Instructions For Schedule H (Form 990) - 2016 (Page 10 of 23) in pdf

is prohibited from charging interest on the

to accept responsibility for the individual’s

facility provided care and if it filed a claim

debt in excess of the rate in effect under

hospital bill for the care, and actions of the

in bankruptcy proceeding.

section 6621(a)(2) at the time the debt is

hospital facility includes actions of any

Line 19e. If the hospital facility took an

sold; the debt is returnable to or recallable

purchaser of the individual’s debt, any

action or actions against an individual

by the hospital facility upon a

debt collection agency or other party to

during the tax year similar to those listed in

determination by the hospital facility or the

which the hospital facility has referred the

lines 19a through 19d before making

purchaser that the individual is

individual’s debt, or any

reasonable efforts to determine the

FAP-eligible; and, if the individual is

substantially-related entity.

individual's eligibility under the facility's

determined to be FAP-eligible and the

Line 19a. Check this box if the hospital

FAP, check line 19e, “Other similar

debt isn't returned to or recalled by the

facility reported adverse information about

actions,” and describe those actions in

hospital facility, the purchaser is required

the individual to consumer credit reporting

Part V, Section C.

to adhere to procedures specified in the

agencies or credit bureaus before making

Line 20. Indicate which efforts the

agreement that ensure that the individual

reasonable efforts to determine the

hospital facility or other authorized party

does not pay, and has no obligation to

individual's eligibility under the facility's

made before initiating any of the actions

pay, the purchaser and the hospital facility

FAP.

listed (whether or not checked) in lines

together more than he or she is personally

Line 19b. Check this box if the hospital

19a through 19d or described in Part V,

responsible for paying as a FAP-eligible

facility sold an individual's debt to another

Section C (describing “other similar

individual.

party before making reasonable efforts to

actions” checked on line 18e or line 19e)

Line 18c. Check this box if the FAP

determine the individual's eligibility under

by checking all applicable boxes in lines

permitted deferring or denying, or

the facility's FAP. Do not check the box if,

20a through 20d. If the hospital facility

requiring a payment before providing,

prior to the sale, the hospital facility

made efforts other than those listed in

medically necessary care because of an

entered into a legally binding written

lines 20a through 20d before initiating any

individual’s nonpayment of one or more

agreement with the purchaser of the debt

of the actions listed in lines 19a through

bills for previously provided care covered

pursuant to which the purchaser is

19d or described in Part V, Section C

under the hospital facility’s FAP.

prohibited from engaging in any ECAs to

(describing "other similar actions" checked

Line 18d. Check this box if the FAP

obtain payment for the care; the purchaser

on line 18e or line 19e), check the box for

permitted actions that require a legal or

is prohibited from charging interest on the

line 20e, “Other,” and describe in Part V,

judicial process, including but not limited

debt in excess of the rate in effect under

Section C.

to: placing a lien on an individual's real

section 6621(a)(2) at the time the debt is

If the hospital facility made no such

property; attaching or seizing an

sold; the debt is returnable to or recallable

efforts before initiating any of the actions

individual's bank account or any other

by the hospital facility upon a

listed (whether or not checked) in lines

personal property; commencing a civil

determination by the hospital facility or the

19a through 19d or described in Part V,

action against an individual; causing an

purchaser that the individual is

Section C (describing “other similar

individual's arrest; causing an individual to

FAP-eligible; and, if the individual is

actions” checked on line 18e or line 19e),

be subject to a writ of body attachment or

determined to be FAP-eligible and the

check the box for line 20f, “None of these

garnishing an individual's wages. Do not

debt isn't returned to or recalled by the

efforts were made.”

include any liens that a hospital facility is

hospital facility, the purchaser is required

Line 20a. Check this box if the hospital

entitled to assert under state law on the

to adhere to procedures specified in the

facility or other authorized party provided

proceeds of a judgment settlement, or

agreement that ensure that the individual

individuals with a written notice that

compromise owed to an individual (or his

does not pay, and has no obligation to

indicated financial assistance is available

or her representative) as a result of

pay, the purchaser and the hospital facility

for eligible individuals, identified the

personal injuries for which the hospital

together more than he or she is personally

ECA(s) that the hospital facility (or other

facility provided care and if it files a claim

responsible for paying as a FAP-eligible

authorized party) intended to initiate to

in bankruptcy proceeding.

individual.

obtain payment for the care, and stated a

Line 18e. If a hospital facility's policies

Line 19c. Check this box if the hospital

deadline after which such ECA(s) may be

permitted the facility to take an action or

facility deferred or denied, or required a

initiated that was no earlier than 30 days

actions against an individual during the tax

payment before providing, medically

after the date that the written notice was

year similar to those listed in lines 18a

necessary care because of an individual’s

provided, along with a plain language

through 18d before making reasonable

nonpayment of one or more bills for

summary of the FAP. If not, describe in

efforts to determine the individual's

previously provided care covered under

Section C.

eligibility under the facility's FAP, check

the hospital facility’s FAP.

Line 20b. Check this box if the hospital

line 18e, “Other similar actions,” and

Line 19d. Check this box if the hospital

facility or other authorized party made a

describe those actions in Part V,

facility took legal action or pursued a

reasonable effort to orally notify

Section C.

judicial process, including but not limited

individuals about the hospital facility’s FAP

Line 18f. If the hospital facility was

to: placing a lien on an individual's real

and about how the individual may obtain

permitted to make no such actions, check

property; attaching or seizing an

assistance with the FAP application

the box for line 18f, “None of these actions

individual's bank account or any other

process at least 30 days before initiating

or similar actions were permitted.”

personal property; commencing a civil

ECAs. If not, describe in Section C.

action against an individual; causing an

Line 19. Indicate any of the actions

Line 20c. Check this box if (1) when an

individual's arrest; causing an individual to

against an individual that the hospital

individual who submitted an incomplete

be subject to a writ of body attachment, or

facility took during the tax year before

FAP application during the application

garnishing an individual's wages. Do not

making reasonable efforts to determine

period, the hospital facility or other

include any liens that a hospital facility is

the individual's eligibility under the facility's

authorized party notified the individual

entitled to assert under state law on the

FAP by checking all applicable boxes. For

about how to complete the FAP

proceeds of a judgment settlement, or

purposes of this question, actions against

application and gave the individual a

compromise owed to an individual (or his

an individual include actions to obtain

reasonable opportunity to do so in

or her representative) as a result of

payment for the care against any other

accordance with Regulations section

personal injuries for which the hospital

individual who has accepted or is required

1.501(r)-6(c)(5); and (2) when an

Instructions for Schedule H

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Instructions For Schedule H (Form 990) - 2016 Page 10

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