Additional Health Department Forms

Forms for Hospital Finance and Charity Care

New Jersey Acute Care Hospitals Cost Reports
Instructions
Form # Form Name/Title Linked File Instruction/ Comments
ACH NJ Acute Care Hospitals Cost Reports
ACH (295k)
NEW! fillable PDF form posted, Word document no longer available.
 
Volumes and Statistics
Form # Form Name/Title Linked File Instruction/ Comments
B Patient Care Volumes
B (888k)
NEW! fillable PDF form posted, Word document no longer available.
 
B-5 Other Statistical Data (excluding SNF)
B-5 (145k)
NEW! fillable PDF form posted, Word document no longer available.  
B-6 Outpatient Volumes By Payer and Outpatient Area
B-6 (189k)
NEW! fillable PDF form posted, Word document no longer available.
 
Cost and Related Reconciling Items
Form # Form Name/Title Linked File Instruction/ Comments
C Cost Center Data
C (323k)
NEW! fillable PDF form posted, Word document no longer available.
 
C-3 Other Cost Details
C-3 (244k)
NEW! fillable PDF form posted, Word document no longer available.  
C-4 Cost Center Budgets Reconciling Items (RIT)
C-4 (222k)
NEW! fillable PDF form posted, Word document no longer available.
 
C-5 Other Operating Income Non-Operating Income
C-5 (179k)
NEW! fillable PDF form posted, Word document no longer available.  
C-6 Nursing Service Details
C-6 (148k)
NEW! fillable PDF form posted, Word document no longer available.
 
Capital Facilities
Form # Form Name/Title Linked File Instruction/ Comments
D-3 Capital Facilities Information
D-3 (866k)
NEW! fillable PDF form posted, Word document no longer available.
 
Revenue and Related Statistics
Form # Form Name/Title Linked File Instruction/ Comments
E Patient Care Gross Revenue
E (226k)
NEW! fillable PDF form posted, Word document no longer available.
 
E-3 Allocation Statistics Matrix
E-3 (248k)
NEW! fillable PDF form posted, Word document no longer available.  
E-4 Gross Revenue and Deductions From Gross Revenue
E-4 (854k)
NEW! fillable PDF form posted, Word document no longer available.
 
E-5 Net Inpatient Revenue Summary
E-5 (183k)
NEW! fillable PDF form posted, Word document no longer available.  
E-6 Net Outpatient Revenue Summary
E-6 (161k)
NEW! fillable PDF form posted, Word document no longer available.
 
E-7 Outpatient Gross Revenue By Payer & Outpatient Area
E-7 (201k)
NEW! fillable PDF form posted, Word document no longer available.  
Employee and Physician Data
Form # Form Name/Title Linked File Instruction/ Comments
H-2 Summary of Medical Professional Budget Component
H-2 (408k)
NEW! fillable PDF form posted, Word document no longer available.
 
Financial Statements
Form # Form Name/Title Linked File Instruction/ Comments
L-1 Balance Sheet
L-1 (227k)
NEW! fillable PDF form posted, Word document no longer available.
 
L-3 Statement of Operations
L-3 (702k)
NEW! fillable PDF form posted, Word document no longer available.  
L-4 Statement of All Funds Cash Flow
L-4 (691k)
NEW! fillable PDF form posted, Word document no longer available.
 
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