Annual Revenues from Patient Care Worksheet Instructions

Based on the instructions below, some providers who apply for the Provider Relief Fund Phase 4 are required to submit the Annual Revenues from Patient Care Worksheet (XSLX - 433 KB). The instructions indicate how and where various data elements are to be entered on the worksheet. Providers must upload the completed worksheet during the application process via the PRF Application and Attestation Portal.

For additional assistance with the application process, contact the Provider Support Line at 866-569-3522, for TTY dial 711. Hours of operation are 8 a.m. to 10 p.m. CT, Monday through Friday.

1. Applicant Name — Enter the name of the entity applying.
2. Tax Identification Number — Enter the TIN without dashes.
3. Applicant's Total Annual Revenues [Auto-populated] — This amount automatically populates from sum of subsidiary/billing TINs in Total Revenues (Cell E14).
   Note: This amount must match the amount reported in Field 10 Total Annual Revenues in the application.
4. Applicant's Annual Net Patient Care Revenues [Auto-populated] — This amount automatically populates from sum of subsidiary/billing TINs in Net Patient Care Revenues (Cell C14).
   Note: This amount must match the amount reported in Field 12 Total Net Patient Care Revenues in the application.
5. Gross Revenues [Auto-populated] — This amount is the gross revenues minus discounts and allowances as shown on the applicant's federal income tax return or consolidated audited financial statements. This amount is calculated as the sum of Total Applicant Revenues (Cell E14) and Total Revenues that are not part of the application (Cell F14).
6. Annual Revenues Information
   1. Subsidiary/Billing TIN — Applicants must include all billing TINs under the filing TIN that provide patient care.
   2. Subsidiary/Billing TIN Name — Include name of subsidiary/billing TIN as it appears in the applicant's federal income tax return.
   3. Net Patient Care Revenues — Enter the amount of revenues for the delivery of services to patients for the subsidiary/billing TIN.
   4. Non-Patient Care Revenues — Enter the amount of revenues not associated with the delivery of services to patients for the subsidiary/billing TIN.
   5. Total Applicant Revenues [Auto-populated] — This amount is the total revenues for the subsidiary/billing. This automatically calculates the sum of the subsidiary/billing TIN’s Net Patient Care Revenues and Non-Patient Care Revenues.
   6. Total revenues that are not part of the application, if applicable — Applicants that are part of a consolidated tax return or consolidated audited financial statement must enter the total revenues included federal income tax return or consolidated audited financial statements that are not attributable to the applicant.