Rhode Island Outpatient Health Care Facility Surcharge Return

Outpatient Health Care Facility Surcharge Return
2013 HCP-64_Layout 1
State of Rhode Island and Providence Plantations

Form HCP-64
Outpatient Health Care Facility Surcharge Return
Name

Federal employer identification number

Address

For the month ending:

MM/DD/YYYY
Address 2

City, town or post office

State

E-mail address

ZIP code

Calculation of Amount Due:
1 Net patient services revenue received.....................................................................................................

1

2 Outpatient health care facility surcharge. Multiply line 1 times 2% (0.02)..............................................

2

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

3

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

4

5 Total interest and penalty amount. Add lines 3 and 4.............................................................................

5

6 TOTAL AMOUNT DUE. Add lines 2 and 5..............................................................................................

6

INSTRUCTIONS
Line 1: Net Patient Services Revenue Received - Enter the
amount of all monies and other consideration received
for patient care services for the month being reported
on this return.

Line 4: Penalty - If remitting after the due date, multiply line 2
time 10% (0.10). Penalty is calculated at 10% of the
surcharge due.
Line 5: Total Interest and Penalty Amount - Add lines 3 and 4.

Line 2: Outpatient Health Care Facility Surcharge - Multiply
line 1 times 2.0% (0.02)

Line 6: Total Amount Due - Add lines 2 and 5.

Line 3: Interest - If remitting after the due date, multiply line 2
times 1.5% (0.015) times the number of months late.
Interest is calculated from the due date of the return to
the date of remittance at a rate of 18% per annum.

PAYMENTS MUST BE MADE BY ELECTRONIC FUNDS
TRANSFER (EFT).
For more information, visit www.tax.ri.gov/contact/ .

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

May the Division of Taxation contact your preparer? YES

Date

State

Telephone number

ZIP code

Revised 09/2013

PTIN

Key #76