NJ Home | Services A to Z | Departments/Agencies | FAQs
Search
DOH Forms
Additional Health Department Forms

Forms for Hospital Finance and Charity Care


New Jersey Acute Care Hospitals Cost Reports
Instructions
Form # Title PDF/WORD Instruction/ Comments
ACH NJ Acute Care Hospitals Cost Reports  
 		 Instructions
pdf 76k
doc 134k  

Volumes and Statistics
Form # Title PDF/WORD Instruction/ Comments
B Patient Care Volumes pdf 12k
doc 32k		  
B-5 Other Statistical Data (excluding SNF) pdf 10k
doc 25k		  
B-6 Outpatient Volumes By Payer & Outpatient Area pdf 12k
doc 42k		  

Cost and Related Reconciling Items
Form # Title PDF/WORD Instruction/ Comments
C Cost Center Data pdf 21k
doc 84k		  
C-3 Other Cost Details pdf 21k
doc 66k		  
C-4 Cost Center Budgets Reconciling Items (RIT) pdf 12k
doc 52k		  
C-5 Other Operating Income Non-Operating Income pdf 13k
doc 33k		  
C-6 Nursing Service Details pdf 8k
doc 26k		  
C-7 Major Moveable Equipment Price Level Depreciation Calculation pdf 10k
doc 27k		  

Capital Facilities
Form # Title PDF/WORD Instruction/ Comments
D-3 Capital Facilities Information pdf 11k
doc 26k		  

Revenue and Related Statistics
Form # Title PDF/WORD Instruction/ Comments
E Patient Care Gross Revenue pdf 16k
doc 67k		  
E-3 Allocation Statistics Matrix pdf 16k
doc 61k		  
E-4 Gross Revenue & Deductions From Gross Revenue pdf 11k
doc 29k		  
E-5 Net Inpatient Revenue Summary pdf 13k
doc 47k		  
E-6 Net Outpatient Revenue Summary pdf 13k
doc 47k		  
E-7 Outpatient Gross Revenue By Payer & Outpatient Area pdf 11k
doc 38k		  

Employee and Physician Data
Form # Title PDF/WORD Instruction/ Comments
H-2 Summary of Medical Professional Budget Component pdf 18k
doc 77k		  

Financial Statements
Form # Title PDF/WORD Instruction/ Comments
L-1 Balance Sheet pdf 20k
doc 56k		  
L-3 Statement of Operations pdf 15k
doc 35k		  
L-4 Statement of All Funds Cash Flow pdf 12k
doc 31k		  
Go to Hospital Finance and Charity Care     Additional Health Department Forms