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pdfSERVICE ANNUAL SURVEY
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
2016 ANNUAL SERVICES REPORT
FORM
SA-62200A
(DRAFT)
Due Date
Need help or have questions?
Call 1-877-787-9860, option "1"
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or Visit
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YOUR RESPONSE IS REQUIRED
BY LAW. Title 13, United States
Code, Sections 131 and 182
authorizes this collection. Sections
224 and 225 requires businesses
and other organizations that
receive this questionnaire to
answer the questions and return
the report to the U.S. Census
Bureau. By Section 9 of the same
law, YOUR CENSUS REPORT
IS CONFIDENTIAL. It may be
seen only by persons sworn
to uphold the confidentiality of
Census Bureau information and
may be used only for statistical
purposes. Under the same law,
information that you report cannot
be used for taxation, regulation,
or investigation and are exempt
from release under the Freedom
of Information Act. Further, copies
of your response retained in
your files are immune from legal
process.
Return via Internet:
https://econhelp.census.gov/sas
Username:
Return via Mail:
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001
To view Survey Results:
census.gov/services
62202015
Password:
GENERAL INSTRUCTIONS
• Any significant change in this firm's operations should be noted in 17 .
• For establishments sold or acquired in 2016 or 2015, report data only for the period the establishments were
operated by this firm.
• Estimates are acceptable if book figures are not available.
• Enter "0" where applicable.
• Do not combine data for two or more detailed lines.
• Report data on an accrual basis, except for payroll.
$ Bil.
Mil.
Thou.
Dol.
• Dollars should be rounded to the nearest dollar.
1 030280456
• If a figure is $1,030,280,456 it should be reported as
Include:
• Data for all Services establishments (excluding data for Retail, Wholesale, Manufacturing, Mining, and
Construction operations) as defined by the survey coverage in 1 B.
• Data for auxiliary facilities primarily engaged in supporting services to those establishment(s) such as warehouses,
garages, central administrative offices, and repair services.
1
A. MAILING ADDRESS
Is this firm's name and mailing address the same as shown in the mailing address above?
Yes
No - Enter corrections in the mailing address above
PENALTY FOR FAILURE TO REPORT
CONTINUE ON PAGE 2
Form SA-62200A
1
Page 2
(DRAFT)
B. SURVEY COVERAGE
Did this firm provide the business activities described below?
Yes
No - Specify this firm's business activity
2
Not Applicable.
3
ORGANIZATIONAL CHANGE
A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in 2016 or 2015?
Yes
No - Go to
4
B. Which of the following organizational changes occurred in 2016 or 2015?
Check all that apply. If more than one organizational change occurred during the reporting period, explain in
Month
Acquisition
Sale
Merger
Day
17 .
Year
Date of organizational change . . . . . . . . . . . . . . . .
AND
Enter detailed information below
Divestiture
Name of company
EIN (9 digits)
Address (Number and street, P.O. Box, etc.)
62202023
City, town, village, etc.
State
ZIP Code
-
CONTINUE ON PAGE 3
Form SA-62200A
4
Page 3
(DRAFT)
REPORTING PERIOD
NOTE: Calendar year data are preferred. If it is not available, please report for the fiscal year that includes at least six
months of data for the 2016 and 2015 calendar year, or, other partial year data included in the 2016 and 2015 calendar
year.
What time period is covered by the data provided in this report?
2016
Beginning Date
Month Day
Year
Calendar year
Fiscal year - Report beginning and ending dates
2015
Beginning Date
Month Day
Year
. . .
Month
Ending Date
Day
Year
2016
Beginning Date
Month Day
Year
Month
Ending Date
Day
Year
2015
Beginning Date
Month Day
Year
Partial year - Report beginning and ending dates . . .
Month
5
Ending Date
Day
Year
Month
Ending Date
Day
Year
TAX STATUS
A. Is this establishment operated on a not-for-profit basis?
Yes
0031
No - Go to
6
B. Was all or part of the income of this establishment or organization exempt from Federal income
taxes under section 501 of the Internal Revenue Code?
Yes
0030
62202031
No
CONTINUE ON PAGE 4
Form SA-62200A
6
Page 4
(DRAFT)
SALES, RECEIPTS, OR REVENUE
What were the revenues for this firm in 2016 and 2015?
Include:
• Report gross billings, except where noted elsewhere on the form.
• Dues and assessments from members and affiliates.
• E-commerce revenue.
Exclude:
• Transfers made within the company.
• Taxes collected directly from customers or clients and paid directly to a local, state, or federal tax agency.
INSTRUCTIONS FOR TAXABLE FIRMS
Include:
• Amounts received for work subcontracted to others.
• For locations that were sold or acquired during a year, only report for the periods that this firm operated the
locations.
• Revenue from services performed by domestic locations of foreign parent firms, subsidiaries, branches, etc.
Exclude:
• Rents from and revenue of separately operated departments, concessions, etc., which are leased to others.
• Commissions from vending machine operators.
• Revenue of foreign subsidiaries (those located outside the U.S., i.e., outside the 50 states, District of Columbia, U.S.
Commonwealth Territories, or U.S. Possessions).
INSTRUCTIONS FOR TAX-EXEMPT FIRMS
Include:
• Program service revenue for services provided in the applicable period, whether or not payment was received in the
applicable period.
• Gross sales of merchandise minus returns and allowances.
• Income from interest, dividends, gross rents (including display space rentals and share of receipts from departments
operated by other companies), royalties, and other investments.
• Gross contributions, gifts, and grants (whether or not restricted for use in operations).
• Commissions earned from the sale of merchandise owned by others (including commissions from vending machine
operators).
• Gross receipts from fundraising activities.
Exclude:
• Gross receipts of departments or concessions operated by other companies.
• Amounts transferred to operating funds from capital or reserve funds.
$ Bil.
62202049
1.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
Net Patient Care Revenue - Using net
patient revenues, report your sources of
revenue in each of the below categories.
Include the value of total patient care
operating receipts collected for the reporting
period. This figure should be reported net of
any negotiated discounts and write-downs for
bad debt. Exclude non-patient care revenue
such as grants, subsidies, contributions,
philanthropy, and sales from gift shops,
cafeteria and parking lot receipts.
a. Government payers - Report revenues
from the following sources:
1. Medicare - Fee for service only from
parts A, B and D (exclude part C) . . .
2. Medicaid - Fee for service only
3. Workers' compensation
. . . .
. . . . . . .
CONTINUE WITH
6
ON PAGE 5
CONTINUE ON PAGE 5
Form SA-62200A
6
Page 5
(DRAFT)
SALES, RECEIPTS, OR REVENUE - Continued
$ Bil.
1.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
Net Patient Care Revenue - Using net
patient revenues, report your sources of
revenue in each of the below categories.
Include the value of total patient care
operating receipts collected for the reporting
period. This figure should be reported net of
any negotiated discounts and write-downs for
bad debt. Exclude non-patient care revenue
such as grants, subsidies, contributions,
philanthropy, and sales from gift shops,
cafeteria and parking lot receipts. - Continued
62202056
a. Government payers - Report revenues
from the following sources: - Continued
4. All other government programs
- Include programs such as but
not limited to: Children's Health
Insurance Program (CHIP), Department
of Defense (DOD), Civilian Health and
Medical Programs of the Department
of Veterans Affairs (CHAMPVA),
TRICARE, Substance Abuse and Mental
Health (SAMHSA), and Indian Health
Services (IHS) . . . . . . . . . . . . . . .
b. Revenue from health care providers
- Include revenue from hospitals, health
practitioners, outpatient care facilities, etc.
c. Private insurance
1. Private health insurance, including
Medicare and Medicaid managed
care plans - Include revenue from
medical plans administered by
private insurers, including employer
sponsored, other group plans,
Medicare part C (managed care plans),
Medicaid managed care plans, and
Federal, State, and Local government
health insurance . . . . . . . . . . . . .
2. Property and casualty insurance
- Include revenue from auto and
homeowners insurance and other
accident/liability insurance. Exclude
workers' compensation insurance . . .
d. Patient out-of-pocket from patients
and their families - Include all
deductibles and co-insurance from private
health insurance, Medicare, Medicaid, and
other public programs paid by beneficiary
or the family of the beneficiary . . . . . . .
e. All other sources of revenue for
patient care - Include all other sources
of revenue for patient care not included in
lines 1a1 through 1d - Specify
2.
Non-Patient Care Revenue
a. Contributions, gifts, and grants
received . . . . . . . . . . . . . . . . . . . .
b. Investment and property income Include interest and dividends.
Exclude gains (losses) from assets sold .
CONTINUE WITH
6
ON PAGE 6
CONTINUE ON PAGE 6
Form SA-62200A
6
Page 6
(DRAFT)
SALES, RECEIPTS, OR REVENUE - Continued
$ Bil.
2.
Non-Patient Care Revenue - Continued
c. Revenue from health care providers
for non-patient care - Include revenue
from health practitioners, hospitals,
outpatient care facilities, and all other
health care practitioners for non-patient
care services provided. Include revenue
for medical administration and other
administrative services, incentive
payments, management fees, medical
director fees, etc. . . . . . . . . . . . . . . .
d. All other non-patient care revenue
- Include other operating and nonoperating revenue (e.g., gift shop sales,
cafeteria sales, parking lot receipts, florist
receipts) - Specify the primary source of
revenue below
3.
TOTAL REVENUE
Sum of lines 1a1 through 2d
7
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
. . . . . . . . .
SALES TAX
A. Did this firm collect any sales taxes in 2016 or 2015?
Yes
No - Go to
8
B. What were the total sales taxes
collected in 2016 and 2015?
Exclude excise taxes . . . . . . . . . . .
8
$ Bil.
Mil.
E-COMMERCE
E-commerce is the sale of goods and services where the buyer places an order, or the price and terms of the sale are
negotiated, over an Internet, mobile device (M-Commerce), extranet, EDI network, electronic mail, or other comparable
online system. Payment may or may not be made online.
A. Did this firm have any e-commerce revenue in 2016 or 2015?
Yes
No - Go to
11
$ Bil.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
62202064
B. What was the total e-commerce
revenue in 2016 and 2015? . . . . . .
9 and 10 Not Applicable.
CONTINUE ON PAGE 7
Form SA-62200A
Page 7
(DRAFT)
11 INPATIENT/OUTPATIENT ACTIVITY
2016
Number
A. Inpatient days and outpatient visits
1. Inpatient Days - Include neonatal and swing days. Exclude newborns
2015
Number
.
2. Outpatient Visits - Include emergency department visits and outpatient
surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Inpatient and outpatient net revenue
1. Total net inpatient revenue
$ Bil.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
. . . .
2. Total net outpatient revenue . . . .
12 ELECTRONIC HEALTH RECORDS
A. Did your firm have expenses for electronic health record systems and related software and services to
install and/or maintain these systems in 2016 and 2015?
Yes
No - Go to
14
B. Amount of expenses for electronic
health record systems in 2016 and
2015 . . . . . . . . . . . . . . . . . .
$ Bil.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
13 Not Applicable.
14 OPERATING EXPENSES
What were the operating expenses for this firm in 2016 and 2015?
Exclude:
• Transfers made within the company.
• Capitalized expenses.
• Interest.
• Bad debt.
• Impairment.
• Income tax.
62202072
Gross annual payroll
Include salaries and wages, commissions, dismissal pay, bonuses, employee contributions to Social Security, income
tax withholding, union dues, group insurance premiums, savings bonds, cash equivalent in-kind, allowances, holiday
pay, vacation pay, sick leave, stock purchase plans, and employee contributions to pension plans. Exclude the cost of
leased employees, employer's cost for fringe benefits, and temporary staff obtained from temporary help services. For
unincorporated businesses, exclude profit or other compensation of proprietors or partners.
All other operating expenses
Include travel and entertainment; postage, shipping or delivery services; warehousing and storage services; royalties;
security services; janitorial and grounds maintenance services; purchased transportation with operators; and other
expenses not reported elsewhere.
CONTINUE ON PAGE 8
Form SA-62200A
Page 8
(DRAFT)
14 OPERATING EXPENSES - Continued
$ Bil.
62202080
1.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
Personnel Costs
a. Gross annual payroll - Total annual
Medicare salaries and wages for all
employees as reported on this firm's IRS
Form 941, Employer's Quarterly Federal
Tax Return, line 5(c) for the four quarters
that correspond to the survey period or
IRS Form 944 Employer's Annual Federal
Tax Return, line 4(c). Include the spread
on stock options that are taxable to
employees as wages . . . . . . . . . . . . .
b. Employer's cost for fringe benefits
- Employer's cost for legally required
programs and programs not required by
law:
1. Health insurance - Insurance
premiums for hospital plans, medical
plans, and single service plans (e.g.,
dental, vision, prescription drugs).
Include premium equivalents for
self-insured plans and fees paid to
third-party administrators (TPAs).
Exclude employee contributions . . .
2. Pension plans:
a. Defined benefit pension plans
- Costs for both qualified and
unqualified defined pension plans.
Pension plans that specify the
benefit to be paid to employees
upon retirement, generally either
a specific amount or a percentage
of compensation. Employer
contributions are based on actuarial
computations that include the
employee's compensation and
years of service and are not
allocated to specific accounts
maintained for employees . . . . .
b. Defined contribution plans Costs under defined contribution
plans. Pension plans that define
the employer contributions to a
separate account provided for each
employee. The employee "benefit"
at retirement depends on the
amount contributed and the results
of the account's activity. Examples
include profit sharing plans, money
purchase (e.g., 401k, 403b) and
stock bonus plans (e.g., ESOPs) . .
3. Payroll taxes, employer paid
insurance premiums (except
health), and other employer
benefits - Include legally-required
fringe benefits (e.g., Social Security,
workers' compensation insurance,
unemployment tax, state disability
insurance programs, Medicare).
Include benefits for life insurance,
"quality of life" benefits (e.g., childcare
assistance, subsidized commuting),
employer contributions to pre-tax
benefit accounts (e.g., health savings
accounts), education assistance, and
other benefits not specified above.
Exclude disbursements from trusts
or funds to satisfy health insurance
claims . . . . . . . . . . . . . . . . . . . .
CONTINUE WITH
14
ON PAGE 9
CONTINUE ON PAGE 9
Form SA-62200A
Page 9
(DRAFT)
14 OPERATING EXPENSES - Continued
$ Bil.
1.
2.
62202098
3.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
Personnel Costs - Continued
c. Temporary staff and leased employee
expense - Total costs paid to Professional
Employer Organizations (PEOs) and
staffing agencies for personnel. Include
all charges for payroll, benefits, and
services . . . . . . . . . . . . . . . . . . . . .
Expensed Materials, Parts, and Supplies
(not for resale)
a. Medical supplies - Materials and
supplies used in providing medical
services to others. Report medical
equipment in line 2b . . . . . . . . . . . . .
b. Expensed equipment - Expensed
computer hardware and other equipment
(e.g., copiers, fax machines, telephones,
shop and lab equipment, CPUs, monitors).
Report packaged software in line 3a.
Report leased and rented equipment in
line 3i . . . . . . . . . . . . . . . . . . . . . .
c. Expensed purchases of other
materials, parts, and supplies Materials and supplies used in providing
services to others; materials and parts
used in repairs; office and janitorial
supplies; small tools; containers and other
packaging materials; and motor fuels . . .
Expensed Purchased Services
a. Expensed purchases of software Purchases of prepackaged, custom coded,
or vendor customized software. Include
software developed or customized
by others, web-design services and
purchases, licensing agreements,
upgrades of software, and maintenance
fees related to software upgrades and
alterations . . . . . . . . . . . . . . . . . . .
b. Data processing and other purchased
computer services - Include web
hosting, computer facilities management
services, computer input preparation, data
storage, computer time rental, optical
scanning services, and other computerrelated advice and services, including
training. Exclude expensed integrated
systems, repair and maintenance of
computer equipment, payroll processing
and credit card transaction fees, and
expenses for telecommunication services
(e.g., Internet, connectivity, telephone) . .
c. Purchased communication services
- Telephone, cellular, and fax services;
computer-related communications (e.g.,
Internet, connectivity, online), and other
wired and wireless communication
services . . . . . . . . . . . . . . . . . . . . .
d. Purchased repairs and maintenance to
machinery and equipment - Expensed
repair and maintenance services to
machinery, vehicles, equipment, and
computer hardware. Exclude materials,
parts, and supplies used for repairs and
maintenance performed by this firm's
employees . . . . . . . . . . . . . . . . . . .
CONTINUE WITH
14
ON PAGE 10
CONTINUE ON PAGE 10
Form SA-62200A
Page 10
(DRAFT)
14 OPERATING EXPENSES - Continued
$ Bil.
3.
62202106
4.
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
Expensed Purchased Services - Continued
e. Purchased repairs and maintenance
to buildings, structures, and offices
- Include repair and maintenance to
integral parts of buildings (e.g., elevators,
heating systems). Exclude materials,
parts, and supplies used for repairs and
maintenance performed by this firm's
employees. Report janitorial and grounds
maintenance services in line 4c . . . . . .
f. Purchased electricity - If the cost of
electricity is included in lease or rental
payments, report in line 3j . . . . . . . . .
g. Purchased fuels (except motor fuels)
- Fuel for heating, power, or generating
electricity (e.g., natural gas, propane, oil,
coal). If the costs are included in lease or
rental payments, report in line 3j . . . . .
h. Water, sewer, refuse removal, and
other utility payments - Include the
cost of hazardous waste removal. If the
costs of these utilities are included in
lease or rental payments, report in line 3j
i. Lease and rental payments for
machinery, equipment, and other
tangible items - Include lease and
rental of transportation equipment without
operators and penalties incurred for
broken leases. Exclude capital and
financing lease agreements and licensing/
leasing of software . . . . . . . . . . . . . .
j. Lease and rental payments for land,
buildings, structures, store spaces,
and offices - Include penalties incurred
for broken leases . . . . . . . . . . . . . . .
k. Purchased advertising and
promotional services - Include
marketing and public relations services
.
l. Purchased professional and technical
services - Include management
consulting, accounting, auditing,
bookkeeping, legal, actuarial, payroll
processing, architectural, engineering,
and other professional services. Exclude
salaries paid to your own employees for
these services . . . . . . . . . . . . . . . . .
m. Professional liability insurance - The
cost of professional liability insurance.
Include professional liability insurance
premiums and amounts set aside for selfinsurance . . . . . . . . . . . . . . . . . . . .
Other Operating Expenses
a. Depreciation and amortization
charges - Include depreciation charges
taken against tangible assets owned and
used by this firm, tangible assets and
improvements owned by this firm within
leaseholds, tangible assets obtained
through capital lease agreements, and
amortization charges against intangible
assets (e.g., patents, copyrights).
Exclude impairment . . . . . . . . . . . . .
b. Governmental taxes and license fees Payments to government agencies for
taxes and licenses. Include business and
property taxes. Exclude income taxes
and sales and excise taxes collected from
customers . . . . . . . . . . . . . . . . . . .
CONTINUE WITH
14
ON PAGE 11
CONTINUE ON PAGE 11
Form SA-62200A
Page 11
(DRAFT)
14 OPERATING EXPENSES - Continued
$ Bil.
4.
Other Operating Expenses - Continued
c. All other operating expenses - All
other operating expenses not reported
above, unless specifically excluded in
the general instructions. Include office
postage paid and package delivery.
Exclude purchases of merchandise for
resale and non-operating expenses. If
this item is greater than 20% of the
total operating expenses, specify
the primary source of the expenses
below
5.
TOTAL OPERATING EXPENSES
Sum of lines 1a through 4c . . . . . . . . . .
Mil.
2016
Thou.
Dol.
$ Bil.
Mil.
2015
Thou.
Dol.
62202114
15 and 16 Not Applicable.
CONTINUE ON PAGE 12
Form SA-62200A
Page 12
(DRAFT)
17 REMARKS - Please use this space to explain any significant year-to-year changes, to clarify responses, or indicate where
data were estimated.
18 CONTACT INFORMATION
Name of person to contact regarding this report (Please print)
Area code
62202122
Telephone
E-mail address
Number
-
Title
Extension
Area code
Fax
Number
-
Website address
THANK YOU for completing your 2016 ANNUAL SERVICES REPORT.
We suggest you keep a copy for your records.
Public reporting burden for this collection of information is estimated to average 3-6 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: ECON Survey Comments 0607-0422, U.S. Census Bureau, 4600 Silver Hill Road, Room EMD-6K064, Washington,
DC 20233. You may e-mail comments to [email protected] . Be sure to use ECON Survey Comments 0607-0422 as the
subject. You are not required to respond to this collection of information if it does not display a valid approval number from the Office of
Management and Budget (OMB). The eight-digit OMB number is 0607-0422 and appears in the upper right corner of the electronic instrument
screen.
| File Type | application/pdf |
| File Title | C:\Users\cogan300\\GIDSSuite\tmpE4F2.tmp |
| Author | cogan300 |
| File Modified | 2016-06-20 |
| File Created | 2016-06-17 |