Form C-5 "New Jersey Acute Care Hospitals Cost Reports - Other Operating Income Non-operating Income" - New Jersey

What Is Form C-5?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download Form C-5 "New Jersey Acute Care Hospitals Cost Reports - Other Operating Income Non-operating Income" - New Jersey

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NEW JERSEY ACUTE CARE HOSPITALS
2020
COST REPORTS
OTHER OPERATING INCOME
NON-OPERATING INCOME ($000’S)
C-5
Hospital: __________________________________________
Hospital Number: |_____|_____|_____|_____|
Do not change any preprinted
wording on this form.
Cost
Items Included
Revenue
Expense
Gain/Loss
Center
As Expense Recover
($000’s)
($000’s)
($000’s)
(1)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
(2)
20
Total Items Included as Expense Recovery
Items Not Included
Revenue
Expense
Gain/Loss
As Expense Recover
($000’s)
($000’s)
($000’s)
(1)
CASE “A”
(3)
21
Research & Education Income (Non-Approved)
22
Sale of medical Supplies to Other Facility
23
Medical Records Transcription
24
25
26
Total Case “A”
CASE “B”
(3)
27
Organ Donations
28
Provision of Services to Another Health Facility
29
Physicians’ Fees Returned to the Hospital
30
Research and Education income (Approved)
31
Salaried House Physicians
32
Pension Reversions
33
34
Total Case “B”
CASE “C”
(3)
35
Blood and Plasma
36
Gift and Coffee Shops
37
Services to Staff Physicians
38
Outpatient/Home Dialysis
39
MICU
40
41
42
43
Total Case “C”
44
Total of Lines 26, 34, and 43 Gain/(Loss) Column
45
Grand Total (Lines 20 and 44)
46
Total of Other Operating and Non-Operating Income per Audited F/S
47
Difference (Line 45 minus Line 46)
(4)
(1)
All Expense recoveries in Form C, Column L related to grant operating income must be itemized by title of grants.
(2)
Should agree with Form C, Page 2 of 2, Line 53, Expense Recovery column (Column L).
(3)
Refer to Financial Elements, NJAC 8:31B-4.61 for definitions of Cases “A,” “B,” and “C.”
(4)
If Line 46 does not agree with Line 45, the hospital must reconcile the difference (Line 47) by attaching an itemized, detailed
explanation.
NEW JERSEY ACUTE CARE HOSPITALS
2020
COST REPORTS
OTHER OPERATING INCOME
NON-OPERATING INCOME ($000’S)
C-5
Hospital: __________________________________________
Hospital Number: |_____|_____|_____|_____|
Do not change any preprinted
wording on this form.
Cost
Items Included
Revenue
Expense
Gain/Loss
Center
As Expense Recover
($000’s)
($000’s)
($000’s)
(1)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
(2)
20
Total Items Included as Expense Recovery
Items Not Included
Revenue
Expense
Gain/Loss
As Expense Recover
($000’s)
($000’s)
($000’s)
(1)
CASE “A”
(3)
21
Research & Education Income (Non-Approved)
22
Sale of medical Supplies to Other Facility
23
Medical Records Transcription
24
25
26
Total Case “A”
CASE “B”
(3)
27
Organ Donations
28
Provision of Services to Another Health Facility
29
Physicians’ Fees Returned to the Hospital
30
Research and Education income (Approved)
31
Salaried House Physicians
32
Pension Reversions
33
34
Total Case “B”
CASE “C”
(3)
35
Blood and Plasma
36
Gift and Coffee Shops
37
Services to Staff Physicians
38
Outpatient/Home Dialysis
39
MICU
40
41
42
43
Total Case “C”
44
Total of Lines 26, 34, and 43 Gain/(Loss) Column
45
Grand Total (Lines 20 and 44)
46
Total of Other Operating and Non-Operating Income per Audited F/S
47
Difference (Line 45 minus Line 46)
(4)
(1)
All Expense recoveries in Form C, Column L related to grant operating income must be itemized by title of grants.
(2)
Should agree with Form C, Page 2 of 2, Line 53, Expense Recovery column (Column L).
(3)
Refer to Financial Elements, NJAC 8:31B-4.61 for definitions of Cases “A,” “B,” and “C.”
(4)
If Line 46 does not agree with Line 45, the hospital must reconcile the difference (Line 47) by attaching an itemized, detailed
explanation.