| |
Data Element |
| Entity Overview |
Repayment ID |
| Tax ID Number (TIN) |
| 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 Information (if applicable) |
TIN of Subsidiary |
Acquisition/Divestiture information
(If Applicable) |
TIN of Acquired/Divested Entity |
| PRF Payments to Recipient |
PRF Funds Received |
| Nursing Home Infection Control Funding Received |
| ARP Rural Funding Received |
| PRF Interest Earned |
Interest earned on PRF, Nursing Home Infection Control, and/or ARP Rural Funding |
| 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 |
General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period |
| Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period |
| ARP Rural Payment Expenditures |
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 |
General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period |
| Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period |
| Net Unreimbursed Expenses Attributable 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 |
Method used to calculate Lost Revenue |
| Upload PRF Reporting Workbook |
| 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 Budget approved prior to March 27th, 2020 |
| Attestation on accuracy of uploaded budget |
| Lost Revenues Option 3: Alternate Reasonable Methodology (If Applicable) |
Lost Revenue Estimate, Quarterly for Reporting Period |
| Upload Narrative Document describing methodology |
| Upload Calculation of Lost Revenues |
| Final Financial Verification |
Certification of accuracy of report |
| Agree to retain and maintain supporting documentation |