HOSPITAL FISCAL REPORT
State Form 49520 (R2/7-02) Indiana State Department of Health (Form Approved by State Board of Accounts, 2000)
I. Name of Hospital City of Hospital Year Begin
Identification of Organization
Year End
Person Completing the Report E-Mail Address Medicare Provider Number Statement One: Summary of Revenue and Expenses
2. Deductions From Revenue $ Contractual Allowance Other Deductions $
1. Gross Patient Service Revenue Inpatient Patient Service Revenue Outpatient Patient Service Revenue Total Gross Patient Service Revenue $ $ $
Total Deductions $
3. Total Operating Revenue Net Patient Service Revenue Other Operating Revenue Total Operating Revenue $ $ $
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ISDH HOSPITAL FISCAL REPORT 4. Operating Expenses Salaries and Wages Depreciation and Amortization Bad Debt Total Operating Expenses $ $ $ $ Employee Benefits Interest Expense Other Expenses $ $ $
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5. Net Revenue and Expenses Excess Revenue $ over Expenses $ Net Nonoperating Gains over Losses Total Net Gain $
6. Assets and Liabilities Total Assets $ Total Liabilities $
Statement Two Revenue Source
Contractual Allowance Gross Patient Revenue $ $ $ $ $ $ Contractual Allowance $ $ $ $ $ $ Net Patient Service Allowance $ $ $ $ $ $
Medicare Medicaid Other Government Other State Other Payers Total
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ISDH HOSPITAL FISCAL REPORT Statement Three Donations Statement
Estimated Incoming Revenue Estimated Outgoing Expenses
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Net Dollar Gain or Loss
Donations Statement Four
$
$ Research Statement
$
Estimated Incoming Revenue
Estimated Outgoing Expenses
Net Dollar Gain or Loss
Research Statement Five:
Education of
$
$ Education Statement
$
Medical Professionals Hospital Patients Community Education
Estimated Incoming Revenue $ $ $
Estimated Outgoing Expenses $ $ $
Net Dollar Gain or Loss $ $ $
Number of Medical Professionals Trained Number of Hospital Patients Educated Number of Citizens Exposed to Health Education Messages
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ISDH HOSPITAL FISCAL REPORT Statement Six: Charity Statement Hospital Charity Charges
Payments From Clients Charity Costs by Hospital Charity Payments by Clients HCI Payments Subtotal Medicaid Shortfalls Subtotal DSH Payments Subtotal Medicare Shortfalls Other Government Programs Total $ $ $ $ $ $ $ $ $ $ $
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Adjustments LESS Costs to Unreimbursed Costs Hospital to Hospital $
$ $ $ $ $ $ $
$ $ $
$
Statement Seven:
Subsidized Health Services for the Community
Estimated Incoming Revenue $ $ $ $ Estimated Outgoing Net Dollar Expenses Gain or Loss $ $ $ $ $ $ $ $
Community Programs Community Assessment Provision of Taxes Other Allocations
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