Instructions For Schedule H (Form 990) - 2016 Page 21
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23Keep for Your Records
Worksheet 6.
Subsidized Health Services (Part I, line 7g)
(C)
(E)
(A)
Medicaid and
Totals
Total
other means-
(subtract
subsidized
tested
columns (B),
health
government
(D)
(C), and (D)
service
(B)
health
Financial
from column
program
Bad debt
programs
assistance
(A))
Program name: ______________________________
Gross patient charges
1.
Gross patient charges from program(s) . . . . . . . . .
1.
Total community benefit expense
2.
Ratio of patient care cost to charges (from
2.
%
%
%
%
Worksheet 2, if used) . . . . . . . . . . . . . . . . . . . . . .
3.
Total community benefit expense (multiply line 1
by line 2, or obtain from cost accounting; enter
3.
column (E) on Part I, line 7g, column (c)) . . . . . . . .
Direct offsetting revenue
4.
Net patient service revenue . . . . . . . . . . . . . . . . .
4.
5.
Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
6.
Total direct offsetting revenue (add lines 4 and 5;
enter column (E) on Part I, line 7g, column
(d)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
7.
Net community benefit expense (subtract line 6
from line 3; enter column (E) on Part I, line 7g,
7.
column (e)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.
Total expense (enter amount from Form 990, Part
IX, line 25, column (A), including the organization's
share of joint venture expenses, and excluding any
bad debt expense included in Part IX,
8.
$
line 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.
Percent of total expense (line 7, column (E)
divided by line 8; enter on Part I, line 7g, column
%
(f))
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.
Instructions for Schedule H
-21-
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