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A TRUE COPY <br />ii) Is the tax uniform across all entities being taxed? Based on 42 CFR § 433.68, a healtIFICATION ON LAST PAGE <br />related tax will be considered to be imposed uniformly even if it excludes Medicaid or W L. BUTLER, CLERK <br />Medicare payments (in whole or in part), or both; or in the case of health care -related tax <br />based on revenue or receipts with respect to a class of items or services, if it excludes either <br />Medicaid or Medicare revenue with respect to a class of items or services, or both. The <br />exclusion of Medicaid revenue must be applied uniformly to all providers being taxed. <br />If no, please explain <br />iii) Is the tax generally redistributive and a waiver of the broad-based or uniform tax requirement <br />was granted in accordance with 42 CFR §433.68(e)? <br />iv) Does the tax program comply with the hold harmless provisions included in 42 CFR § <br />433.68(f)? <br />If no, please explain <br />v) Does every tax paying entity receive a supplemental payment equal to or exceeding its tax cost? <br />If yes, please explain <br />6. Please answer the following regarding provider funds received from the healthcare entity and/or other <br />health care entities. <br />a. Are provider voluntary payments or in-kind services received by the organization as defined in 42 <br />CFR § 433>52? <br />No <br />b. How much of the organization's revenue is received from provider -related donations (Provide the <br />total revenue and the provider -related donation amounts)? <br />Amount <br />Total Revenue $ - <br />Provider Related Donations $ - <br />c. Do individual provider donations exceed $5,000 per year or $50,000 per year for a health care <br />organizational entity? <br />No <br />