Additional Health Department Forms

Forms for Hospital Finance and Charity Care

New Jersey Acute Care Hospitals Cost Reports
Instructions
Form # Title PDF/WORD Instruction/ Comments
ACH NJ Acute Care Hospitals Cost Reports pdf 265k
 
NEW! fillable PDF form posted, Word document no longer available.  
Volumes and Statistics
Form # Title PDF/WORD Instruction/ Comments
B Patient Care Volumes pdf 1586k
 
NEW! fillable PDF form posted, Word document no longer available.  
B-5 Other Statistical Data (excluding SNF) pdf 1566k
 
NEW! fillable PDF form posted, Word document no longer available.  
B-6 Outpatient Volumes By Payer and Outpatient Area pdf 899k
 
NEW! fillable PDF form posted, Word document no longer available.  
Cost and Related Reconciling Items
Form # Title PDF/WORD Instruction/ Comments
C Cost Center Data pdf 1020k
 
NEW! fillable PDF form posted, Word document no longer available.  
C-3 Other Cost Details pdf 927k
 
NEW! fillable PDF form posted, Word document no longer available.  
C-4 Cost Center Budgets Reconciling Items (RIT) pdf 908k
 
NEW! fillable PDF form posted, Word document no longer available.  
C-5 Other Operating Income Non-Operating Income pdf 865k
 
NEW! fillable PDF form posted, Word document no longer available.  
C-6 Nursing Service Details pdf 833k
 
NEW! fillable PDF form posted, Word document no longer available.  
Capital Facilities
Form # Title PDF/WORD Instruction/ Comments
D-3 Capital Facilities Information pdf 853k
 
NEW! fillable PDF form posted, Word document no longer available.  
Revenue and Related Statistics
Form # Title PDF/WORD Instruction/ Comments
E Patient Care Gross Revenue pdf 912k
 
NEW! fillable PDF form posted, Word document no longer available.  
E-3 Allocation Statistics Matrix pdf 934k
 
NEW! fillable PDF form posted, Word document no longer available.  
E-4 Gross Revenue and Deductions From Gross Revenue pdf 854k
 
NEW! fillable PDF form posted, Word document no longer available.  
E-5 Net Inpatient Revenue Summary pdf 869k
 
NEW! fillable PDF form posted, Word document no longer available.  
E-6 Net Outpatient Revenue Summary pdf 868k
 
NEW! fillable PDF form posted, Word document no longer available.  
E-7 Outpatient Gross Revenue By Payer & Outpatient Area pdf 887k
 
NEW! fillable PDF form posted, Word document no longer available.  
Employee and Physician Data
Form # Title PDF/WORD Instruction/ Comments
H-2 Summary of Medical Professional Budget Component pdf 1095k
 
NEW! fillable PDF form posted, Word document no longer available.  
Financial Statements
Form # Title PDF/WORD Instruction/ Comments
L-1 Balance Sheet pdf 1030k
 
NEW! fillable PDF form posted, Word document no longer available.  
L-3 Statement of Operations pdf 1399k
 
NEW! fillable PDF form posted, Word document no longer available.  
L-4 Statement of All Funds Cash Flow pdf 2236k
 
NEW! fillable PDF form posted, Word document no longer available.  
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