Financial and Organizational Information Regarding Our Hospital

Transparency Completeness Checklist (HB 321 & HB 186)
Prepared by the Georgia Alliance of Community Hospitals and Georgia Hospital Association
HB 321 Document/List/Report Required: Special Requirements/Notes: Date Posted:
Consolidated Financial Statements including Hospital Contains HB 321 required note (gross patient revenue, allowances, charity care, and net patient revenue) 10/01/19
Combining or Consolidating Schedules/Financial Information break out for Hospital Subsidiaries Contains GAAS required report: see Independent Auditor's Report in Audited Financials 10/01/19
IRS Form 990 Copies of Schedule H and other filed Schedules (except Schedule B) 10/01/19
AHQ 248 Annual Hospital Questionnaire Final and Filed 10/01/19
Medicaid DSH Survey DSH Survey Part I
DSH Survey Part II		 10/01/19
List of Real Property Holdings Owned by Hospital 10/01/19
List of Hospital Indebtedness
GACH/GHA template: see Audited Financial Statements, Note 7		 Does not include names of any bond disclosure sites to which hospital submitted info 10/01/19
Report of End of Year Net Assets (see Audited Financials, Note 8) Includes assets for hospital, parent, subsidiaries, and foundation controlled or owned by hospital or parent 10/01/19
Dated Organizational Chart 10/01/19
Compensation Benefits Report 10/01/19
Evidence of Hospital Accreditation (e.g. the Joint Commission or DNV) 10/01/19
Indigent and Charity Care Policy 10/01/19
Debt Collection Policy 10/01/19
Audited Financial Statements - Hospital N/A 10/01/19
Audited Financial Statements - Hospital Parent Company N/A 10/01/19
Combining or Consolidating Schedules/Financial Information break out for Hospital & Brother/Sister Co. N/A 10/01/19
Audited Financial Statements - Hospital Subsidiaries N/A 10/01/19
Alternative IRS Form 990 (if available) N/A 10/01/19
Community Benefit Report N/A 10/01/19
List of Hospital JVs and Ownership Interests N/A 10/01/19
Statement that there is no going concern disclosure in the hospital's audited financial statements N/A 10/01/19
Copy of any "going concern" note in Hospital Financial Statements N/A 10/01/19
HB 186 Documents Required: Special Requirements: Date Posted:
Any ASC Surveys Filed by Hospital N/A 10/01/19
Any Imaging Center Surveys by Hospital N/A 10/01/19