Arizona > Workers Comp
Self-Insured Hospital Report - Arizona
| Self-Insured Hospital Report Form. This is a Arizona form and can be used in Workers Comp . |
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S E L F - I N S U R E D HOSPITAL R E P O R T F O R 2 0 0 6 THE INDUSTRIAL COMMISSION OF ARIZONA SELF INSURED NAME: PERIOD COVERED: To INSTRUCTIONS ON SEPARATE PAGE This report is subject to verification by ICA auditors Operating Expenses Line 1 Line 2 Line 3 Line 4 Line 5 Line 6 Line 7 Line 8 Payroll Employee Benefits (including taxes, insurance, etc.) Surgeon's and Physicians' fees Pharmacy Miscellaneous supplies and services Depreciation Utilities Licenses and taxes (fill in the bolded cells) Total Operating Expenses (total of lines 1, 2, 3, 4, 5, 6, 7 & 8) Revenue and cash flow: Charges for services: Line 9 Line 10 Line 11 Line 12 Line 13 Line 14 In-patient care Out-patient care Miscellaneous revenue Employee paid premiums Employer paid premiums Total Revenue (total of lines 9, 10, 11, 12 & 13) Line 15 Cash balance at beginning of year. Line 16 Total cash available (total of lines 14 and 15) Line 17 Investments (cash basis only) Line 18 Operating expenses (cash basis only) Line 19 Other disbursements (specify) Net cash balance at end of year (line 16 less lines 17, 18 and 19) 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. Officer Signature: Officer Name: Officer Title: Date of Officer Signature: Name and Title of Person completing form if different from above: Date Form Completed: American LegalNet, Inc. www.FormsWorkflow.com Primary Email Address: Alternative Email Address: FAX Number: Primary Phone Number: Alternative Phone Number:
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