Form 1 Data Form Elements

COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Payment Reporting Activities

PRF Reporting Activities - 4 Data Form Elements.xlsx

COVID-19 Provider Relief Fund (PRF) Reporting Activities

OMB: 0906-0068

Document [xlsx]
Download: xlsx | pdf
Data Element
Entity Overview Tax ID Number (TIN)
Provider Type
Provider Sub-Type
Business Name
Doing-Business-As Name - optional
Street 1+2
City
State
Zip
Filing Contact Name
Filing Contact Title
Filing Contact Phone Number
Filing Contact Email
Subsidiary Questionnaire Subsidiaries that are eligible health care providers?
Acquire or divest subsidiaries during the period of availability of funds?
Parent reporting on your behalf for General Dist.?
TIN of parent(s) reporting on your behalf
Were Targeted Distribution funds transferred to or by a Parent?
How much Targeted Distribution was transferred to the parent entity?

TIN of Subsidiary

Parent reporting on this TIN?
Acquisition/Divestiture information
(If Applicable)
TIN of Acquired/Divested Entity
Acquired or Divested?
Date of Acquisition or Divestiture
PRF Received for TIN
% Ownership
Did/Do you hold a controlling interest in this entity?
Certification of PRF Payments to Recipient PRF Funds received > $10k
PRF Interest Earned Interest earned on Nursing Home Infection Control
Interest earned on Other PRF
Single Audit Federal Tax Classification
Exempt Payee code (optional)
Exempt from FATCA Reporting Code
Fiscal Year End Date
Subjected to Single Audit?
Were PRF funds included in the audit?
Other Assistance Received during Period of Availability Treasury, Small Business Administration (SBA) and the CARES Act/Paycheck Protection Program (PPP), Quarterly for Reporting Period
FEMA CARES Act Funds, Quarterly for Reporting Period
CARES Act Testing, Quarterly for Reporting Period
Local, State, and Tribal Government Assistance, Quarterly for Reporting Period
Business Insurance, Quarterly for Reporting Period
Other Assistance, Quarterly for Reporting Period
Nursing Home Infection Control Payment Expenditures < $500K (If Applicable) General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period
Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period
Nursing Home Infection Control Payment Expenditures >= $500K (If Applicable) Mortgage/Rent, Quarterly for Reporting Period
Insurance, Quarterly for Reporting Period
Personnel, Quarterly for Reporting Period
Fringe Benefits, Quarterly for Reporting Period
Lease Payments, Quarterly for Reporting Period
Utilities/Operations, Quarterly for Reporting Period
Other General and Administrative Expenses, Quarterly for Reporting Period
Supplies, Quarterly for Reporting Period
Equipment, Quarterly for Reporting Period
Information Technology (IT), Quarterly for Reporting Period
Facilities, Quarterly for Reporting Period
Other Healthcare Related Expenses, Quarterly for Reporting Period
Other PRF Payment Expenditures < $500K General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period
Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period
Other PRF Payment Expenditures >= $500K Mortgage/Rent, Quarterly for Reporting Period
Insurance, Quarterly for Reporting Period
Personnel, Quarterly for Reporting Period
Fringe Benefits, Quarterly for Reporting Period
Lease Payments, Quarterly for Reporting Period
Utilities/Operations, Quarterly for Reporting Period
Other General and Administrative Expenses, Quarterly for Reporting Period
Supplies, Quarterly for Reporting Period
Equipment, Quarterly for Reporting Period
Information Technology (IT), Quarterly for Reporting Period
Facilities, Quarterly for Reporting Period
Other Healthcare Related Expenses, Quarterly for Reporting Period
Net Unreimbursed Expenses Atributable to Coronavirus Net General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period
Net Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period
Type of Lost Revenues Calculation Reporting on 2019 Actual Revenue, 2020 Budgeted Revenue, or Estimated Lost Revenue?
Lost Revenues Option 1: Revenue Actuals - 2019-2021 (If applicable) Medicare A + B, Quarterly for Reporting Period
Medicare C, Quarterly for Reporting Period
Medicaid/CHIP, Quarterly for Reporting Period
Commercial Insurance, Quarterly for Reporting Period
Self-Pay (No Insurance), Quarterly for Reporting Period
Other, Quarterly for Reporting Period
Lost Revenues Option 2: 2020 Budgeted to Actual (If Applicable) Medicare A + B, Quarterly for Reporting Period
Medicare C, Quarterly for Reporting Period
Medicaid/CHIP, Quarterly for Reporting Period
Commercial Insurance, Quarterly for Reporting Period
Self-Pay (No Insurance), Quarterly for Reporting Period
Other, Quarterly for Reporting Period
Upload Button for 2020/21 Budget approved prior to March 27th, 2020
Upload Button for Attestation by CEO, CFO, or Similar Responsibility on accuracy of Budget Submitted
Lost Revenues Option 3: Alternate Reasonable Methodology (If Applicable) Lost Revenue Estimate (2020/21), Quarterly for Reporting Period
Upload Narrative Document descibing methodology
Upload Calculation of Lost Revenues
Upload additional supporting documentation
Personnel Metrics Contracted Personnel
Contracted/Clinical
Non-clinical
Full-time Personnel
Clinical
Non-clinical
Part-time Personnel
Clinical
Non-clinical
Hired
Clinical
Non-clinical
Separated
Clinical
Non-clinical
Furloughed Personnel
Clinical
Non-clinical
Patient Metrics Number of Inpatient Admissions
Number of Outpatient Visits (In person and Telehealth)
Number of Emergency Department Visits
Number of Facility Resident Patients (for Long- and Short-term Residential Facilities)
Facility Metrics Number of Medical/Surgical Beds
Number of Critical Care Beds
Number of Other Beds
Survey Questions (Agree/Disagree) The PRF payments had a significant impact on my overall yearly finances.
(Yes/No) The PRF payment(s) helped maintain solvency and/or prevent bankruptcy.
(Check all that apply) PRF payments significantly affected my ability to
(Yes/No) The PRF payment(s) helped retain staff that otherwise would have been furloughed or terminated.
(Yes/No) The PRF payment(s) helped re-hire or re-activate staff from furlough.
(Agree/Disagree) The PRF payment(s) helped to make the changes needed to operate during the pandemic (e.g., by acquiring PPE, creating temporary facilities, providing for virtual visits, etc.).
(Check all that applies) PRF payment(s) helped facility operations and patient care by allowing our facility to
(Yes/No) The PRF payment(s) helped care for and/or treat patients with COVID-19 (for applicable treatment facilities).
Please describe the impact these funds had on the business or patient services. (Optional)
Final Financial Verification Reporting on RHC COVID-19 Testing complete?
Certification of accuracy of report
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