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The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
Line 1a. As a medical research
organization, you must be associated with
a hospital described in section 501(c)(3),
a federal hospital, or an instrumentality of
a government. Provide the name of the
hospital(s) you’re associated with and
describe the relationship(s).
Line 1b. List your assets and their fair
market value and the portion of your
assets directly devoted to medical
research. Don’t complete the remainder of
Schedule C.
Line 2. Answer “Yes,” if you’re a
cooperative hospital service organization
and describe the services you provide to
your member hospitals and the exempt
status of your membership. Don’t
complete the remainder of Schedule C.
Line 3. Answer “Yes,” if all the doctors in
your community are eligible for staff
privileges at your facility. You must answer
“Yes,” even if staff privileges at your
facilities are limited by capacity, provided
that all qualified medical professionals in
your community may seek and would be
considered for eligibility.
Answer “No,” if all doctors in your
community aren’t eligible for staff
privileges at your facility.
If you answer “No,” describe in detail
how you limit eligibility for staff privileges
at your facility. Include details of your
eligibility criteria and selection procedures
for your courtesy staff of doctors.
Line 4. Answer “Yes,” if you admit all
patients in your community who can pay
for themselves or through some form of
third-party reimbursement (for example,
private health insurance, Medicare, or
Medicaid).
Answer “No,” if you limit admission for
these individuals in any way and describe
your admission policy in detail, including
how and why you restrict patient
admission.
Line 5. Answer “Yes,” if you offer
emergency medical or hospital care at
your facility on a 24-hour basis, seven
days a week.
Line 5a. Answer “Yes,” if the reason you
don’t maintain a full-time emergency room
is either because you’re a specialty
hospital where emergency care would be
inappropriate for the services you provide
or another emergency medical care facility
that provides such services is located so
near to you as to make such services as
you might provide duplicative.
Line 6. Answer “Yes,” if you provide free
or low-cost medical or hospital care
services. If you answer “Yes,” describe
your policy and to whom you provide
these services. Include details on how
these services promote benefits to the
community. For example, you may want
to indicate how you determine who is
eligible for the services, how you inform
the general public about your policy, any
requirements you require of patients to
receive reduced cost or free care, and any
agreements you might have with
municipalities or government agencies to
subsidize the cost of admitting or treating
patients through this policy.
Line 7. Answer “Yes,” if you have a
formal program of medical training and
research. If you answer “Yes,” describe
your program, including the programs you
offer, the scope of such programs, and
affiliation with other hospitals or medical
care providers with which you carry on the
medical training or research programs.
Line 8. Answer “Yes,” if you have a
formal program of community educational
programs and describe your programs,
including the types of programs offered,
the scope of the programs, and affiliation
with other hospitals or medical care
providers with whom you offer community
educational programs.
Line 9. Answer “Yes,” if you have a board
of directors that is representative of the
community you serve or if an
organization described under section
501(c)(3) with a community board
exercises rights or powers over you.
Answer “Yes,”if you’re subject to a
state corporate practice of medicine law
that requires your governing board to be
composed solely of physicians licensed to
practice medicine in the state.
Line 9a. List each board member by
name and describe that person’s
relationship to you. Also, for each board
member, describe if and how that
individual represents the community.
Generally, hospital employees and staff
physicians aren’t individuals considered to
be community representatives. If you
operate under a parent organization
whose board of directors isn’t comprised
of a majority of individuals who are
representative of the community you
serve, provide the requested information
for your parent organization's board of
directors as well.
Line 10. Section 501(r). Answer “Yes,” if
you operate a facility that is required by a
state to be licensed, registered, or
similarly recognized as a hospital.
Organizations that respond “Yes,” to this
question are required to meet additional
requirements described in section 501(r)
to be considered a hospital exempt from
taxation by section 501(c).
Line 10a. A community health needs
assessment (CHNA) is an assessment of
the significant health needs of the
community. To meet the requirements of
section 501(r)(3), a CHNA must take into
account input from persons who represent
the broad interests of the community
served by the hospital facility, including
those with special knowledge of or
expertise in public health, and must be
made widely available to the public. Each
hospital facility must conduct a CHNA at
least once every 3 years and adopt an
implementation strategy to meet the
community health need identified through
such CHNA.
Answer “Yes,” if the hospital facility
conducted a complying CHNA in the
current tax year or in either of the 2
immediately preceding tax years or if the
hospital facility intends to conduct a
CHNA before the end of its first 3-year
period.
Line 10b. A financial assistance policy
(FAP), sometimes referred to as a charity
care policy, is a policy describing how an
organization will provide financial
assistance at its hospital(s) and other
facilities, if any. Financial assistance
includes free or discounted health
services provided to persons who meet
the organization’s criteria for financial
assistance and are unable to pay for all or
a portion of the services. Financial
assistance doesn’t include:
•
Bad debt or uncollectible charges that
the organization recorded as revenue but
wrote off due to a patient’s failure to pay or
the cost of providing such care to such
patients;
•
The difference between the cost of care
provided under Medicaid or other
means-tested government programs or
under Medicare and the revenue derived
therefrom;
•
Self-pay or prompt pay discounts; or
•
Contractual adjustments with any
third-party payors.
Answer “Yes,” if the hospital facility has
adopted a written financial assistance
policy and a written policy relating to
emergency medical care as required by
section 501(r)(4).
Line 10c. Under section 501(r)(5), the
maximum amounts that can be charged to
FAP-eligible individuals for emergency or
other medically necessary care are the
amounts generally billed to individuals
who have insurance covering such care.
Answer “Yes,” if the hospital facility:
1. Limits or will limit any charges to
FAP-eligible individuals to whom the
hospital facility provided emergency or
other medically necessary services to not
more than the amounts generally billed to
individuals who had insurance covering
such care; and
2. Prohibits, or upon beginning
operations will prohibit, the use of gross
charges as described in section 501(r)(5).
The hospital facility may check “Yes,” if
it charged more than the amounts
generally billed to individuals who had
Instructions for Form 1023
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