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

Previous:
FY20 Statements - 6/26/20
FY19 Statements - 10/1/19
Contains HB 321 required note (gross patient revenue, allowances, charity care, and net patient revenue) 07/07/21
Combining or Consolidating Schedules/Financial Information break out for Hospital Subsidiaries

Previous:
2020 Schedules - 6/26/20
2019 Schedules - 10/1/19
Contains GAAS required report: see Independent Auditor's Report in Audited Financials 07/07/21
IRS Form 990

Previous:
FY19 Form - 6/26/20
FY18 Form - 10/1/19
Copies of Schedule H and other filed Schedules (except Schedule B) 07/07/21
AHQ

Previous:
2019 AHQ - 6/26/20
2018 AHQ - 10/1/19
248 Annual Hospital Questionnaire Final and Filed 07/07/21
Medicaid DSH Survey 2019

Previous:
2018 DSH Survey - 6/26/21
2017 DSH Survey: part 1 & part 2 - 10/1/19
Disproportionate Share Hospital (DSH) Examination Parts I & II  07/07/21
List of Real Property Holdings Owned by Hospital 07/07/21
List of Hospital Indebtedness
GACH/GHA template: see Audited Financial Statements, Note 8

Previous:
FY20 Statements - 6/26/20
FY19 Statements - 10/1/19
Does not include names of any bond disclosure sites to which hospital submitted info 07/07/21
Report of End of Year Net Assets: see Audited Financials, Note 9

Previous:
FY20 Statements - 6/26/20
FY19 Statements - 10/1/19
Includes assets for hospital, parent, subsidiaries, and foundation controlled or owned by hospital or parent 07/07/21
Dated Organizational Chart - 5/1/21

Dated Organizational Chart - 11/1/21

Corporate Chart - 10/1/19
07/07/21
Compensation Benefits Report

Previous:
2019 Report - 6/26/20
2018 Report - 10/1/19
07/07/21
Evidence of Hospital Accreditation (e.g. the Joint Commission or DNV) 10/01/19
Indigent and Charity Care Policy

Previous:
2019 Policy - 10/1/19
06/26/20
Debt Collection Policy

Previous:
2019 Policy - 10/1/19
06/26/20
Audited Financial Statements - Hospital N/A 06/26/20
Audited Financial Statements - Hospital Parent Company N/A 06/26/20
Combining or Consolidating Schedules/Financial Information break out for Hospital & Brother/Sister Co. N/A 06/26/20
Audited Financial Statements - Hospital Subsidiaries N/A 06/26/20
Alternative IRS Form 990 (if available) N/A 10/01/19
Community Benefit Report N/A 01/11/21
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:
Shepherd Center Financial Survey

Previous:
2018 Survey - 11/2/20
N/A 07/07/21
Any ASC Surveys Filed by Hospital N/A 06/26/20
Any Imaging Center Surveys by Hospital N/A 10/01/19