The Ag Cbp I form emerges as a pivotal document for non-profit hospitals, highlighting their commitment to providing community benefits as part of their operational mandate. Designed to promote transparency and accountability, this form serves as an annual report for non-profit hospitals to demonstrate their efforts in serving the health care needs of their communities. Detailed in the form are sections for hospitals to articulate their mission statement, which lays the foundation of their commitment to healthcare services. Additionally, hospitals must furnish their most recent Community Benefits Plan, shedding light on goals, objectives, and the populations served. Crucial to this report is the inclusion of charity care provided, which is care offered at no cost to the patient, distinguishing it from bad debt. Hospitals are required to report the actual cost of these services, ensuring a clear and accurate reflection of their contributions. Equally critical is the attachment of the current charity care policy, offering a comprehensive view of the hospital’s strategy towards indigent health care. Through the aggregation of these elements, the Form AG-CBP-1 becomes a testament to the non-profit hospital's role and responsibility in fostering community health, while adhering to the standards set forth by legal and regulatory bodies.
| Question | Answer |
|---|---|
| Form Name | Form Ag Cbp I |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | ag cbp 1, form ag cbp 1 illinois, il cbp benefits form, il cbp hospital |
Form |
KWAME RAOUL |
Rev 01/19 |
ATTORNEY GENERAL |
Annual Non Profit Hospital Community Benefits Plan Report
Hospital or Hospital System:
Mailing Address:
(Street Address/P.O. Box) |
(City, State, Zip) |
Physical Address (if different than mailing address):
(Street Address/P.O. Box) |
(City, State, Zip) |
Reporting Period: __/__/__ through __/__/__ Taxpayer Number:
Month Day YearMonth Day Year
Iffiling a consolidated financial report for a health system, list below the Illinois hospitals included in the consolidated report.
Hos11ital Name |
Address |
FEIN# |
1.ATTACH Mission Statement:
The reporting entity must provide an organizational mission statement that identifies the hospital's commitment to serving the health care needs ofthe community and the date it was adopted.
2.ATTACH Community Benefits Plan:
The reporting entity must provide it's most recent Community Benefits Plan and specify the date it was adopted. The plan should be an operational plan for serving health care needs ofthe community. The plan must:
1.Set out goals and objectives for providing community benefits including charity care and
indigent health care.
2.Identify the populations and communities served by the hospital.
3.Disclose health care needs that were considered in developing the plan.
3.REPORT Charity Care:
Charity care is care for which the provider does not expect to receive payment from the patient or a
Charity Care............................................................................$ ATTACH Charity Care Policy:
Reporting entity must attach a copy ofits current charity care policy and specify the date it was adopted.
