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

Consolidated Financial Statements (10/1/2019)

Contains HB 321 required note (gross patient revenue, allowances, charity care, and net patient revenue) 06/26/20

Combining or Consolidating Schedules/Financial Information break out for Hospital Subsidiaries

Consolidating Schedules (10/1/2019)

Contains GAAS required report: see Independent Auditor's Report in Audited Financials 06/26/20

IRS Form 990

IRS Form 990 (10/1/2019)

Copies of Schedule H and other filed Schedules (except Schedule B) 06/26/20

AHQ

AHQ (10/1/2019)

248 Annual Hospital Questionnaire Final and Filed 06/26/20

Medicaid DSH Survey 2019

DSH Survey 2017: part 1 & part 2 (10/1/2019)

Disproportionate Share Hospital (DSH) Examination Parts I & II  06/26/20
List of Real Property Holdings Owned by Hospital 10/01/19

List of Hospital Indebtedness
GACH/GHA template: see Audited Financial Statements, Note 7

Audited Financial Statements (10/1/2019)

Does not include names of any bond disclosure sites to which hospital submitted info 06/26/20

Report of End of Year Net Assets (see Audited Financials, Note 8)

Audited Financial Statements (10/1/2019)

Includes assets for hospital, parent, subsidiaries, and foundation controlled or owned by hospital or parent 06/26/20

Dated Organizational Chart

Dated Organizational Chart (10/1/2019)

06/26/20

Compensation Benefits Report

Compensation Benefits Report (10/1/2019)

06/26/20
Evidence of Hospital Accreditation (e.g. the Joint Commission or DNV) 10/01/19

Indigent and Charity Care Policy

Indigent and Charity Care Policy (10/1/2019)

06/26/20

Debt Collection Policy

Debt Collection Policy (10/1/2019)

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 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:
Shepherd Center Financial Survey N/A 11/02/20
Any ASC Surveys Filed by Hospital N/A 06/26/20
Any Imaging Center Surveys by Hospital N/A 10/01/19