Financial assistance report pdf 2026

1. Click ‘Get Form’ to open the financial assistance report in the editor.
2. Begin by filling in the 'Reporting Hospital' section, including the mailing address, city, state, zip code, and taxpayer number.
3. Attach a copy of each Hospital Financial Assistance Application form used during the reporting period. If multiple forms were used, note the date any amended form was adopted.
4. Provide details on your Presumptive Eligibility Policy by attaching a copy that outlines the criteria for determining presumptive eligibility.
5. Complete the statistics section by entering data for applications submitted, approved under presumptive policy, approved outside it, denied applications, and total financial assistance provided.
6. If applicable, ensure you file this report alongside your Community Benefits Plan Report or Worksheet C Part I as required.
7. Finally, certify the report by signing and dating it at the bottom of the form.

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