Form 13790 (5-2006)

Form 13790

(May 2006)

COMPLIANCE CHECK QUESTIONNAIRE

TAX-EXEMPT HOSPITALS

OMB No.

1545-2015

This questionnaire asks for information about your hospital and how it operates. Answer the questions based on

your hospital’s most recently completed tax period. If additional space is needed, attach additional sheets.

Please complete the questionnaire and follow the instructions in the letter for returning the information to us.

PART I – ORGANIZATION

Name of Hospital: EIN:

Most Recently Completed Tax Period:

PART II – OPERATIONS

Please indicate the category below that best described your hospital or the type of service it provided to the majority of

admissions. Check only one box.

General medical and surgical

Hospital unit of an institution (prison, college etc)

Hospital unit within an institution for the mentally retarded

Surgical

Psychiatric

Tuberculosis and other respiratory diseases

Cancer

Heart

Alcoholism and other chemical dependency

Organization is not a §501(c)(3) hospital. If you checked

this box, stop here and return the questionnaire to us.

Obstetrics and gynecology

Eye, ear, nose and throat

Rehabilitation

Orthopedic

Chronic disease

Institution for the mentally retarded

Acute long-term care

Other — Specify:

Patients

Inpatients Outpatients

Emergency Room

Patients

2) What were the total number of:

How many had private insurance?

4) How many had Medicare?

5) How many had Medicaid?

6) How many had other public insurance?

7) How many had no insurance?

8) Did your hospital deny medical services to any individuals with:

a) private insurance? Yes No

If yes, please explain.

b) Medicare? Yes No

If yes, please explain.

c) Medicaid? Yes No

If yes, please explain.

Form 13790 (5-2006)

Page 1 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

d) other public health insurance? Yes No

If yes, please explain.

e) no insurance? Yes No

If yes, please explain.

Emergency Room

Did your hospital operate an emergency room? Yes No

If no, please explain.

10)

What were the emergency room’s hours of operation?

24 hours a day, 365 days a year

Other — please explain.

11) Did your hospital’s emergency room have a trauma center? Yes No

12) If yes, what was the trauma center’s level of certification?

Level I

Level II

Level III

Level IV

Level V

Other — please describe.

13) Did your hospital’s emergency room provide services to all members of the community regardless of their ability to pay?

Yes No

If no, please explain.

14)

Did your hospital’s emergency room deny services to any individuals that requested such services? Yes No

If yes, please explain.

Board of Directors

15) How many directors were on your hospital’s board?

16)

What was the professional background of each director?

Please indicate the number of directors in each category listed below.

Accounting

Government

Philanthropy

Banking/Finance

Insurance

Public/Elected Official

Business

Law

Religion

Community Service

Management

Retail

Education/Academia

Manufacturing

Social Services

Fine Arts

Medicine/Health Care

Other (specify)

17)

How often did the board of directors meet?

Monthly Quarterly Annually

Other — please describe.

18) On average, how many of the directors were present at each meeting?

Form 13790 (5-2006)

Page 2 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

Medical Staff Privileges

19) Were all qualified physicians in your community eligible for medical staff privileges at your hospital? Yes No

If no, please explain.

20) Have you denied any qualified physician’s application for medical staff privileges? Yes No

If yes, please explain.

Medical Research

21)

Did your hospital conduct any medical research programs? Yes No

If yes, please answer questions 22 through 24. If no, go to question 25.

22)

How much did your hospital spend on medical research programs? $

23)

How much of your hospital’s funding for medical research came from:

a) public sources (for example, government grants) $

b) private sources (for example, contracts with for-profit corporations) $

24) Did your hospital limit public access to the findings or results from any of its medical research programs? Yes No

If yes, please explain.

25) How much did your hospital provide in grants to individuals or organizations to fund

medical research programs? $

26) Was public access limited to the findings or results from any medical research programs for which your hospital provided

grants? Yes No

If yes, please explain.

27)

Did your hospital conduct any medical trial studies? Yes No

If yes, answer questions 28 and 29. If no, go to question 30.

28)

How much of your hospital’s funding for medical trial studies came from:

a) public sources (for example, government grants) $

b) private sources (for example, contracts with for-profit corporations) $

29) Did your hospital limit public access to the findings or results from any of its medical trial studies? Yes No

If yes, please explain.

Professional Medical Education and Training

30)

Did your hospital conduct any professional medical education and training programs?

If yes, answer questions 31 and 32. If no, go to question 33.

Yes No

31)

How much did your hospital spend on professional medical education and training programs? $

32)

How much of your funding for professional medical education and training came from:

a) public sources (for example, government grants) $

b) private sources (for example, contracts with for-profit corporations) $

Form 13790 (5-2006)

Page 3 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

33)

Did your hospital provide grants to individuals or organizations to fund professional medical education and

training programs? Yes No

If yes, how much did it spend? $

Uncompensated Care

34)

Did your hospital have a written policy stating the circumstances under which it would provide

uncompensated care? Yes No

Please explain.

35) How many individuals received uncompensated care from your hospital?

36)

How much did your hospital spend on uncompensated care? $

37) Did your hospital treat as uncompensated care the excess of what it charged for services and the amount:

a) private insurance paid or allowed for such services

(including any patient co-payments and deductibles)? Yes No

If yes, please explain.

b) Medicare paid or allowed for such services (including any patient co-payments and deductibles)? Yes No

If yes, please explain.

c) Medicaid paid or allowed for such services (including any patient co-payments and deductibles)? Yes No

If yes, please explain.

d) other public insurance paid or allowed for such services

(including any patient co-payments and deductibles)? Yes No

If yes, please explain.

e) individuals without insurance paid your hospital for such services? Yes No

Please explain.

38)

Did your hospital treat bad debts as uncompensated care? Yes No

Please explain.

39)

Did your hospital treat any other items or costs as uncompensated care? Yes No

If yes, please explain.

40) Did your hospital report its expenditures for uncompensated care to a state government? Yes No

If yes, what amount did it report? $

Form 13790 (5-2006)

Page 4 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

41) Did your hospital provide:

a) inpatient services to any individual without compensation? Yes No

If yes, please describe your policy.

b) outpatient services to any individual without compensation? Yes No

If yes, please describe your policy.

c) emergency room services to any individual without compensation? Yes No

If yes, please describe your policy.

42)

If you answered yes to 41 a, b, or c, indicate below, for each category of patient, when your hospital determined that it

would provide services to any individual without compensation? Check all that apply.

At or Less than 30 30 to 90 More than 90 When Other

before days after days after days after insurance (explain

providing providing providing providing denied all or below)

services services services services part of claim

Inpatient

Outpatient

Emergency

Room

If you checked the other box, please describe:

Billing Practices

43) Did your hospital require all individuals to pay, or make arrangements to pay, prior to, or at the time it provided:

a) inpatient services? Yes No

b) outpatient services? Yes No

c) emergency room services? Yes No

44) In the space provided below, please explain your payment policies for:

a) inpatients

b) outpatients

Form 13790 (5-2006)

Page 5 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

c) emergency room patients

45)

How many days after your hospital provided services did it send the patient a bill?

46)

How many days after the billing date did the patient have to pay for services?

47) If a patient failed to pay for services, how many notices did your hospital send before it began collection actions?

48) Did your hospital refer all past due bills to collection agencies? Yes No

49) Did your hospital enter into installment agreements or other extended payment arrangements

with patients who were unable to pay? Yes No

50)

Please describe the circumstances in which you would enter into installment agreements or other extended payment

arrangements with patients who were unable to pay.

51) How many days after a patient had not paid all or part of a bill did your hospital classify it as a bad debt?

52) Did your hospital charge all patients the same price for the same services? Yes No

If yes, go to question 57. If no, answer questions 53-56.

53) Did your hospital charge patients with private insurance higher prices for hospital services than patients with public

insurance (including Medicare and Medicaid)? Yes No

Please explain.

54) Did your hospital charge patients with no insurance higher prices for hospital services than patients with public insurance

(including Medicare and Medicaid)? Yes No

Please explain.

55) Did your hospital charge patients with no insurance higher prices for hospital services than patients with

private insurance? Yes No

Please explain.

56) Did your hospital charge individuals different prices for hospital services based on their income, assets or

ability to pay for such services? Yes No

Please explain.

Form 13790 (5-2006)

Page 6 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

Community Programs

57) Did your hospital provide medical screening programs for the community? Yes No

If yes, answer questions 58 through 60. If no, go to question 61.

58)

How much did your hospital spend on medical screening programs for the community? $

59) Were all members of the community eligible for your hospital’s medical screening programs? Yes No

If no, please explain.

60) Did the hospital charge a fee for any community medical screening programs? Yes No

If yes, please explain.

61)

Did your hospital provide immunization programs for the community? Yes No

If yes, answer questions 62 through 64. If no, go to question 65.

62)

How much did your hospital spend on immunization programs for the community? $

63) Were all members of the community eligible for your hospital’s immunization programs? Yes No

If no, please explain.

64) Did your hospital charge a fee for its community immunization programs? Yes No

If yes, please explain.

65)

Did your hospital provide any lectures, seminars or other educational programs for the community? Yes No

If yes, answer questions 66 through 68. If no, go to question 69.

66)

How much did your hospital spend on lectures, seminars and other educational programs

for the community? $

67)

Were all members of the community eligible for your hospital’s community educational programs? Yes No

If no, please explain.

68)

Did your hospital charge a fee for its community education programs? Yes No

If yes, please explain.

69) Did your hospital conduct studies on the unmet health care needs of the community? Yes No

If yes, how much did your hospital spend on these studies? $

70)

Did your hospital have programs to improve access to health care for individuals who lacked insurance? Yes No

If yes, how much did your hospital spend on these programs? $

71) Did your hospital produce or distribute newsletters or publications that provided information to the community

on health care issues? Yes No

If yes, how much did your hospital spend on these newsletters or publications? $

Form 13790 (5-2006)

Page 7 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

72) Did your hospital have any other programs or activities that promoted health for the benefit of the community?

Yes No

If yes, please explain and indicate how much was spent on these programs and activities.

PART III – COMPENSATION PRACTICES

Please answer the questions in this part as it pertains to employees in your hospital who are disqualified persons within the

meaning of Internal Revenue Code (IRC) Section 4958(f)(1).

1) Please provide the names and titles of your hospital’s officers, directors, trustees and key employees and amounts

of salary and other compensation paid by your hospital to such officers, directors, trustees and key employees.

Add additional sheets if necessary.

Name Title

Salary

Other Compensation

Salary includes all forms of cash and non-cash compensation received whether paid currently or deferred.

Other Compensation includes contributions to employee benefit plans and deferred compensation plans, and

expense allowances from non-accountable plans.

2) Did your hospital have a formal written compensation policy? Yes No

Was compensation approved, in advance, by individuals that did not have a conflict of interest with the

compensation arrangement being approved? Yes No

4) Who in your hospital set the compensation for officers, directors, trustees, and key employees? Check all that apply.

Officers Board of Directors Compensation Committee

Other — please explain:

Please check any of the following that your hospital used to determine compensation amounts:

Published surveys of compensation at similar institutions;

Internet research on compensation at similar institutions conducted by your employees;

Phone survey(s) of compensation at similar institutions conducted by your hospital’s employees;

Outside expert report prepared specifically for your hospital by an expert employed by your hospital for this

purpose;

Outside expert report prepared by an expert employed by an unrelated organization;

Written offers of employment from similar institutions; and

Other — please describe:

Form 13790 (5-2006)

Page 8 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

Please check the appropriate boxes, in the following chart, regarding factors included in the comparability data used by

your hospital:

COMPARABILITY FACTORS:

YES NO

Was factor checked used for all

§ 4958(f)(1) employees? *

Yes No*

Level of Employee Education and Experience

Specific Responsibilities of Position

Same Geographic or Metropolitan Area

Services of a Similar Nature Provided

Similar Number of Beds, Admissions, or Outpatient Visits

Other Factors. Please explain.

*If no, please explain.

Did your hospital’s comparability data include information from other tax-exempt hospitals? Yes No

If no, please explain.

8) Was your hospital’s actual compensation set within the range of comparability data? Yes No

If no, please explain.

9) Did your hospital have a business relationship with any of its officers, directors, trustees or

key employees other than through their position as officers, directors, trustees, or key employees? Yes No

If yes, identify the individuals and describe the business relationship below.

Name Title Description of Business Relationship

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the

United States. We need it to ensure that you are complying with these laws.

The IRS may not conduct or sponsor, and an organization is not required to provide the information requested on a form that is subject to

the Paperwork Reduction Act unless the form displays a valid OMB number. Books or records relating to a collection of information must be

retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and tax

return information are confidential, as required by 26 U.S.C. 6103 and 6104.

Form 13790 (5-2006)

Page 9 Catalog Number 48381U Department of the Treasury — Internal Revenue Service

Clear Button