Free ANNUAL NONPROFIT HOSPITAL COMMUNITY BENEFIT STATEMENT - Indiana

ANNUAL NONPROFIT HOSPITAL COMMUNITY BENEFIT STATEMENT
State Form 50654 (10-01) Indiana State Department of Health Indiana Code 16-21-9

I.

Identification of Nonprofit Hospital

Name Of Hospital City Of Hospital Name Of Charity Benefit Representative Telephone Number Year Of Statement Eligibility Statement Has the CEO identified your hospital as a "Nonprofit Hospital"? Yes: _____ No: ________

II.

Documentation of Previously Filed Information

NAME OF DOCUMENT Community Benefit Plan Original Long-Range Hospital Objectives for charity care Hospital Mission Statement List of Communities Served Needs Assessment Copy of Charity Care Policy Statement of Public Notice

DATE FILED WITH ISDH

ANY CHANGES (yes/no)

III.

Identification of New Objectives (Optional)

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ISDH

ANNUAL NONPROFIT HOSPITAL COMMUNITY BENEFIT STATEMENT

IV.

Allocation of Dollars and Persons Served Under Adopted Charity Policy

List Last Three Years Persons Served in twelve-month period Charity Care Allocation

($

)

($

)

($

)

V.

Annual Community Benefit Programs and Net Cost of Operation NET COSTS OF PROGRAM ($ ) ($ ) ($ ) ($ ) ($ )

NAME OF PROGRAM 1. 2. 3. 4. 5.

Will hospital file additional paper document to provide more details or descriptions of Projects that were funded to support community services? ___Yes ____ No If applicable, name of hospital web site that contains information on community benefits www: __________________________ VI. Identification of Additional Non-Hospital Charity Costs. STREET ADDRESS NET COSTS OF CHARITY CARE ($ ($ Comments ) )

ORGANIZATION PROVIDING CHARITY CARE

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