Form Ag Cbp I – Fill Out and Use This PDF

Form AG-CBP-1	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 government-sponsored

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 third-party payer. Charity care does not include bad debt. In reporting charity care, the reporting entity must report the actual cost of services provided, based on the total cost to charge ratio derived from the hospital's Medicare cost report (CMS 2552-96 Worksheet C, Part 1, PPS Inpatient Ratios), not the charges for the services.

Charity Care............................................................................$ ATTACH Charity Care Policy:

Reporting entity must attach a copy ofits current charity care policy and specify the date it was adopted.