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Financial assistance report pdf 2026
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- Click ‘Get Form’ to open the financial assistance report in the editor.
- Begin by filling in the 'Reporting Hospital' section, including the mailing address, city, state, zip code, and taxpayer number.
- 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.
- Provide details on your Presumptive Eligibility Policy by attaching a copy that outlines the criteria for determining presumptive eligibility.
- Complete the statistics section by entering data for applications submitted, approved under presumptive policy, approved outside it, denied applications, and total financial assistance provided.
- If applicable, ensure you file this report alongside your Community Benefits Plan Report or Worksheet C Part I as required.
- Finally, certify the report by signing and dating it at the bottom of the form.
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