Rhode Island Hospital Licensing Fee

Hospital Licensing Fee
Form HCP-4
State of Rhode Island Division of Taxation

Form HCP-4
13112399990101

Hospital Licensing Fee Report
Name

Federal employer identification number

Address

For the period ending:

June
Report

July
Remittance

October 1, 2019 through September 30, 2020
Address 2

City, town or post office

State

E-mail address

ZIP code

Calculation of Amount Due:
1 Gross patient services revenue. See instructions....................................

1

2 Amount of Charity Care, Bad Debts Expense and Contract Allowances...

2

3 Net patient services revenue. Subtract line 2 from line 1.......................................................................

3

4 Net licensing fee due. Multiply line 3 by 5.656% (0.05656)....................................................................

4

5 Discount for hospitals located in Washington County ONLY. Multiply line 4 by 37% (0.3700)...............

5

6 AMOUNT DUE. Subtract line 5 from line 4.............................................................................................

6

7 Interest calculated at 1.5% per month. See instructions.........................................................................

7

8 Penalty calculated at 10%. See instructions ..........................................................................................

8

9 TOTAL AMOUNT DUE. Add lines 6, 7 and 8..........................................................................................

9

INSTRUCTIONS
NOTE: AS OUTLINED IN RIGL 23-17-38.1, THIS RETURN IS DUE BY
JUNE 15, 2022 EVEN THOUGH THE REMITTANCE IS NOT DUE UNTIL
JULY 13, 2022.

Line 5: Discount for Washington County hospitals. Pursuant to RIGL
23-17-38.1, hospitals located in Washington County, Rhode Island shall
receive a discount of 37% on the hospital license fee of 5.656% (0.05656).

Check the applicable box regarding which filing this return covers.
Line 6: Amount Due. Subtract line 5 from line 4.
Line 1: Gross Patient Services Revenue. Enter the amount reported on
line 1 of Worksheet G3, Medicare Hospital and Hospital Health Care
Complex Cost Report for the Hospital Fiscal Year ending September 30, 2020.
Line 2: Deductions. Enter the amount of Charity Care, Bad Debts
Expense and Contract Allowances.

Line 7: Interest. If remitting after July 13, 2022, multiply line 6 by 1.5%
(0.0150) times the number of months late. Interest is calculated from
July 13, 2022 to the date of remittance at a rate of 18% per annum.
Line 8: Penalty. If remitting after July 13, 2022 multiply line 6 by 10%
(0.1000). Penalty is calculated at 10% of the net licensing fee due.

Line 3: Net Patient Services Revenue. Subtract line 2 from line 1.
Line 4: Net Licensing Fee Due. Multiply line 3 by 5.656% (0.05656).

Line 9: Total Amount Due. Add lines 6, 7 and 8.

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Authorized officer signature
Print name
Date
Telephone number

Paid preparer signature

Paid preparer address

Print name

City, town or post office

Date

State

ZIP code

Telephone number

PTIN

May the Division of Taxation contact your preparer? YES
Revised
06/2022