Medicaid Disproportionate Share Hospital Annual Reporting

Definition of Uncompensated Care:

A

B

B

C

D

E

F

G

H

I

J

K

L

M

N

O

Hospital Name

Medicare Provider

Medicaid Provider

Type of

Type of

Medicaid Inpatient

Low Income

DSH

Regular

Medicaid Managed

Supplemental/

Indigent

Transfers

Total Cost

Uncompensated

Medicaid Eligible

Number

Number

Hospital

Hospital

Utilization

Utilization

Payments

Medicaid Rate

Care Organization

Enhanced Medicaid

Care Revenue

of Care

Care Costs

& Uninsured

Ownership

Rate

Rate

Payments

Payments

Payments

Individuals

OMB Approved # 0938-0746 (mm/yyyy)