APPEND DOCUMENTATION AS ATTACHMENT 8, IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. SECTION V. Charity Care Information Charity Care information MUST be furnished for ALL substantive projects. 1. All applicants and co-applicants shall indicate the amount of charity care for the latest three audited fiscal years, the cost of charity care and the ratio of that charity care cost to net patient revenue. 2. If the applicant owns or operates one or more facilities, the reporting shall be for each individual facility located in Illinois. If charity care costs are reported on a consolidated basis, the applicant shall provide documentation as to the cost of charity care; the ratio of that charity care to the net patient revenue for the consolidated financial statement; the allocation of charity care costs; and the ratio of charity care cost to net patient revenue for the facility under review. 3. If the applicant is not an existing facility, it shall submit the facility's projected patient mix by payer source, anticipated charity care expense and projected ratio of charity care to net patient revenue by the end of its second year of operation. Charity care" means care provided by a health care facility for which the provider does not expect to receive payment from the patient or a thirdparty payer (20 ILCS 3960/3). Charity Care must be provided at cost. A table in the following format must be provided for all facilities as part of Attachment 9. APPEND DOCUMENTATION AS ATTACHMENT 9, IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. After paginating the entire completed application indicate, in the chart below, the page numbers for the included attachments: INDEX OF ATTACHMENTS ATTACHMENT NO. PAGES
APPEND DOCUMENTATION AS ATTACHMENT 8, IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. SECTION V. Charity Care Information Charity Care information MUST be furnished for ALL substantive projects. 1. All applicants and co-applicants shall indicate the amount of charity care for the latest three audited fiscal years, the cost of charity care and the ratio of that charity care cost to net patient revenue. 2. If the applicant owns or operates one or more facilities, the reporting shall be for each individual facility located in Illinois. If charity care costs are reported on a consolidated basis, the applicant shall provide documentation as to the cost of charity care; the ratio of that charity care to the net patient revenue for the consolidated financial statement; the allocation of charity care costs; and the ratio of charity care cost to net patient revenue for the facility under review. 3. If the applicant is not an existing facility, it shall submit the facility's projected patient mix by payer source, anticipated charity care expense and projected ratio of charity care to net patient revenue by the end of its second year of operation. Charity care" means care provided by a health care facility for which the provider does not expect to receive payment from the patient or a thirdparty payer (20 ILCS 3960/3). Charity Care must be provided at cost. A table in the following format must be provided for all facilities as part of Attachment 9. APPEND DOCUMENTATION AS ATTACHMENT 9, IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. After paginating the entire completed application indicate, in the chart below, the page numbers for the included attachments: INDEX OF ATTACHMENTS ATTACHMENT NO. PAGES
2018-08%20NICU%20Exemption%20Application%20Form%20CLEAN.docx