — At the election of the Hospital Applicant for

ship, limited liability company) and the relationship with one or more

each applicable year, either

hospital owners.

•

10 percent of payments to the Relevant Hospital Entity and any

Line 7 — List the property index numbers (PIN) included in your

Hospital Affiliate designated by the relevant Hospital Entity (pro-

application for exemption. If you need additional room to list multiple

vided that such hospital affiliate’s operations provide financial or

PINs, attach a separate statement. Attach a copy of the legal de-

operational support for or receive financial or operational sup-

scription if the property is a division.

port from the Relevant Hospital Entity) under Medicaid or other

means-tested programs, including, but not limited to, General

Definitions

Assistance, the Covering ALL KIDS Health Insurance Act, and

Hospital - Any institution, place, building, buildings on a campus, or

the State Children’s Health Insurance Program; or

other health care facility located in Illinois that is licensed under the

•

the amount of subsidy provided by the Relevant Hospital Entity

Hospital Licensing Act and has a hospital owner.

and any hospital affiliate designated by the Relevant Hospital

Entity (provided that such hospital affiliate’s operations pro-

Hospital owner - A not-for-profit corporation that is the title holder

vide financial or operational support for or receive financial or

of a hospital, or the owner of the beneficial interest in an Illinois land

operational support from the Relevant Hospital Entity) to state or

trust that is the titleholder of a hospital.

local government in treating Medicaid recipients and recipients

Hospital affiliate - Any corporation, partnership, limited partnership,

of means-tested programs, including but not limited to General

joint venture, limited liability company, association or other organiza-

Assistance, the Covering ALL KIDS Health Insurance Act, and

tion, other than a hospital owner, that directly or indirectly controls, is

the State Children’s Health Insurance Program.

controlled by, or is under common control with one or more hospital

The amount of subsidy for purposes of the item is calculated in the

owners and that supports, is supported by, or acts in furtherance of

same manner as unreimbursed costs are calculated for Medicaid

the exempt health care purposes of at least one of those hospital

and other means-tested government programs on federal Form 990,

owners’ hospitals.

Schedule H. Unreimbursed costs shall be net of fee-for-services pay-

Hospital system - A hospital and one or more other hospitals or

ments, payments pursuant to an assessment, quarterly payments,

hospital affiliates related by common control or ownership.

and all other payments included on the Schedule H.

Line 16 — Dual-eligible subsidy — This is the amount of subsidy

Step 2: Provide information about exemptions or

provided to the government by treating dual-eligible Medicare/Med-

applications

icaid patients. The amount of subsidy is calculated by multiplying

the Relevant Hospital Entity’s ratio of dual-eligible patients to total

Follow the instructions on the form.

Medicare patients by the Relevant Hospital Entity’s unreimbursed

costs for Medicare (calculated in the same manner as federal Form

Step 3: Provide the following about the services

990, Schedule H).

and activities for the relevant hospital entity

Line 17 — Relief of the burden of government related to health

Line 10 — Check whether the figures for services and activities you

care of low-income individuals — Complete Schedule A and at-

will enter on Lines 12 through 18 are for the hospital year or the aver-

tach it and a copy of the CMS 2552-10 Worksheet C, Part 1.

age of the previous three fiscal years ending with the hospital year.

Line 18 — Enter any other activity by the hospital that the depart-

Hospital year - The fiscal year of the relevant hospital entity, or the

ment determines relieves the burden of government or addresses the

fiscal year of one of the hospital owners in the hospital system if

health of low-income or underserved individuals. Clearly specify the

the relevant hospital entity is a hospital system with members with

service or activity. Attach all supporting documentation.

different fiscal years, that ends in the year for which the exemption is

sought.

Line 12 — Charity care — Free or discounted services provided

Step 4: Calculate and determine the exemption

pursuant to the Relevant Hospital Entity’s financial assistance policy,

Follow the instructions on the form. All lines must be completed.

measured at cost, including discounts provided under the Hospital

Uninsured Patient Act. Attach Form AG-CBP-I.

Step 5: Identify the person to contact regarding this

Line 13 — Health services to low-income and underserved in-

application

dividuals — Unreimbursed costs of the Relevant Hospital Entity for

Follow the instructions on the form.

providing without charge, paying for, or subsidizing goods, activities,

or services for the purpose of addressing the health of low-income

Step 6: Signature and notarization

or underserved individuals. Those activities or services may in-

clude, but are not limited to, financial or in-kind support to affiliated

The application must be signed under oath, verifying that all of the

or unaffiliated hospitals, hospital affiliates, community clinics, or

information is true and correct to the best of the applicant’s knowl-

programs that treat low-income or underserved individuals; providing

edge and belief. This application must be notarized before sending

or subsidizing outreach or educational services to low-income or un-

to the county board of review.

derserved individuals for disease management and prevention; free

PTAX-300-H Instructions front (R-02/13)

Ptax-300-H Form - Application For Hospital Property Tax Exemption - County Board Of Review Statement Of Facts Page 3

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