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Data Element |
Entity Overview |
Tax ID Number (TIN) |
Provider Type |
Provider Sub-Type |
Business Name |
Doing-Business-As Name - optional |
Street 1+2 |
City |
State |
Zip |
Filing Contact Name |
Filing Contact Title |
Filing Contact Phone Number |
Filing Contact Email |
Subsidiary Questionnaire |
Subsidiaries that are eligible health care providers? |
Acquire or divest subsidiaries during the period of availability of funds? |
Parent reporting on your behalf for General Dist.? |
TIN of parent(s) reporting on your behalf |
Were Targeted Distribution funds transferred to or by a Parent? |
How much Targeted Distribution was transferred to the parent entity? |
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TIN of Subsidiary |
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Parent reporting on this TIN? |
Acquisition/Divestiture information (If Applicable) |
TIN of Acquired/Divested Entity |
Acquired or Divested? |
Date of Acquisition or Divestiture |
PRF Received for TIN |
% Ownership |
Did/Do you hold a controlling interest in this entity? |
Certification of PRF Payments to Recipient |
PRF Funds received > $10k |
PRF Interest Earned |
Interest earned on Nursing Home Infection Control |
Interest earned on Other PRF |
Single Audit |
Federal Tax Classification |
Exempt Payee code (optional) |
Exempt from FATCA Reporting Code |
Fiscal Year End Date |
Subjected to Single Audit? |
Were PRF funds included in the audit? |
Other Assistance Received during Period of Availability |
Treasury, Small Business Administration (SBA) and the CARES Act/Paycheck Protection Program (PPP), Quarterly for Reporting Period |
FEMA CARES Act Funds, Quarterly for Reporting Period |
CARES Act Testing, Quarterly for Reporting Period |
Local, State, and Tribal Government Assistance, Quarterly for Reporting Period |
Business Insurance, Quarterly for Reporting Period |
Other Assistance, Quarterly for Reporting Period |
Nursing Home Infection Control Payment Expenditures < $500K (If Applicable) |
General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period |
Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period |
Nursing Home Infection Control Payment Expenditures >= $500K (If Applicable) |
Mortgage/Rent, Quarterly for Reporting Period |
Insurance, Quarterly for Reporting Period |
Personnel, Quarterly for Reporting Period |
Fringe Benefits, Quarterly for Reporting Period |
Lease Payments, Quarterly for Reporting Period |
Utilities/Operations, Quarterly for Reporting Period |
Other General and Administrative Expenses, Quarterly for Reporting Period |
Supplies, Quarterly for Reporting Period |
Equipment, Quarterly for Reporting Period |
Information Technology (IT), Quarterly for Reporting Period |
Facilities, Quarterly for Reporting Period |
Other Healthcare Related Expenses, Quarterly for Reporting Period |
Other PRF Payment Expenditures < $500K |
General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period |
Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period |
Other PRF Payment Expenditures >= $500K |
Mortgage/Rent, Quarterly for Reporting Period |
Insurance, Quarterly for Reporting Period |
Personnel, Quarterly for Reporting Period |
Fringe Benefits, Quarterly for Reporting Period |
Lease Payments, Quarterly for Reporting Period |
Utilities/Operations, Quarterly for Reporting Period |
Other General and Administrative Expenses, Quarterly for Reporting Period |
Supplies, Quarterly for Reporting Period |
Equipment, Quarterly for Reporting Period |
Information Technology (IT), Quarterly for Reporting Period |
Facilities, Quarterly for Reporting Period |
Other Healthcare Related Expenses, Quarterly for Reporting Period |
Net Unreimbursed Expenses Atributable to Coronavirus |
Net General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period |
Net Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period |
Type of Lost Revenues Calculation |
Reporting on 2019 Actual Revenue, 2020 Budgeted Revenue, or Estimated Lost Revenue? |
Lost Revenues Option 1: Revenue Actuals - 2019-2021 (If applicable) |
Medicare A + B, Quarterly for Reporting Period |
Medicare C, Quarterly for Reporting Period |
Medicaid/CHIP, Quarterly for Reporting Period |
Commercial Insurance, Quarterly for Reporting Period |
Self-Pay (No Insurance), Quarterly for Reporting Period |
Other, Quarterly for Reporting Period |
Lost Revenues Option 2: 2020 Budgeted to Actual (If Applicable) |
Medicare A + B, Quarterly for Reporting Period |
Medicare C, Quarterly for Reporting Period |
Medicaid/CHIP, Quarterly for Reporting Period |
Commercial Insurance, Quarterly for Reporting Period |
Self-Pay (No Insurance), Quarterly for Reporting Period |
Other, Quarterly for Reporting Period |
Upload Button for 2020/21 Budget approved prior to March 27th, 2020 |
Upload Button for Attestation by CEO, CFO, or Similar Responsibility on accuracy of Budget Submitted |
Lost Revenues Option 3: Alternate Reasonable Methodology (If Applicable) |
Lost Revenue Estimate (2020/21), Quarterly for Reporting Period |
Upload Narrative Document descibing methodology |
Upload Calculation of Lost Revenues |
Upload additional supporting documentation |
Personnel Metrics |
Contracted Personnel |
Contracted/Clinical |
Non-clinical |
Full-time Personnel |
Clinical |
Non-clinical |
Part-time Personnel |
Clinical |
Non-clinical |
Hired |
Clinical |
Non-clinical |
Separated |
Clinical |
Non-clinical |
Furloughed Personnel |
Clinical |
Non-clinical |
Patient Metrics |
Number of Inpatient Admissions |
Number of Outpatient Visits (In person and Telehealth) |
Number of Emergency Department Visits |
Number of Facility Resident Patients (for Long- and Short-term Residential Facilities) |
Facility Metrics |
Number of Medical/Surgical Beds |
Number of Critical Care Beds |
Number of Other Beds |
Survey Questions |
(Agree/Disagree) The PRF payments had a significant impact on my overall yearly finances. |
(Yes/No) The PRF payment(s) helped maintain solvency and/or prevent bankruptcy. |
(Check all that apply) PRF payments significantly affected my ability to |
(Yes/No) The PRF payment(s) helped retain staff that otherwise would have been furloughed or terminated. |
(Yes/No) The PRF payment(s) helped re-hire or re-activate staff from furlough. |
(Agree/Disagree) The PRF payment(s) helped to make the changes needed to operate during the pandemic (e.g., by acquiring PPE, creating temporary facilities, providing for virtual visits, etc.). |
(Check all that applies) PRF payment(s) helped facility operations and patient care by allowing our facility to |
(Yes/No) The PRF payment(s) helped care for and/or treat patients with COVID-19 (for applicable treatment facilities). |
Please describe the impact these funds had on the business or patient services. (Optional) |
Final Financial Verification |
Reporting on RHC COVID-19 Testing complete? |
Certification of accuracy of report |