HUD-92422 Data Request

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Overview

Definitions
Account Groupings
Quarterly Reporting Only
Monthly Reporting - 1st Qtr
Monthly Reporting - 2nd Qtr
Monthly Reporting - 3rd Qtr
Monthly Reporting - 4th Qtr

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Sheet 1: Definitions

Section 242 Mortgage Insurance for Hospitals Program
ACCOUNT DEFINITIONS
The following table is the definition of certain accounts. If there is a conflict between the following definitions and the definition in the Regulatory Agreement, the definition in the Regulatory Agreement controls.
Cash	For the mortgagor, include all highly liquid investments that are readily convertible to cash such as commercial papers and short-term investments that are included in the current asset section of the balance sheet. [see note 3 below]
Patient Accounts Receivable	This is accounts receivable pertaining only to patient care for the mortgagor. It is usually displayed net of allowance for uncollectible accounts and contractual adjustments. If the gross amount is given, subtract these items from the gross amount to get to the net accounts receivable figure. Do not include other receivables, grant receivables, miscellaneous receivables or receivables from third party agencies.
Qualified Liquid Investments	For the mortgagor: Qualified Liquid Investments are generally made up of marketable securities, CD's, and bond investments that are undesignated and available for general operational use of the hospital within six months or less if so desired. Qualified liquid investments does not include: a) Any accounts, investments, etc. that are part of a self insurance fund; b) Proceeds of any borrowings including without limitation: (1) any internal affiliate loans regardless of the maturity date, (2) proceeds of any outstanding accounts receivable financing; (3) proceeds from lines of credit, or (4) funds supporting a letter of credit, loan guarantee, etc. c) Investments in any related entity or entity controlled by a related entity; d) Pledges receivable; e) Permanently restricted net assets; f) Reserve funds related to an issuance of bonds; g) Amounts shown as an unfunded or under funded reserve(s); h) Mortgage Reserve Fund(s) or other loan reserve funds; or i) Any items that cannot be clearly identified as meeting the criteria of this definition in the financial statements of the organization. Generally alternative investments are excluded from Qualified Liquid investments. Investments designated by the board for future use or for general capital improvements and that are not part of the Equipment Replacement Reserve Fund (or similar fund) nor excluded by any of the other categories listed in this definition may be classified as Qualified Liquid Investments and shall not be excluded because of the designation by the board.
Hospital Held Non Liquid Qualified Investments	This account includes amounts that met all of the criteria for Qualified Liquid Investments except:
	1.                  they could not be made available for general operational use within six months, or
	2.                  they were classified as alternative investments.
Assets Whose Use is Limited:	For the mortgagor, this is the total of the non-current portion of all restricted or temporarily restricted assets whose use is limited. It includes the Mortgage Reserve Fund and any reserve accounts such as self-insurance reserves or pension reserves. Do not add back the current portion of this item that has been designated as a current asset in the financial statements.
Plant, Property, and Equipment	This is the total land, land improvements, plant, property, fixed assets, and equipment, moveable equipment, and medical equipment recorded on the balance sheet in accordance with GAAP for the mortgagor.
Accounts Payable	For the mortgagor, this item should reflect what is owed on materials, supplies, utilities, and other personnel expenses. Exclude accrued salaries, wages, employee benefits, professional fees and accrued interest.
Current portion of Long Term Debt and Capital Leases	For the mortgagor, this includes the current portion of all types of capital debt including current portion of leases (with more than one year of duration) recorded on the balance sheet.
Long Term Debt and Capital Leases	This should include all capital debt that is not included in current liabilities including capital leases and other leases (with more than one year of duration) that are recorded on the balance sheet for the mortgagor. It does not include any related bonds as they are not a part of the mortgagor.
Generally Accepted Accounting Principles distinguish the net assets of a corporation with appropriate descriptions depending on the organizational structure of the entity. Section 242 uses the following mapping for the treatment of these items and entering data on the Quarterly Data Request.
	This should be for only the mortgagor.
Unrestricted Net Assets
	For profit entities:
	Common stock issued and outstanding
	Common stock shares
	Retained earnings
	Paid in capital
	Partner’s capital
	Not-for- Profit entities
	Unrestricted Net Assets
	Governmental entities
	Unrestricted Net assets
	Invested in capital assets net of related debt
Temporarily Restricted	Net Assets marked as temporarily restricted for the mortgagor.
Permanently Restricted	Assets held by a related foundation for the benefit of the hospital may be entered on this line if they appear on the balance sheet, otherwise only enter assets for the Mortgagor. Enter assets restricted as to use.
Patient Revenue net of contractual allowances and discounts	Follow Health care industry practice.
Provison for Bad Debts	bad debts related to patient care in accordance with Healthcare industry practice.
Net Patient Service Revenue net of Bad Debts	Follow Health care industry practice.
Other operating revenue	For the mortgagor.
	(Income from investments, unrestricted contributions, interest income, gains from the sale of assets, non-operating revenues, and extraordinary gains are excluded from operating revenue) In certain case where the dollar amounts are assured, revenues from taxation may be included.[1]
Total Operating Revenue	Total operating revenue for the mortgagor. Total Operating Revenue is defined as: Net Patient Service Revenue plus Other Operating Revenue
Salaries and wages	Salaries and wages for non-physician employees for the mortgagor.
Physician salaries and wages	Employee physician salary and wages including call pay. (Do not include physicians acting in a non-medical capacity such as the CEO). Include emergency department, medical directors, hospitalists, physicians working in clinics and other employee physicians.
Employee Benefits	Enter employee benefits if available.
Professional Fees	Professional fees are defined as contract physicians.
Supplies	Catch-all category, include all expenses that do not fit elsewhere.
Non-operating income	Income from investments, unrestricted contributions, interest income, gains from the sale of assets, non-operating revenues, extraordinary gains, gains from subsidiaries excluded from the mortgagor, grant revenues (when there is not an offsetting expense), and tax revenues[2] are examples of non operating income.
Net Income	Net Income; Revenues in excess of expenses
Related Entity Liquid Investments	Investments that are held by a Financially Related Organization as defined by GAAP, and (1) can be made available to the Mortgagor, (2) are designated for the sole benefit of the Mortgagor, (3) are included in the audited financial statements of the Mortgagor as Beneficial Interest in Net Assets Held by a Financially Related Organization, (4) are unencumbered, and (5) have a: (a) stated maturity of six months or less, plus (b) the estimated liquidation value of investments which could be liquidated within six (6) months
Related Entity Non-liquid Investments	Investments that meet the definition of Related Entity Liquid Investments except for condition (5).
[1] Tax fee programs where a hospital pays a “fee or contribution” and then receives increased Disproportionate Share Funds back may be included in Other Operating Income. Other tax revenue may be included if permitted by HUD.
[2] Tax fee programs where a hospital pays a “fee or contribution” and then receives increased Disproportionate Share Funds back may be included in Other Operating Income. Other tax revenue may be included if permitted by HUD.
[3] The term “Mortgagor” was redefined in FY2012 in both the covenants and the new edition of HUD Handbook 4615.1 as: “the borrower and its successors and Affiliates under the HUD-Insured Mortgage, to the extent that its assets, liabilities, net assets, revenues, and expenses are encumbered by the Mortgage and the Security Agreement, including without limitation leased equipment for the benefit of the Hospital and restricted assets. {Note: Loan documents prior to 2013 may have used the term Mortgaged Entity.]
	OMB Control #2502-0602
	Exp 05/31/2015
	Form HUD-92422 (9/2012)

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Sheet 2: Account Groupings

Section 242 Mortgage Insurance for Hospitals Program
ACCOUNT GROUPINGS
The following chart showings the typical accounts that are included in the account heading for entry into the Quarterly Data request and entry into HMIMIS. This chart is not intended to restrict the separate accounts that a hospital may have on its balance sheet. Certain headings have been omitted such as Accumulated Depreciation or Net Patient Revenue as the heading itself is self-definitive and standard throughout the healthcare industry. Additional accounts should be classified based on the pattern.
Main Heading	Typical Accounts
Cash and Temporary Investments	Cash
	Cash on hand
	Savings
	Checking
	CDs
	Marketable securities
	Investments
	Short-term investments
	Assets limited as to use-current portion only
Accounts Receivable, net	Patient Accounts Receivable net
Accounts Receivable, gross	Patient Accounts Receivable gross
Other Receivable	Other Receivable
Qualified Liquid Investments	Qualified Liquid Investments
	Board Designated for Capital Improvements
	Other non-current assets (if investments)
	LESS amount pledged on line of credit
	LESS amount pledged on letter of credit
	LESS amount due to underfunding of self insured fund
	LESS amount due to underfunding of pension fund
Limited Use or Designated Assets	Assets limited as to use
	Debt Escrow Fund
	MRF
	Deferred financing costs
	Permanently restricted assets
	Investment in affiliates
	Assets tied up by a Letter of Credit (LOC)
	Self-insured trust
	Pension Fund
	Restricted by Donor
	PLUS amount pledged on line of credit
	PLUS amount pledged on letter of credit
	PLUS amount due to underfunding of self insured fund
	PLUS amounts due to underfunding of pension fund
	Deferred Tax Asset
Net Plant Property and Equipment	Total Fixed Assets (net of accumulated depreciation)
	Property and equipment, net
	Property, Plant and Equipment
	Land Improvement
	Real Estate
	Building Improvement
	Leasehold Improvements
	Construction in Progress
	With related accumulated depreciation accounts
Accounts Payable	Accounts Payable
	Trade Accounts Payable
	Other, Construction & retainage payable
Accrued Expenses	Accrued Expenses
	Accrued interest payable
	Other Accrued Expenses
Current Portion of Long-Term Debt	Current portion of capital debt
	Current portion of mortgages
	Current portion of notes payable
	Current portion of long term lease obligations
	Current portion of equipment purchases
Total Other Current Liabilities	Other current liabilities
	Accrued Salaries & Benefits
	Payables to 3rd party payors
	Other
	Due to related entity
Long-Term Capital Debt & Leases	Mortgages Payable
	Lease Obligations
Total Other Long-Term Liabilities	Other long-term debt
	Minority interest in Consolidated Sub
	Other Non-current
	Deferred Revenues
	Deferred tax liability
Unrestricted Net Assets	Unrestricted
	Common stock issued and outstanding
	Common stock shares
	Retained earnings
	Paid in capital
	Partner’s Capital
	Invested in capital assets net of related debt
Temporarily Restricted Net Assets	Temporarily restricted
Restricted Net Assets	Restricted
	Permanently Restricted, held by related organization
	Permanently Restricted Net Assets
Other Operating Revenues	Other operating revenue
	Rental income
	Cafeteria sales
	Rental of space
	Amounts received from Related Organizations offset by operating expenses
	Release of Temporarily Restricted Assets for operating purposes
	Certain permitted tax revenues[1]
	Total Other Operating Revenue
Total Salaries and wages	Salaries and Wages
	(Do not include salaries and wages for physician employees unless employed as other than a physician such as a CEO who is also a physician.
Salaries and wages -Physician	Salaries & wages of physicians
Employee Benefits
Professional Fees	Contract Physician Fees
Total Supply Expense	Supplies
	Purchased services and other contract services
	Utilities
	Insurance
	Other expenses
	[Note: some hospitals prefer to exclude utilities, insurance, and other expenses from supply expense and restrict this account to supplies, office supplies, central sterile supply, etc. This is also acceptable to group these items in a separate grouping titled “Other Operating Expenses.”
Non-operating revenue	Non-operating revenue
	Contributions
	Grants
	Interest income
	Investment income
	Net realized gains & investment income
	Net assets released from restrictions for capital assets
	Gain on disposal of property and equipment
	Income less expenses of non-mortgaged entities
	Minority interest in consolidated subsidiary
Non-operating expense	Non-operating expense
	Non-operating losses
	Change in additional minimum pension liability
	Loss on sale of assets
	Loss on disposal of assets
	Loss on disposal of property and equipment
Extraordinary Items and Income Taxes	Cumulative effect of accounting change
	Gains or losses on the extinguishment of debt
	Accelerated depreciation due to the HUD insured project
	Income taxes unless specifically permitted otherwise
	Losses or Gains from sale of equipment
	Losses or Gains from discontinued operations
Other changes in Net Assets	This is a catch-all field for any other causes for changes in Net Assets such as a change in accounting principle, distribution (or contributions) of Net Assets, an increase or decrease due to restatement of prior period earnings, gifts of permanently restricted assets, additional paid in capital, etc. It is equal to the current period total net assets less the amount of total net assets from the prior year annual financial statements, less unrecognized gains and losses, less changes in temporarily restricted assets.
[1] Tax fee programs where a hospital pays a “fee or contribution” and then receives increased Disproportionate Share Funds back may be included in Other Operating Income. Other tax revenue may be included if permitted by HUD.
	OMB Control #2502-0602
	Exp 05/31/2015
	Form HUD-92422 (9/2012)

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Sheet 3: Quarterly Reporting Only

Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING							OMB Approval No. 2502-0602
ENTER HOSPITAL NAME HERE			ENTER FYE HERE				(Exp. 05/31/2015)
	If monthly reporting is required enter 1, if quarterly enter 2						form HUD-92422-OHF
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website or may be obtained from your account executive.
(B.) Please call your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in yellow.
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description		1st Qtr	2nd Qtr	3rd Qtr	4th Qtr
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments
Gross Patient Receivables
Allowance for Doubtful Accounts						Allowance for doubtful accounts should be entered as a negative number.
Net Accounts Receivable		$-	$-	$-	$-
All Other Current Assets
Total Current Assets		$-	$-	$-	$-
Qualified Liquid Investments
Hospital Held Non-Liquid Qual. Invest.
Limited Use or Desginated Assets
Gross Property, Plant & Equipment
Accumulated Depreciation						Accumulated Depreciation should be entered as a negative number.
Net Property, Plant & Equipment		$-	$-	$-	$-
All Other Non-current Assets
Total Assets		$-	$-	$-	$-
Accounts Payable
Accrued Expenses
Current Portion of LT Debts
All Other Current Liabilities
Total Current Liabilities		$-	$-	$-	$-
Long Term Capital Debt
All Other Long Term Liabilities
Total Long Term Liabilities		$-	$-	$-	$-
Total Liabilities		$-	$-	$-	$-
Unrestricted Fund Balance
Temporarily Restricted Fund Balance
Restricted Fund Balance
Total Net Assets		$-	$-	$-	$-
Total Net Assets + Total Liabilities		$-	$-	$-	$-
Income Statement
Net Inpatient Revenue (1) (6)
Net Outpatient Revenue (1) (6)
Patient Service Rev net of Contr. Allow. & discounts		$-	$-	$-	$-
Provision for Bad Debts						enter provison for Bad Debts as a negative number.
Net Patient service Revenue less Provision for Bad Debts		$-	$-	$-	$-
All Other Operating Revenue
Total Operating Revenue		$-	$-	$-	$-
Salaries & Wages
Physician Salaries & wages
Employee Benefits
Contract Physician Fees
Total Supplies Expense
Depreciation Expense (incl Lease Amortization)
Amortization Expense (excl Lease Amortization)
Interest Expense
Bad Debt Expense (1)
All Other Operating Expenses
Total Operating Expense		$-	$-	$-	$-
Income from Operations		$-	$-	$-	$-
All Non-Operating Revenue						For rows 69 to 71 Enter increases to Net Income as a positive number and decreases to Net Income as a negative number.
All Non-Operating Expense
Extraordinary Items & Income Tax Revenue
Net Income		$-	$-	$-	$-
Unrecognized Gains/Losses
Changes in Temp Restrict Net Assets
Other Changes in Fund Balance (2)
Net Increase/Decrease in Fund Balance		$-	$-	$-	$-
Mortage Reserve Fund
Required MRF Balance
Actual MRF Balance
FHA-Insured Mortgage
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages						For Row 83, for Borrowers with multiple FHA-insured mortgages, please input as a formula. (i.e. =(loan1amount+loan2amount)
Net Inpatient Revenue (1)		$-	$-	$-	$-
Medicare
Medicaid
Commercial Insurance
HMO/Managed Care
Self Pay
Other
Inpatient Utilization
Total Licensed Beds
Total Staffed Beds
Acute Medical/Surgical Service
Number of Beds
Discharges
Patient Days
Newborn Service
Number of Beds
Discharges
Patient Days
Other Acute Care Services
Number of Beds
Discharges
Patient Days
Other Non-Acute Care
Number of Beds
Discharges
Patient Days
Swing Bed (SNF)
Discharges
Patient Days
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)
ALOS (5)
Non-Medicare
Case Mix Index (3)
ALOS (5)
All Patients
Case Mix Index (3)
ALOS (5)
Inpatient Cost per Discharge
Outpatient Utilization
Emergency Room Visits
Observation Visits
Observation Days
Ambulatory Surgeries
Clinic Visits
Other Outpatient Visits
Staffing
Total Full-Time Equivalents (4)
Rows 135 and 136 ONLY APPLY if required by the Regulatory Agreement
Related Entity Liquid Investments
Related Entity non-liquid Investments
Rows 139 through 156 ONLY APPLY to Critical Access Hospitals. All other hospitals skip to row 157
Income Statement
Tax Revenues (that are included in revenue as reported in the income statement)
Utilization
Nursing home occupancy
Nursing home payor mix
Medicare
Medicaid
Private
Other
Observation Days
Respite Days
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
1.	Has the Hospital undertaken any major physical facility changes affecting operations (renovation, relocation, addition or deletion of services)?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
2.	Has the Hospital identified any positive or negative trends in service utilization statistics, financial indicators or ratios?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
3.	Have there been any significant achievements to the Hospital’s Strategic Long Range / Business Plan?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
4.	Has there been any change in Board membership or Executive Management?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants? Have actions or events triggered or required waivers or approvals from any financial institutions or other parties for violating financial, negative or reporting covenants?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A18+A19=A20		Yes	Yes	Yes	Yes
A17+A20+A21=A22		Yes	Yes	Yes	Yes
A22+A23+A24+A25+A28+A29=A30		Yes	Yes	Yes	Yes
A32+A33+A34+A35=A36		Yes	Yes	Yes	Yes
A37+A38=A39		Yes	Yes	Yes	Yes
A36+A38=A39		Yes	Yes	Yes	Yes
A41+A42+A43=A44		Yes	Yes	Yes	Yes
A40+A44=A45		Yes	Yes	Yes	Yes
A30=A45		Yes	Yes	Yes	Yes
Income Statement
A48+A49=A50		Yes	Yes	Yes	Yes
A50+A51+A53=A54		Yes	Yes	Yes	Yes
A56+A57+A58+A59+A60+A61+A62+A63+A64+A65=A66		Yes	Yes	Yes	Yes
A67+A69+A70+A71=A72		Yes	Yes	Yes	Yes
A72+A74+A75+A76=A77		Yes	Yes	Yes	Yes
A85+A86+A87+A88+A89+A90=A48		Yes	Yes	Yes	Yes
Various Edit Checks
A50<=A54		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
A54-A66+A69+A70+A71=A72		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp + extraordinary items = net income
A56+A57+A58+A59+A60+A61+A62+A63+A64<=A66		Yes	Yes	Yes	Yes	tot supplies exp + tot sal & benefits + prof. fees+dep exp + amort+ int exp + bad debt exp <= tot op exp
A17+A20+A21<=A22		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
A22+A25+A28<=A30		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
A30=A40+A41+A42+A43		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted +temporarily restricted + restricted net assets
A32+A33+A34<=A36		Yes	Yes	Yes	Yes	AP + accrued exp + current portion LT debt <= Current liabilities
A36+A37<=A40		Yes	Yes	Yes	Yes	total current liab + LT capital debt< = total liabilities
Enter the Total Net assets from Prior Year
A41+A42+A43-$B232-A72=A74+A75+A76		Yes	Yes	Yes	Yes	prior year net asset + net incom+other changes in net assets= current year net assets
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

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Sheet 4: Monthly Reporting - 1st Qtr

Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING							OMB Approval No. 2502-0602
ENTER FYE HERE							(Exp. 05/31/2015)
ENTER HOSPITAL NAME HERE							form HUD-92422-OHF
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website or may be obtained from your account executive.
(B.) Please call your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in yellow.
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description	Entry Label	1st Month	2nd Month	3rd Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments
Gross Patient Receivables
Allowance for Doubtful Accounts						Allowance for doubtful accounts should be entered as a negative number.
Net Accounts Receivable		$-	$-	$-	$-
All Other Current Assets
Total Current Assets		$-	$-	$-	$-
Qualified Liquid Investments
Hospital Held Non-Liquid Qual. Invest.
Limited Use or Desginated Assets
Gross Property, Plant & Equipment
Accumulated Depreciation						Accumulated Depreciation should be entered as a negative number.
Net Property, Plant & Equipment		$-	$-	$-	$-
All Other Non-current Assets
Total Assets		$-	$-	$-	$-
Accounts Payable
Accrued Expenses
Current Portion of LT Debts
All Other Current Liabilities
Total Current Liabilities		$-	$-	$-	$-
Long Term Capital Debt
All Other Long Term Liabilities
Total Long Term Liabilities		$-	$-	$-	$-
Total Liabilities		$-	$-	$-	$-
Unrestricted Fund Balance
Temporarily Restricted Fund Balance
Restricted Fund Balance
Total Net Assets		$-	$-	$-	$-
Total Net Assets + Total Liabilities		$-	$-	$-	$-
Income Statement
Net Inpatient Revenue (1) (6)
Net Outpatient Revenue (1) (6)
Patient Service Rev net of Contr. Allow. & discounts		$-	$-	$-	$-
Provision for Bad Debts						enter provison for Bad Debts as a negative number.
Net Patient service Revenue less Provision for Bad Debts		$-	$-	$-	$-
All Other Operating Revenue
Total Operating Revenue		$-	$-	$-	$-
Salaries & Wages
Physician Salaries & wages
Employee Benefits
Contract Physician Fees
Total Supplies Expense
Depreciation Expense (incl Lease Amortization)
Amortization Expense (excl Lease Amortization)
Interest Expense
Bad Debt Expense (1)
All Other Operating Expenses
Total Operating Expense		$-	$-	$-	$-
Income from Operations		$-	$-	$-	$-
All Non-Operating Revenue						For rows 69 to 71 Enter increases to Net Income as a positive number and decreases to Net Income as a negative number.
All Non-Operating Expense
Extraordinary Items & Income Tax Revenue
Net Income		$-	$-	$-	$-
Unrecognized Gains/Losses
Changes in Temp Restrict Net Assets
Other Changes in Fund Balance (2)
Net Increase/Decrease in Fund Balance		$-	$-	$-	$-
Mortage Reserve Fund
Required MRF Balance
Actual MRF Balance
FHA-Insured Mortgage
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages						For Row 83, for Borrowers with multiple FHA-insured mortgages, please input as a formula. (i.e. =(loan1amount+loan2amount)
Net Inpatient Revenue (1)		$-	$-	$-	$-
Medicare
Medicaid
Commercial Insurance
HMO/Managed Care
Self Pay
Other
Inpatient Utilization
Total Licensed Beds
Total Staffed Beds
Acute Medical/Surgical Service
Number of Beds
Discharges
Patient Days
Newborn Service
Number of Beds
Discharges
Patient Days
Other Acute Care Services
Number of Beds
Discharges
Patient Days
Other Non-Acute Care
Number of Beds
Discharges
Patient Days
Swing Bed (SNF)
Discharges
Patient Days
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)
ALOS (5)
Non-Medicare
Case Mix Index (3)
ALOS (5)
All Patients
Case Mix Index (3)
ALOS (5)
Inpatient Cost per Discharge
Outpatient Utilization
Emergency Room Visits
Observation Visits
Observation Days
Ambulatory Surgeries
Clinic Visits
Other Outpatient Visits
Staffing
Total Full-Time Equivalents (4)
Rows 135 and 136 ONLY APPLY if required by the Regulatory Agreement
Related Entity Liquid Investments
Related Entity non-liquid Investments
Rows 139 through 156 ONLY APPLY to Critical Access Hospitals. All other hospitals skip to row 157
Income Statement
Tax Revenues (that are included in revenue as reported in the income statement)
Utilization
Nursing home occupancy
Nursing home payor mix
Medicare
Medicaid
Private
Other
Observation Days
Respite Days
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
1.	Has the Hospital undertaken any major physical facility changes affecting operations (renovation, relocation, addition or deletion of services)?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
2.	Has the Hospital identified any positive or negative trends in service utilization statistics, financial indicators or ratios?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
3.	Have there been any significant achievements to the Hospital’s Strategic Long Range / Business Plan?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
4.	Has there been any change in Board membership or Executive Management?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants? Have actions or events triggered or required waivers or approvals from any financial institutions or other parties for violating financial, negative or reporting covenants?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A18+A19=A20		Yes	Yes	Yes	Yes
A17+A20+A21=A22		Yes	Yes	Yes	Yes
A22+A23+A24+A25+A28+A29=A30		Yes	Yes	Yes	Yes
A32+A33+A34+A35=A36		Yes	Yes	Yes	Yes
A37+A38=A39		Yes	Yes	Yes	Yes
A36+A38=A39		Yes	Yes	Yes	Yes
A41+A42+A43=A44		Yes	Yes	Yes	Yes
A40+A44=A45		Yes	Yes	Yes	Yes
A30=A45		Yes	Yes	Yes	Yes
Income Statement
A48+A49=A50		Yes	Yes	Yes	Yes
A50+A51+A53=A54		Yes	Yes	Yes	Yes
A56+A57+A58+A59+A60+A61+A62+A63+A64+A65=A66		Yes	Yes	Yes	Yes
A67+A69+A70+A71=A72		Yes	Yes	Yes	Yes
A72+A74+A75+A76=A77		Yes	Yes	Yes	Yes
A85+A86+A87+A88+A89+A90=A48		Yes	Yes	Yes	Yes
Various Edit Checks
A50<=A54		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
A54-A66+A69+A70+A71=A72		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp + extraordinary items = net income
A56+A57+A58+A59+A60+A61+A62+A63+A64<=A66		Yes	Yes	Yes	Yes	tot supplies exp + tot sal & benefits + prof. fees+dep exp + int exp + bad debt exp <= tot op exp
A17+A20+A21<=A22		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
A22+A25+A28<=A30		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
A30=A40+A41+A42+A43		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted +temporarily restricted + restricted net assets
A32+A33+A34<=A36		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= Current liabilities
A36+A37<=A40		Yes	Yes	Yes	Yes	total current liab + LT capital debt< = total liabilities
Enter the Total Net assets from Prior Year
A41+A42+A43-$B232-A72=A74+A75+A76		Yes	Yes	Yes	Yes	prior year net asset + net incom+other changes in net assets= current year net assets
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

---

Sheet 5: Monthly Reporting - 2nd Qtr

Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING							OMB Approval No. 2502-0602
ENTER FYE HERE							(Exp. 05/31/2015)
ENTER HOSPITAL NAME HERE							form HUD-92422-OHF
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website or may be obtained from your account executive.
(B.) Please call your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in yellow.
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description	Entry Label	4th Month	5th Month	6th Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments
Gross Patient Receivables
Allowance for Doubtful Accounts						Allowance for doubtful accounts should be entered as a negative number.
Net Accounts Receivable		$-	$-	$-	$-
All Other Current Assets
Total Current Assets		$-	$-	$-	$-
Qualified Liquid Investments
Hospital Held Non-Liquid Qual. Invest.
Limited Use or Desginated Assets
Gross Property, Plant & Equipment
Accumulated Depreciation						Accumulated Depreciation should be entered as a negative number.
Net Property, Plant & Equipment		$-	$-	$-	$-
All Other Non-current Assets
Total Assets		$-	$-	$-	$-
Accounts Payable
Accrued Expenses
Current Portion of LT Debts
All Other Current Liabilities
Total Current Liabilities		$-	$-	$-	$-
Long Term Capital Debt
All Other Long Term Liabilities
Total Long Term Liabilities		$-	$-	$-	$-
Total Liabilities		$-	$-	$-	$-
Unrestricted Fund Balance
Temporarily Restricted Fund Balance
Restricted Fund Balance
Total Net Assets		$-	$-	$-	$-
Total Net Assets + Total Liabilities		$-	$-	$-	$-
Income Statement
Net Inpatient Revenue (1) (6)
Net Outpatient Revenue (1) (6)
Patient Service Rev net of Contr. Allow. & discounts		$-	$-	$-	$-
Provision for Bad Debts						enter provison for Bad Debts as a negative number.
Net Patient service Revenue less Provision for Bad Debts		$-	$-	$-	$-
All Other Operating Revenue
Total Operating Revenue		$-	$-	$-	$-
Salaries & Wages
Physician Salaries & wages
Employee Benefits
Contract Physician Fees
Total Supplies Expense
Depreciation Expense (incl Lease Amortization)
Amortization Expense (excl Lease Amortization)
Interest Expense
Bad Debt Expense (1)
All Other Operating Expenses
Total Operating Expense		$-	$-	$-	$-
Income from Operations		$-	$-	$-	$-
All Non-Operating Revenue						For rows 69 to 71 Enter increases to Net Income as a positive number and decreases to Net Income as a negative number.
All Non-Operating Expense
Extraordinary Items & Income Tax Revenue
Net Income		$-	$-	$-	$-
Unrecognized Gains/Losses
Changes in Temp Restrict Net Assets
Other Changes in Fund Balance (2)
Net Increase/Decrease in Fund Balance		$-	$-	$-	$-
Mortage Reserve Fund
Required MRF Balance
Actual MRF Balance
FHA-Insured Mortgage
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages						For Row 83, for Borrowers with multiple FHA-insured mortgages, please input as a formula. (i.e. =(loan1amount+loan2amount)
Net Inpatient Revenue (1)		$-	$-	$-	$-
Medicare
Medicaid
Commercial Insurance
HMO/Managed Care
Self Pay
Other
Inpatient Utilization
Total Licensed Beds
Total Staffed Beds
Acute Medical/Surgical Service
Number of Beds
Discharges
Patient Days
Newborn Service
Number of Beds
Discharges
Patient Days
Other Acute Care Services
Number of Beds
Discharges
Patient Days
Other Non-Acute Care
Number of Beds
Discharges
Patient Days
Swing Bed (SNF)
Discharges
Patient Days
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)
ALOS (5)
Non-Medicare
Case Mix Index (3)
ALOS (5)
All Patients
Case Mix Index (3)
ALOS (5)
Inpatient Cost per Discharge
Outpatient Utilization
Emergency Room Visits
Observation Visits
Observation Days
Ambulatory Surgeries
Clinic Visits
Other Outpatient Visits
Staffing
Total Full-Time Equivalents (4)
Rows 135 and 136 ONLY APPLY if required by the Regulatory Agreement
Related Entity Liquid Investments
Related Entity non-liquid Investments
Rows 139 through 156 ONLY APPLY to Critical Access Hospitals. All other hospitals skip to row 157
Income Statement
Tax Revenues (that are included in revenue as reported in the income statement)
Utilization
Nursing home occupancy
Nursing home payor mix
Medicare
Medicaid
Private
Other
Observation Days
Respite Days
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
1.	Has the Hospital undertaken any major physical facility changes affecting operations (renovation, relocation, addition or deletion of services)?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
2.	Has the Hospital identified any positive or negative trends in service utilization statistics, financial indicators or ratios?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
3.	Have there been any significant achievements to the Hospital’s Strategic Long Range / Business Plan?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
4.	Has there been any change in Board membership or Executive Management?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants? Have actions or events triggered or required waivers or approvals from any financial institutions or other parties for violating financial, negative or reporting covenants?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A18+A19=A20		Yes	Yes	Yes	Yes
A17+A20+A21=A22		Yes	Yes	Yes	Yes
A22+A23+A24+A25+A28+A29=A30		Yes	Yes	Yes	Yes
A32+A33+A34+A35=A36		Yes	Yes	Yes	Yes
A37+A38=A39		Yes	Yes	Yes	Yes
A36+A38=A39		Yes	Yes	Yes	Yes
A41+A42+A43=A44		Yes	Yes	Yes	Yes
A40+A44=A45		Yes	Yes	Yes	Yes
A30=A45		Yes	Yes	Yes	Yes
Income Statement
A48+A49=A50		Yes	Yes	Yes	Yes
A50+A51+A53=A54		Yes	Yes	Yes	Yes
A56+A57+A58+A59+A60+A61+A62+A63+A64+A65=A66		Yes	Yes	Yes	Yes
A67+A69+A70+A71=A72		Yes	Yes	Yes	Yes
A72+A74+A75+A76=A77		Yes	Yes	Yes	Yes
A85+A86+A87+A88+A89+A90=A48		Yes	Yes	Yes	Yes
Various Edit Checks
A50<=A54		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
A54-A66+A69+A70+A71=A72		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp + extraordinary items = net income
A56+A57+A58+A59+A60+A61+A62+A63+A64<=A66		Yes	Yes	Yes	Yes	tot supplies exp + tot sal & benefits + prof. fees+dep exp + int exp + bad debt exp <= tot op exp
A17+A20+A21<=A22		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
A22+A25+A28<=A30		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
A30=A40+A41+A42+A43		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted +temporarily restricted + restricted net assets
A32+A33+A34<=A36		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= Current liabilities
A36+A37<=A40		Yes	Yes	Yes	Yes	total current liab + LT capital debt< = total liabilities
Enter the Total Net assets from Prior Year
A41+A42+A43-$B232-A72=A74+A75+A76		Yes	Yes	Yes	Yes	prior year net asset + net incom+other changes in net assets= current year net assets
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

---

Sheet 6: Monthly Reporting - 3rd Qtr

Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING							OMB Approval No. 2502-0602
ENTER FYE HERE							(Exp. 05/31/2015)
ENTER HOSPITAL NAME HERE							form HUD-92422-OHF
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website or may be obtained from your account executive.
(B.) Please call your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in yellow.
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description	Entry Label	7th Month	8th Month	9th Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments
Gross Patient Receivables
Allowance for Doubtful Accounts						Allowance for doubtful accounts should be entered as a negative number.
Net Accounts Receivable		$-	$-	$-	$-
All Other Current Assets
Total Current Assets		$-	$-	$-	$-
Qualified Liquid Investments
Hospital Held Non-Liquid Qual. Invest.
Limited Use or Desginated Assets
Gross Property, Plant & Equipment
Accumulated Depreciation						Accumulated Depreciation should be entered as a negative number.
Net Property, Plant & Equipment		$-	$-	$-	$-
All Other Non-current Assets
Total Assets		$-	$-	$-	$-
Accounts Payable
Accrued Expense
Current Portion of LT Debts
All Other Current Liabilities
Total Current Liabilities		$-	$-	$-	$-
Long Term Capital Debt
All Other Long Term Liabilities
Total Long Term Liabilities		$-	$-	$-	$-
Total Liabilities		$-	$-	$-	$-
Unrestricted Fund Balance
Temporarily Restricted Fund Balance
Restricted Fund Balance
Total Net Assets		$-	$-	$-	$-
Total Net Assets + Total Liabilities		$-	$-	$-	$-
Income Statement
Net Inpatient Revenue (1) (6)
Net Outpatient Revenue (1) (6)
Patient Service Rev net of Contr. Allow. & discounts		$-	$-	$-	$-
Provision for Bad Debts
Net Patient service Revenue less Provision for Bad Debts		$-	$-	$-	$-
All Other Operating Revenue
Total Operating Revenue		$-	$-	$-	$-
Salaries & Wages
Physician Salaries & wages
Employee Benefits
Contract Physician Fees
Total Supplies Expense
Depreciation Expense (incl Lease Amortization)
Amortization Expense (excl Lease Amortization)
Interest Expense
Bad Debt Expense (1)
All Other Operating Expenses
Total Operating Expense		$-	$-	$-	$-
Income from Operations		$-	$-	$-	$-
All Non-Operating Revenue						For rows 69 to 71 Enter increases to Net Income as a positive number and decreases to Net Income as a negative number.
All Non-Operating Expense
Extraordinary Items & Income Tax Revenue
Net Income		$-	$-	$-	$-
Unrecognized Gains/Losses
Changes in Temp Restrict Net Assets
Other Changes in Fund Balance (2)
Net Increase/Decrease in Fund Balance		$-	$-	$-	$-
Mortage Reserve Fund
Required MRF Balance
Actual MRF Balance
FHA-Insured Mortgage
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages						For Row 83, for Borrowers with multiple FHA-insured mortgages, please input as a formula. (i.e. =(loan1amount+loan2amount)
Net Inpatient Revenue (1)		$-	$-	$-	$-
Medicare
Medicaid
Commercial Insurance
HMO/Managed Care
Self Pay
Other
Inpatient Utilization
Total Licensed Beds
Total Staffed Beds
Acute Medical/Surgical Service
Number of Beds
Discharges
Patient Days
Newborn Service
Number of Beds
Discharges
Patient Days
Other Acute Care Services
Number of Beds
Discharges
Patient Days
Other Non-Acute Care
Number of Beds
Discharges
Patient Days
Swing Bed (SNF)
Discharges
Patient Days
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)
ALOS (5)
Non-Medicare
Case Mix Index (3)
ALOS (5)
All Patients
Case Mix Index (3)
ALOS (5)
Inpatient Cost per Discharge
Outpatient Utilization
Emergency Room Visits
Observation Visits
Observation Days
Ambulatory Surgeries
Clinic Visits
Other Outpatient Visits
Staffing
Total Full-Time Equivalents (4)
Rows 135 and 136 ONLY APPLY if required by the Regulatory Agreement
Related Entity Liquid Investments
Related Entity non-liquid Investments
Rows 139 through 156 ONLY APPLY to Critical Access Hospitals. All other hospitals skip to row 157
Income Statement
Tax Revenues (that are included in revenue as reported in the income statement)
Utilization
Nursing home occupancy
Nursing home payor mix
Medicare
Medicaid
Private
Other
Observation Days
Respite Days
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
1.	Has the Hospital undertaken any major physical facility changes affecting operations (renovation, relocation, addition or deletion of services)?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
2.	Has the Hospital identified any positive or negative trends in service utilization statistics, financial indicators or ratios?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
3.	Have there been any significant achievements to the Hospital’s Strategic Long Range / Business Plan?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
4.	Has there been any change in Board membership or Executive Management?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants? Have actions or events triggered or required waivers or approvals from any financial institutions or other parties for violating financial, negative or reporting covenants?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A18+A19=A20		Yes	Yes	Yes	Yes
A17+A20+A21=A22		Yes	Yes	Yes	Yes
A22+A23+A24+A25+A28+A29=A30		Yes	Yes	Yes	Yes
A32+A33+A34+A35=A36		Yes	Yes	Yes	Yes
A37+A38=A39		Yes	Yes	Yes	Yes
A36+A38=A39		Yes	Yes	Yes	Yes
A41+A42+A43=A44		Yes	Yes	Yes	Yes
A40+A44=A45		Yes	Yes	Yes	Yes
A30=A45		Yes	Yes	Yes	Yes
Income Statement
A48+A49=A50		Yes	Yes	Yes	Yes
A50+A51+A53=A54		Yes	Yes	Yes	Yes
A56+A57+A58+A59+A60+A61+A62+A63+A64+A65=A66		Yes	Yes	Yes	Yes
A67+A69+A70+A71=A72		Yes	Yes	Yes	Yes
A72+A74+A75+A76=A77		Yes	Yes	Yes	Yes
A85+A86+A87+A88+A89+A90=A48		Yes	Yes	Yes	Yes
Various Edit Checks
A50<=A54		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
A54-A66+A69+A70+A71=A72		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp + extraordinary items = net income
A56+A57+A58+A59+A60+A61+A62+A63+A64<=A66		Yes	Yes	Yes	Yes	tot supplies exp + tot sal & benefits + prof. fees+dep exp + int exp + bad debt exp <= tot op exp
A17+A20+A21<=A22		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
A22+A25+A28<=A30		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
A30=A40+A41+A42+A43		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted +temporarily restricted + restricted net assets
A32+A33+A34<=A36		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= Current liabilities
A36+A37<=A40		Yes	Yes	Yes	Yes	total current liab + LT capital debt< = total liabilities
Enter the Total Net assets from Prior Year
A41+A42+A43-$B232-A72=A74+A75+A76		Yes	Yes	Yes	Yes	prior year net asset + net incom+other changes in net assets= current year net assets
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

---

Sheet 7: Monthly Reporting - 4th Qtr

Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING							OMB Approval No. 2502-0602
ENTER FYE HERE							(Exp. 05/31/2015)
ENTER HOSPITAL NAME HERE							form HUD-92422-OHF
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website or may be obtained from your account executive.
(B.) Please call your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in yellow.
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description	Entry Label	10th Month	11th Month	12th Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments
Gross Patient Receivables
Allowance for Doubtful Accounts						Allowance for doubtful accounts should be entered as a negative number.
Net Accounts Receivable		$-	$-	$-	$-
All Other Current Assets
Total Current Assets		$-	$-	$-	$-
Qualified Liquid Investments
Hospital Held Non-Liquid Qual. Invest.
Limited Use or Desginated Assets
Gross Property, Plant & Equipment
Accumulated Depreciation						Accumulated Depreciation should be entered as a negative number.
Net Property, Plant & Equipment		$-	$-	$-	$-
All Other Non-current Assets
Total Assets		$-	$-	$-	$-
Accounts Payable
Accrued Expenses
Current Portion of LT Debts
All Other Current Liabilities
Total Current Liabilities		$-	$-	$-	$-
Long Term Capital Debt
All Other Long Term Liabilities
Total Long Term Liabilities		$-	$-	$-	$-
Total Liabilities		$-	$-	$-	$-
Unrestricted Fund Balance
Temporarily Restricted Fund Balance
Restricted Fund Balance
Total Net Assets		$-	$-	$-	$-
Total Net Assets + Total Liabilities		$-	$-	$-	$-
Income Statement
Net Inpatient Revenue (1) (6)
Net Outpatient Revenue (1) (6)
Patient Service Rev net of Contr. Allow. & discounts		$-	$-	$-	$-
Provision for Bad Debts
Net Patient service Revenue less Provision for Bad Debts		$-	$-	$-	$-
All Other Operating Revenue
Total Operating Revenue		$-	$-	$-	$-
Salaries & Wages
Physician Salaries & wages
Employee Benefits
Contract Physician Fees
Total Supplies Expense
Depreciation Expense (incl Lease Amortization)
Amortization Expense (excl Lease Amortization)
Interest Expense
Bad Debt Expense (1)
All Other Operating Expenses
Total Operating Expense		$-	$-	$-	$-
Income from Operations		$-	$-	$-	$-
All Non-Operating Revenue						For rows 69 to 71 Enter increases to Net Income as a positive number and decreases to Net Income as a negative number.
All Non-Operating Expense
Extraordinary Items & Income Tax Revenue
Net Income		$-	$-	$-	$-
Unrecognized Gains/Losses
Changes in Temp Restrict Net Assets
Other Changes in Fund Balance (2)
Net Increase/Decrease in Fund Balance		$-	$-	$-	$-
Mortage Reserve Fund
Required MRF Balance
Actual MRF Balance
FHA-Insured Mortgage
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages						For Row 83, for Borrowers with multiple FHA-insured mortgages, please input as a formula. (i.e. =(loan1amount+loan2amount)
Net Inpatient Revenue (1)		$-	$-	$-	$-
Medicare
Medicaid
Commercial Insurance
HMO/Managed Care
Self Pay
Other
Inpatient Utilization
Total Licensed Beds
Total Staffed Beds
Acute Medical/Surgical Service
Number of Beds
Discharges
Patient Days
Newborn Service
Number of Beds
Discharges
Patient Days
Other Acute Care Services
Number of Beds
Discharges
Patient Days
Other Non-Acute Care
Number of Beds
Discharges
Patient Days
Swing Bed (SNF)
Discharges
Patient Days
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)
ALOS (5)
Non-Medicare
Case Mix Index (3)
ALOS (5)
All Patients
Case Mix Index (3)
ALOS (5)
Inpatient Cost per Discharge
Outpatient Utilization
Emergency Room Visits
Observation Visits
Observation Days
Ambulatory Surgeries
Clinic Visits
Other Outpatient Visits
Staffing
Total Full-Time Equivalents (4)
Rows 135 and 136 ONLY APPLY if required by the Regulatory Agreement
Related Entity Liquid Investments
Related Entity non-liquid Investments
Rows 139 through 156 ONLY APPLY to Critical Access Hospitals. All other hospitals skip to row 157
Income Statement
Tax Revenues (that are included in revenue as reported in the income statement)
Utilization
Nursing home occupancy
Nursing home payor mix
Medicare
Medicaid
Private
Other
Observation Days
Respite Days
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
1.	Has the Hospital undertaken any major physical facility changes affecting operations (renovation, relocation, addition or deletion of services)?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
2.	Has the Hospital identified any positive or negative trends in service utilization statistics, financial indicators or ratios?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
3.	Have there been any significant achievements to the Hospital’s Strategic Long Range / Business Plan?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
4.	Has there been any change in Board membership or Executive Management?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants? Have actions or events triggered or required waivers or approvals from any financial institutions or other parties for violating financial, negative or reporting covenants?
	1st Quarter
	2nd Quarter
	3rd Quarter
	4th Quarter
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A18+A19=A20		Yes	Yes	Yes	Yes
A17+A20+A21=A22		Yes	Yes	Yes	Yes
A22+A23+A24+A25+A28+A29=A30		Yes	Yes	Yes	Yes
A32+A33+A34+A35=A36		Yes	Yes	Yes	Yes
A37+A38=A39		Yes	Yes	Yes	Yes
A36+A38=A39		Yes	Yes	Yes	Yes
A41+A42+A43=A44		Yes	Yes	Yes	Yes
A40+A44=A45		Yes	Yes	Yes	Yes
A30=A45		Yes	Yes	Yes	Yes
Income Statement
A48+A49=A50		Yes	Yes	Yes	Yes
A50+A51+A53=A54		Yes	Yes	Yes	Yes
A56+A57+A58+A59+A60+A61+A62+A63+A64+A65=A66		Yes	Yes	Yes	Yes
A67+A69+A70+A71=A72		Yes	Yes	Yes	Yes
A72+A74+A75+A76=A77		Yes	Yes	Yes	Yes
A85+A86+A87+A88+A89+A90=A48		Yes	Yes	Yes	Yes
Various Edit Checks
A50<=A54		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
A54-A66+A69+A70+A71=A72		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp + extraordinary items = net income
A56+A57+A58+A59+A60+A61+A62+A63+A64<=A66		Yes	Yes	Yes	Yes	tot supplies exp + tot sal & benefits + prof. fees+dep exp + int exp + bad debt exp <= tot op exp
A17+A20+A21<=A22		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
A22+A25+A28<=A30		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
A30=A40+A41+A42+A43		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted +temporarily restricted + restricted net assets
A32+A33+A34<=A36		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= Current liabilities
A36+A37<=A40		Yes	Yes	Yes	Yes	total current liab + LT capital debt< = total liabilities
Enter the Total Net assets from Prior Year
A41+A42+A43-$B232-A72=A74+A75+A76		Yes	Yes	Yes	Yes	prior year net asset + net incom+other changes in net assets= current year net assets
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!