Fill and Sign the Self Insured Hospital Report Form

Self Insured: Period covered: $ $ $ $ SELF-INSURED HOSPITAL REPORT THE INDUSTRIAL COMMISSION OF ARIZONA toREAD INSTRUCTIONS ON REVERSE SIDE 1. Operating expenses: 2. Payroll.3. Employee benefits (including payroll taxes, insurance, etc.) 4. Surgeons' and physicians' fees. 5. Pharmacy.6. Miscellaneous supplies and services. 7. Depreciation.8. Utilities.9. Licenses and taxes. 11.Total operating expenses 12. Revenue and cash flow: 13. Charges for services: 14.In-patient care. 15.Out-patient care. 16.Miscellaneous revenue. 17.Employee paid premiums. 18.Employer paid premiums. 19.Total revenue 20. Cash balance at beginning of year. 21. Total cash available (total of lines 19 and 20). 22. Investments (cash basis only). 23. Operating expenses (cash basis only). 24. Other disbursements (specify). 25. Net cash balance at end of year (line 21 less lines 22, 23 and 24). This report subject to verification by ICA auditors I certify this report is a true and complete account of operating expenses, revenue and cash flow, and net cash balances for the period stated. Signature:Title:Date: INSTRUCTIONS FOR HOSPITAL REPORT The ''Hospital Report'' is required of self-insurers that operate a hospital, pursuant to A.R.S. 23-1070.Lines1-11Show the total cost of operations of the hospital for the calendar year. Lines12- 19Show all revenue received by the hospital during the calendar year. Lines20-25Show the cash flow for the calendar year.