Part V. Facility — 2025 Inst 990 (Schedule H) (PDF)

In Part V, the organization must list all of its hospital facilities in Section A, complete separate Sections B and C for each of its hospital facilities or facility reporting groups listed in Section A, and list its non-hospital health care facilities in Section D.

Facility reporting groups. If the organization is able to check the same checkboxes for all Part V, Section B, questions for more than one of its hospital facilities, it may file a single Section B and Section C for all facilities in that facility reporting group. For each of those facilities, the organization would assign and list the facility reporting group letter in the “Facility reporting group” column in Section A. Assign letter A to the facility reporting group with the greatest number of facilities, letter B to the group with the second greatest number of facilities, and so forth. For instance, three hospital facilities with identical answers to the Section B checkboxes would be assigned facility group letter A, while two other hospital facilities with identical answers would be assigned facility group letter B.

Section A Complete Part V, Section A, by listing all of the organization's hospital facilities that it operated during the tax year . List these facilities in order of size from largest to smallest, measured by a reasonable method (for example, the number of patients served or total revenue per facility). “Hospital facilities” are facilities that, at any time during the tax year, were required to be licensed, registered, or similarly recognized as a hospital under state law. A hospital facility is operated by an organization whether the facility is operated directly by the organization or through a disregarded entity or joint venture treated as a partnership. For each hospital facility, list its name, address, primary website address, and state license number (and if a group return, the name and employer identification number (EIN) of the subordinate hospital organization that operates the hospital facility), and check the applicable column(s).

“Licensed hospital” is a facility licensed, registered, or similarly recognized by a state as a hospital.

“General medical & surgical” refers to a hospital primarily engaged in providing diagnostic and medical treatment (both surgical and nonsurgical) to inpatients with a wide variety of medical conditions, and that may provide outpatient services, anatomical pathology services, diagnostic X-ray services, clinical laboratory services, operating room services, and pharmacy services.

“Children's hospital” is a center for provision of health care to children, and includes independent acute care children's hospitals, children's hospitals within larger medical centers, and independent children's specialty and rehabilitation hospitals.

“Teaching hospital” is a hospital that provides training to medical students, interns, residents, fellows, nurses, or other health professionals and providers, provided that such educational programs are accredited by the appropriate national accrediting body.

“Critical access hospital” (CAH) is a hospital designated as a CAH by a state that has established a State Medicare Rural Hospital Flexibility Program in accordance with Medicare rules.

“Research facility” is a facility that conducts research.

“ER–24 hours” refers to a facility that operates an emergency room 24 hours a day, 365 days a year.

“ER–other” refers to a facility that operates an emergency room for periods less than 24 hours a day, 365 days a year.

Complete the “Other (describe)” column for each hospital facility that the organization operates that isn't described in the other columns of Part V, Section A.

In the upper left-hand corner of the Part V, Section A, table, list the total number of hospital facilities that the organization operated during the tax year.

If the organization needs additional space to list all of its hospital facilities, it should duplicate Section A and use as many duplicate copies of Section A as needed, number each page, and renumber the line numbers in the left-hand margin (an organization with 15 facilities should renumber lines 1–5 on the second page as lines 11–15).

Section B Section B requires reporting on a hospital facility -by-hospital facility basis. The organization must complete a Section B for each of its hospital facilities or facility reporting groups listed in Section A. At the top of each page of Section B, list the name of the hospital facility or the facility reporting group letter. In the space provided, list the line number of the hospital facility, or line numbers of the hospital facilities in a facility reporting group (from Part V, Section A).

If the organization could check the same checkboxes for all Part V, Section B, questions for more than one of its hospital facilities, it may file a single Section B for all facilities in that facility reporting group.

References in these Section B instructions to a “hospital facility” taking a certain action mean that the hospital organization took action through or on behalf of the hospital facility.

Line 1. Answer “Yes” if the hospital facility was first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year.

Line 2. Answer “Yes” if the hospital facility was acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year. If “Yes,” provide details in Section C.

Lines 3 through 12c. A CHNA is an assessment of the significant health needs of the community. To meet the requirements of section 501(r)(3), a CHNA must take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health, and must be made widely available to the public. Each hospital facility must conduct a CHNA at least once every 3 years, and adopt an implementation strategy to meet the community health needs identified through such CHNA.

Line 3. Answer “Yes” if the hospital facility conducted a CHNA in the current tax year or in either of the 2 immediately preceding tax years . If “Yes,” indicate what the CHNA describes by

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checking all applicable boxes. If the CHNA describes information that doesn't have a corresponding checkbox, check line 3j, “Other,” and describe this information in Part V, Section C. If “No,” skip to line 12.

Line 3a. Check this box if the CHNA report defines the community served by the hospital facility and a description of how the community was determined.

Line 3c. Check this box if the CHNA report describes the resources potentially available to address the significant health needs identified through the CHNA, including existing health care facilities and resources within the community that are available to respond to the health needs of the community.

Line 3d. Check this box if the CHNA report describes the process and methods used to conduct the CHNA.

Line 3e. In Part V, Section C, indicate if the significant health needs are a prioritized description of the significant health needs of the community and identified through the CHNA. If not, explain how the health needs identified will be prioritized.

Line 3g. Check this box if the CHNA report describes the process and criteria used in identifying certain health needs as significant and prioritizing those significant health needs.

Line 3h. Check this box if the CHNA report describes how the hospital facility solicited and took into account input received from persons who represent the broad interests of the community it serves.

Line 3i. Check this box if the CHNA report describes the evaluation of the impact of any actions that were taken, since the hospital facility finished conducting its immediately preceding CHNA, to address the significant health needs identified in the hospital facility’s prior CHNA(s).

Line 5. Answer “Yes” if the hospital facility took into account input from persons who represent the broad interests of the community served by the hospital facility, including at least one state, local, tribal, or regional governmental public health department (or equivalent department or agency), or a State Office of Rural Health described in section 338J of the Public Health Service Act (section 254r), with knowledge, information, or expertise relevant to the health needs of that community, members of medically underserved, low-income, and minority populations in the community served by the hospital facility, or individuals or organizations serving or representing the interests of such populations; and written comments received on the hospital facility's most recently conducted CHNA and most recently adopted implementation strategy.

If the organization checked “Yes,” summarize in Part V, Section C, in general terms, how and over what time period such input was provided (for example, whether through meetings, focus groups, interviews, surveys, or written comments, and between what dates); the names of any organizations providing input; and describe the medically underserved, low-income, or minority populations being represented by organizations or individuals that provided input. A CHNA report doesn't need to name or otherwise identify any specific individual providing input on the CHNA. In the event a hospital facility solicits, but cannot obtain, input from a source required by line 5, the hospital facility's CHNA report must also describe the hospital facility's efforts to solicit input from such source.

Line 6a. Answer “Yes” if the hospital facility's CHNA was conducted with one or more other hospital facilities. “One or more other hospital facilities” includes related and unrelated hospital facilities. If “Yes,” list in Part V, Section C, the other hospital facilities with which the hospital facility conducted its CHNA.

Line 6b. Answer “Yes” if the hospital facility's CHNA was conducted with one or more organizations other than hospital facilities. If “Yes,” list in Part V, Section C, the other organizations with which the hospital facility conducted its CHNA.

Line 7. Answer “Yes” if the hospital facility made its most recently conducted CHNA widely available to the public. If “Yes,” indicate how the hospital facility made the CHNA widely available to the public by checking all applicable boxes. If the hospital facility made the CHNA widely available to the public by means other than those listed on lines 7a through 7c, check line 7d, “Other,” and describe these means in Part V, Section C.

Line 7a. Check this box if the CHNA was made available on the hospital facility’s website or the hospital organization’s website. If line 7a is checked, list in the space provided the direct website address, or URL, where the CHNA can be accessed.

Line 7b. Check this box if the CHNA was made available on a website other than the hospital facility’s website or the hospital organization’s website. If line 7b is checked, list in the space provided the direct website address, or URL, where the CHNA can be accessed.

Line 7c. Check this box if a paper copy of the CHNA was made available for public inspection upon request and without charge at the hospital facility.

Line 8. Answer “Yes” if the hospital facility adopted an implementation strategy to meet the significant health needs identified through its most recently conducted CHNA. If “No,” skip to line 11.

Line 10. Answer “Yes” if the hospital facility’s most recently adopted implementation strategy is posted on a website. If “Yes,” answer line 10a. If “No,” skip to line 10b.

Line 10a. List in the space provided the direct website address, or URL, where the implementation strategy can be accessed and skip to line 11.

Line 10b. Answer “Yes” if the hospital facility’s most recently adopted implementation strategy is attached.

Line 11. Explain in Part V, Section C, how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that aren't being addressed together with the reasons why such needs aren't being addressed. For example, a hospital facility might identify limited financial or other resources as reasons why it didn't take action to address a need identified in its most recently conducted CHNA.

Line 12a. Answer “Yes” if the organization was liable, at any time during the tax year, for the $50,000 excise tax incurred under section 4959 for failure to conduct a CHNA and adopt an implementation strategy as required under section 501(r)(3). Section 501(r)(3) requires each hospital facility to conduct a CHNA, in the tax year or in either of the immediately preceding 2 tax years, that takes into account input from persons who represent the broad interests of the community served by the facility, including those with special knowledge of or expertise in public health, and to make the CHNA widely available to the public. Section 501(r)(3) also requires each hospital facility to adopt an implementation strategy to meet the community health needs identified through its CHNA.

Line 12b. Answer “Yes” to line 12b if the organization answered “Yes” to line 12a and filed Form 4720, Return of Certain Excise Taxes Under Chapters 41 and 42 of the Internal Revenue Code, to report the section 4959 excise tax it incurred. Answer “Yes” if the organization filed Form 4720 during the tax year or after the tax year but prior to the filing of this return.

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Line 12c. If line 12b is “Yes,” report the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities that incurred the tax.

Lines 13 through 16. See the instructions for Part I, line 1, of Schedule H (Form 990) for the definition of “financial assistance policy” (FAP). Answer “Yes” only if the FAP applies to all emergency and other medically necessary care provided by the hospital facility, including all such care provided in the hospital facility by a substantially related entity.

Line 13. Answer “Yes” if, during the tax year, the hospital facility had a written FAP that explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care. If “Yes,” indicate the eligibility criteria explained in the FAP by checking all applicable boxes. If the FAP describes information that doesn't have a corresponding checkbox, check line 13h, “Other,” and describe this information in Part V, Section C.

Line 13a. See the instructions for Part I, line 3a, of Schedule H (Form 990) for the definition of “Federal Poverty Guidelines” (FPG). Check this box if, during the tax year, the hospital facility had a written FAP that used FPG for determining eligibility for free or discounted medical care. Show the specific threshold by writing in the percentage amount. If the hospital facility used FPG for determining eligibility for free or discounted medical care, but not both free and discounted medical care, enter “000” in the percentage amount for which FPG wasn't used.

Line 13b. Check this box if the hospital facility used an income level other than FPG and explain in Part V, Section C, what criteria the hospital facility used to determine eligibility for free or discounted care (including whether the hospital facility used the income level of patients, patients’ families, or patients’ guarantors as a factor).

Line 13c. Check this box if the hospital facility used the asset level of patients, patients' families, or patients' guarantors as a factor in determining eligibility for financial assistance.

Line 13d. Check this box if the hospital facility considered whether patients were “medically indigent,” as defined in the instructions for Part I, line 4, of Schedule H (Form 990), in determining eligibility for financial assistance.

Line 13e. Check this box if the hospital facility used the insurance status of patients, patients' families, or patients' guarantors as a factor in determining eligibility for financial assistance.

Line 13g. Check this box if the hospital facility considered residency as a factor in determining eligibility for financial assistance.

Line 14. Answer “Yes” if, during the tax year, the hospital facility had a written FAP that explained the basis for calculating amounts charged to patients.

Line 15. Answer “Yes” if, during the tax year, the hospital facility had a written FAP that explained the method for applying for financial assistance. If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including the accompanying instructions) explained the method for applying for financial assistance by checking all applicable boxes. If the FAP explains a method(s) for applying for financial assistance other than those listed on lines 15a through 15d, check line 15e, “Other,” and explain the method(s) in Part V, Section C.

Line 15a. Check this box if the hospital facility described all of the information it may require an individual to provide as part of the application.

Line 15b. Check this box if the hospital facility described all of the supporting documentation it may require an individual to submit as part of the application.

Line 15c. Check this box if the hospital facility provided contact information of hospital facility staff that the hospital facility has identified as an available source of assistance with FAP applications.

Line 15d. Check this box if the hospital facility provided the contact information of a nonprofit organization or government agency that the hospital facility has identified as an available source of assistance with FAP applications.

Line 16. Answer “Yes” if, during the tax year, the FAP was widely publicized within the community served by the hospital facility. If “Yes,” indicate how the hospital facility publicized the policy by checking all applicable boxes. If the hospital facility publicized the policy within the community served by the hospital facility by means that aren't listed on lines 16a–16i, check line 16j, “Other,” and describe in Part V, Section C, how the FAP was publicized within the community served by the hospital facility.

Line 16g. Check this box if individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or other measures reasonably calculated to attract patients' attention.

Line 16i. Check this box if the FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s) spoken by limited-English proficiency (LEP) populations, such as by translating these documents into the language(s) spoken by each LEP language group that constitutes the lesser of 1,000 individuals or 5% of the community served by the hospital facility or the population likely to be affected or encountered by the hospital facility.

Line 16j. “Other” measures to publicize the policy within the community served by the hospital facility may include, but aren't limited to, having registration personnel refer uninsured and/or low-income patients to financial counselors to discuss the policy. Check the box for line 16j if, instead of the detailed policy, the hospital facility provided a summary of the policy in a manner listed on lines 16a–16i.

Line 17. Answer “Yes” if, during the tax year, the hospital facility had either a separate written billing and collections policy or a written FAP that described any actions that the hospital facility (or other authorized party) may take related to obtaining payment of a bill for medical care, including, but not limited to, any extraordinary collection actions (ECAs); the process and time frames the hospital facility (or other authorized party) uses in taking those actions (including, but not limited to, the reasonable efforts it will make to determine whether an individual is FAP-eligible before engaging in ECAs); and the office, department, committee, or other body with the final authority or responsibility for determining that the hospital facility has made reasonable efforts to determine whether an individual is FAP-eligible and may therefore engage in ECAs against the individual.

Lines 18 and 19. “Other similar actions” don't include sending the patient a bill.

Note: Section 501(r)(6) requires a hospital facility to forego ECAs before the facility has made reasonable efforts to determine the individual's eligibility under the facility's FAP.

Line 18. Indicate what actions against an individual the hospital facility was permitted to take during the tax year under its policies before making reasonable efforts to determine the

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individual's eligibility under the facility's FAP by checking all applicable boxes.

Line 18a. Check this box if the FAP permitted reporting adverse information about the individual to consumer credit reporting agencies or credit bureaus.

Line 18b. Check this box if the FAP permitted selling an individual's debt to another party. Don't check the box if, prior to the sale, the hospital facility entered into a legally binding written agreement with the purchaser of the debt pursuant to which the purchaser is prohibited from engaging in any ECAs to obtain payment for the care; the purchaser is prohibited from charging interest on the debt in excess of the rate in effect under section 6621(a)(2) at the time the debt is sold; the debt is returnable to or recallable by the hospital facility upon a determination by the hospital facility or the purchaser that the individual is FAP-eligible; and, if the individual is determined to be FAP-eligible and the debt isn't returned to or recalled by the hospital facility, the purchaser is required to adhere to procedures specified in the agreement that ensure that the individual doesn't pay, and has no obligation to pay, the purchaser and the hospital facility together more than the individual is personally responsible for paying as a FAP-eligible individual.

Line 18c. Check this box if the FAP permitted deferring or denying, or requiring a payment before providing, medically necessary care because of an individual’s nonpayment of one or more bills for previously provided care covered under the hospital facility’s FAP.

Line 18d. Check this box if the FAP permitted actions that require a legal or judicial process, including but not limited to placing a lien on an individual's real property; attaching or seizing an individual's bank account or any other personal property; commencing a civil action against an individual; causing an individual's arrest; causing an individual to be subject to a writ of body attachment; or garnishing an individual's wages. Don't include any liens that a hospital facility is entitled to assert under state law on the proceeds of a judgment, settlement, or compromise owed to an individual (or the individual’s representative) as a result of personal injuries for which the hospital facility provided care and if it files a claim in a bankruptcy proceeding.

Line 18e. If a hospital facility's policies permitted the facility to take an action or actions against an individual during the tax year similar to those listed on lines 18a through 18d before making reasonable efforts to determine the individual's eligibility under the facility's FAP, check line 18e, “Other similar actions,” and describe those actions in Part V, Section C.

Line 18f. If the hospital facility was permitted to make no such actions, check the box for line 18f, “None of these actions or other similar actions were permitted.”

Line 19. Indicate any of the actions against an individual that the hospital facility took during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP by checking all applicable boxes. For purposes of this question, actions against an individual include actions to obtain payment for the care against any other individual who has accepted or is required to accept responsibility for the individual’s hospital bill for the care, and actions of the hospital facility include actions of any purchaser of the individual’s debt, any debt collection agency or other party to which the hospital facility has referred the individual’s debt, or any substantially related entity.

Line 19a. Check this box if the hospital facility reported adverse information about the individual to consumer credit reporting agencies or credit bureaus before making reasonable efforts to determine the individual's eligibility under the facility's FAP.

Line 19b. Check this box if the hospital facility sold an individual's debt to another party before making reasonable efforts to determine the individual's eligibility under the facility's FAP. Don't check the box if, prior to the sale, the hospital facility entered into a legally binding written agreement with the purchaser of the debt pursuant to which the purchaser is prohibited from engaging in any ECAs to obtain payment for the care; the purchaser is prohibited from charging interest on the debt in excess of the rate in effect under section 6621(a)(2) at the time the debt is sold; the debt is returnable to or recallable by the hospital facility upon a determination by the hospital facility or the purchaser that the individual is FAP-eligible; and, if the individual is determined to be FAP-eligible and the debt isn't returned to or recalled by the hospital facility, the purchaser is required to adhere to procedures specified in the agreement that ensure that the individual doesn't pay, and has no obligation to pay, the purchaser and the hospital facility together more than the individual is personally responsible for paying as a FAP-eligible individual.

Line 19c. Check this box if the hospital facility deferred or denied, or required a payment before providing, medically necessary care because of an individual’s nonpayment of one or more bills for previously provided care covered under the hospital facility’s FAP.

Line 19d. Check this box if the hospital facility took legal action or pursued a judicial process, including but not limited to placing a lien on an individual's real property; attaching or seizing an individual's bank account or any other personal property; commencing a civil action against an individual; causing an individual's arrest; causing an individual to be subject to a writ of body attachment; or garnishing an individual's wages. Don't include any liens that a hospital facility is entitled to assert under state law on the proceeds of a judgment, settlement, or compromise owed to an individual (or the individual’s representative) as a result of personal injuries for which the hospital facility provided care and if it filed a claim in a bankruptcy proceeding.

Line 19e. If the hospital facility took an action or actions against an individual during the tax year similar to those listed in lines 19a through 19d before making reasonable efforts to determine the individual's eligibility under the facility's FAP, check line 19e, “Other similar actions,” and describe those actions in Part V, Section C.

Line 20. Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in lines 19a through 19d or described in Part V, Section C (describing “other similar actions” checked in line 18e or line 19e), by checking all applicable boxes in lines 20a through 20d. If the hospital facility made efforts other than those listed in lines 20a through 20d before initiating any of the actions listed in lines 19a through 19d or described in Part V, Section C (describing "other similar actions" checked in line 18e or line 19e), check the box for line 20e, “Other,” and describe in Part V, Section C.

If the hospital facility made no such efforts before initiating any of the actions listed (whether or not checked) in lines 19a through 19d or described in Part V, Section C (describing “other similar actions” checked in line 18e or line 19e), check the box for line 20f, “None of these efforts were made.”

Line 20a. Check this box if the hospital facility or other authorized party provided individuals with a written notice that indicated financial assistance is available for eligible individuals, identified the ECA(s) that the hospital facility (or other authorized party) intended to initiate to obtain payment for the care, and stated a deadline after which such ECA(s) may be initiated that was no earlier than 30 days after the date that the written notice

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was provided, along with a plain language summary of the FAP. If not, describe in Section C.

Line 20b. Check this box if the hospital facility or other authorized party made a reasonable effort to orally notify individuals about the hospital facility’s FAP and about how the individual may obtain assistance with the FAP application process at least 30 days before initiating ECAs. If not, describe in Section C.

Line 20c. Check this box if (1) when an individual submitted an incomplete FAP application during the application period, the hospital facility or other authorized party notified the individual about how to complete the FAP application and gave the individual a reasonable opportunity to do so in accordance with Regulations section 1.501(r)-6(c)(5); and (2) when an individual submitted a complete FAP application during the application period, the hospital facility or other authorized party determined whether the individual is FAP-eligible for the care and otherwise met the requirements described in Regulations section 1.501(r)-6(c)(6). If not, describe in Section C.

Line 20d. Check this box if the hospital facility or other authorized party made presumptive eligibility determinations in accordance with Regulations section 1.501(r)-6(c)(2). If not, describe in Section C.

Line 21. Answer “Yes” if, during the tax year, the hospital facility had in place a written policy about emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals without regard to their eligibility under the hospital facility's FAP. A hospital facility's emergency medical care policy doesn't meet this requirement unless it prohibits the hospital facility from engaging in actions that discourage individuals from seeking emergency medical care, such as by demanding that emergency department patients pay before receiving treatment for emergency medical conditions or by permitting debt collection activities that interfere with the provision, without discrimination, of emergency medical care. If “No,” indicate the reasons why the hospital facility didn't have a written nondiscriminatory policy relating to emergency medical care by checking all applicable boxes. If the reason the hospital facility didn't have a written nondiscriminatory policy relating to emergency medical care isn't listed in lines 21a through 21c, check line 21d, “Other,” and describe the reason(s) in Part V, Section C.

The hospital facility may check “Yes” if it had a written policy that required compliance with 42 U.S.C. 1395dd (Emergency Medical Treatment and Active Labor Act (EMTALA)).

For purposes of line 21, the term “emergency medical conditions” means:

(a) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

Placing the health of the individual (or, for a pregnant woman, the health of the woman or the unborn child) in serious jeopardy,
Serious impairment to bodily functions, or
Serious dysfunction of any bodily organ or part; or

(b) For a pregnant woman who is having contractions:

That there is inadequate time to effect a safe transfer to another hospital before delivery, or
That transfer may pose a threat to the health or safety of the woman or the unborn child.

Lines 22–24. For purposes of lines 22–24, the term “FAP-eligible” means eligible for assistance under the hospital facility's FAP.

Line 22. Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care by checking the appropriate box.

Note: Under section 501(r)(5), the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care are the amounts generally billed to individuals who have insurance covering such care.

Line 23. Answer “Yes” if, during the tax year, the hospital facility charged any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care. If “Yes,” explain in Part V, Section C, except as provided in the next paragraph.

The hospital facility may check “No” if it charged more than the amounts generally billed to individuals who had insurance covering such care to an individual if the charge in excess of amounts generally billed (AGB) wasn't made or requested as a pre-condition of providing medically necessary care to the FAP-eligible individual; as of the time of the charge, the FAP-eligible individual hadn't submitted a complete FAP application and hadn't otherwise been determined by the hospital facility to be FAP-eligible for the care; and, if the individual subsequently submits a complete FAP application and is determined to be FAP-eligible for the care, the hospital facility refunds any amount that exceeds the amount the individual is determined to be personally responsible for paying as a FAP-eligible individual, unless such excess amount is less than $5.

Line 24. Answer “Yes” if, during the tax year, the hospital facility charged any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual, and explain in Part V, Section C, the circumstances in which it used gross charges. A bill that itemizes a reduction applied to a gross charge for a service doesn't need to be reported if the amount charged to the individual for such service is less than the amount of the gross charge.

The hospital facility may check “No” if it charged gross charges for any medical care covered under the FAP if the charge in excess of AGB wasn't made or requested as a pre-condition of providing medically necessary care to the FAP-eligible individual; as of the time of the charge, the FAP-eligible individual hadn't submitted a complete FAP application and hadn't otherwise been determined by the hospital facility to be FAP-eligible for the care; and, if the individual subsequently submits a complete FAP application and is determined to be FAP-eligible for the care, the hospital facility refunds any amount that exceeds the amount the individual is determined to be personally responsible for paying as a FAP-eligible individual, unless such excess amount is less than $5.

Section C Use Section C to provide descriptions required for Part V, Section B, lines 2, 3e, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24, as applicable. Complete a separate Section C for each hospital facility or facility reporting group for which the organization completed Section B; complete one Section C for each Section B.

If completing Section C for a single hospital facility, identify the specific name and line number (from Schedule H (Form

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990), Part V, Section A) of the hospital facility to which the responses in Section C relate.

If completing Section C for a facility reporting group, list the reporting group letter, then list each hospital facility in that group separately by name and line number (from Section A). For each hospital facility, provide the descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.), and name of hospital facility.

Line 2: If the organization checked “Yes,” provide details regarding the hospital facility(ies) acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year.
Line 3j: If the organization checked line 3j, describe the other content included in the hospital facility's CHNA report.
Line 5: If the organization checked “Yes,” summarize, in general terms, how and over what time period such input was provided (for example, whether through meetings, focus groups, interviews, surveys, or written comments, and between what dates); the names of any organizations providing input; and describe the medically underserved, low-income, or minority populations being represented by organizations or individuals that provided input. A CHNA report doesn't need to name or otherwise identify any specific individual providing input on the CHNA. In the event a hospital facility solicits, but cannot obtain, input from a source required by line 5, the hospital facility's CHNA report must also describe the hospital facility's efforts to solicit input from such source.
Line 6a: If the organization checked “Yes,” list the other hospital facilities with which the hospital facility conducted its CHNA.
Line 6b: If the organization checked “Yes,” list the organizations other than hospital facilities with which the hospital facility conducted its CHNA.
Line 7d: If the organization checked line 7d, describe the other means that the hospital facility used to make its CHNA widely available.
Line 11: Describe how the hospital facility is addressing the significant health needs identified in its most recently conducted CHNA and any such needs that aren't being addressed together with the reasons why such needs aren't being addressed.
Line 21d: If the organization checked line 21d, describe the other reasons why the hospital facility didn't have a written nondiscriminatory policy for emergency medical care.
Line 23: If the organization answered “Yes” to line 23, explain the circumstances in which the hospital facility charged any FAP-eligible individual more than the amounts generally billed to individuals who had insurance covering such care.
Line 24: If the organization answered “Yes” to line 24, explain the circumstances in which the hospital facility charged any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual.

Section D Complete Part V, Section D, by listing all of the non-hospital health care facilities that the organization operated during the tax year . A facility is operated by an organization whether it is operated directly by the organization or through a disregarded entity or joint venture treated as a partnership. List each of these facilities in order of size from largest to smallest, measured by a reasonable method (for example, the number of patients served or total revenue per facility). For each non-hospital health care facility, list its name and address and describe the type of facility. These types of facilities may include, but aren't limited to, rehabilitation and other outpatient clinics, diagnostic centers, mobile clinics, and skilled nursing facilities.

List the total number of non-hospital health care facilities that the organization operated during the tax year.

If the organization needs additional space to list all of its non-hospital health care facilities, it should duplicate Section D and use as many duplicate copies of Section D as needed, number each page, and renumber the line numbers in the left-hand margin (for example, an organization with 15 such facilities should renumber lines 1–5 on the 2nd page as lines 11– 15).

Line 3j: If the organization checked line 3j, describe the other content included in the hospital facility's CHNA report.
Line 5: If the organization checked “Yes,” summarize, in general terms, how and over what time period such input was provided (for example, whether through meetings, focus groups, interviews, surveys, or written comments, and between what dates); the names of any organizations providing input; and describe the medically underserved, low-income, or minority populations being represented by organizations or individuals that provided input. A CHNA report doesn't need to name or otherwise identify any specific individual providing input on the CHNA. In the event a hospital facility solicits, but cannot obtain, input from a source required by line 5, the hospital facility's CHNA report must also describe the hospital facility's efforts to solicit input from such source.
Line 2: If the organization checked “Yes,” provide details regarding the hospital facility(ies) acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year.
Line 13b: Describe the criteria the hospital facility used to determine eligibility for free or discounted care (including whether the hospital facility used the income level of patients, patients’ families, or patients’ guarantors as a factor).
Line 13h: If the organization checked line 13h, describe the other eligibility criteria used.
Line 15e: If the organization checked line 15e, describe the other methods for applying for financial assistance.
Line 16j: If the organization checked line 16j, describe other ways that the hospital facility publicized its FAP.
Line 18e: If the organization checked line 18e, describe the other similar actions that the hospital facility was permitted to take under its policies during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP.
Line 19e: If the organization checked line 19e, describe the other similar actions that the hospital facility was permitted to take under its policies during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP.
Line 20e: If the organization checked line 20e, describe the other efforts that the hospital facility made.
Line 21c: If the organization checked line 21c, describe how the hospital facility limited who was eligible to receive care for emergency services.
Line 13b: Describe the criteria the hospital facility used to determine eligibility for free or discounted care (including
Line 6a: If the organization checked “Yes,” list the other hospital facilities with which the hospital facility conducted its CHNA.
Line 6b: If the organization checked “Yes,” list the organizations other than hospital facilities with which the hospital facility conducted its CHNA.
Line 7d: If the organization checked line 7d, describe the other means that the hospital facility used to make its CHNA widely available.
Line 11: Describe how the hospital facility is addressing the significant health needs identified in its most recently conducted CHNA and any such needs that aren't being addressed together with the reasons why such needs aren't being addressed.

12 2025 Instructions for Schedule H (Form 990)

whether the hospital facility used the income level of patients, patients’ families, or patients’ guarantors as a factor).

Line 13h: If the organization checked line 13h, describe the other eligibility criteria used.
Line 15e: If the organization checked line 15e, describe the other methods for applying for financial assistance.
Line 16j: If the organization checked line 16j, describe other ways that the hospital facility publicized its FAP.
Line 18e: If the organization checked line 18e, describe the other similar actions that the hospital facility was permitted to take under its policies during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP.
Line 19e: If the organization checked line 19e, describe the other similar actions that the hospital facility was permitted to take under its policies during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP.
Line 20e: If the organization checked line 20e, describe the other efforts that the hospital facility made.
Line 21c: If the organization checked line 21c, describe how the hospital facility limited who was eligible to receive care for emergency services.

subtracted for purposes of calculating the percentages in this column).

Part I, line 7. Provide an explanation of the costing methodology used to calculate the amounts entered for each line in the table. If a cost accounting system was used, indicate whether the cost accounting system addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, or self-pay). Also, indicate if a cost-to-charge ratio was used for any of the figures in the table. Describe whether this cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges, and, if not, what kind of cost-to-charge ratio was used and how it was derived. If some other costing methodology was used besides a cost accounting system, cost-to-charge ratio, or a combination of the two, describe the method used.

Line 21d: If the organization checked line 21d, describe the other reasons why the hospital facility didn't have a written nondiscriminatory policy for emergency medical care.
Line 23: If the organization answered “Yes” to line 23, explain the circumstances in which the hospital facility charged any FAP-eligible individual more than the amounts generally billed to individuals who had insurance covering such care.
Line 24: If the organization answered “Yes” to line 24, explain the circumstances in which the hospital facility charged any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual.