Application Instructions

Field 1

Contact Person Name

Enter the first and last name of a contact person who is authorized to submit the application and who can be contacted if HRSA has additional questions or needs to follow up. The application must be completed by an authorized representative of the applicant entity.

Field 2

Contact Person Title

Enter the title of the contact person listed in Field 1. If the applicant is an individual, enter “Individual.”

Field 3

Contact Person Phone Number

Enter the phone number where the contact person listed in Field 1 can best be reached. Do not include extensions.

Field 4

Contact Person Email

Enter the email address where the contact person listed in Field 1 can best be reached.

Tip: This will be the primary way that HRSA will contact you about next steps for the application, including urgent requests for additional information. Ensure that the email address is correct and the contact person will be responsive.

Field 5

Applicant/Provider Type

Select the single provider type that best describes your organization.

Fields 6-8 Intentionally Removed

Field 9

CMS Certification Number (CCN), if applicable

Enter the applicant’s CMS Certification Number (CCN). The applicant may enter more than one CCN.

Field 10

Total Annual Revenues

Enter the dollar amount of applicant’s total annual revenues number from its most recently filed federal income tax return of 2018, 2019, or 2020.  If the applicant is not required to file a tax return, enter the amount from its most recent audited financial statements.  If audited financial statements are not available for those periods, enter the amount from the entities most recent management-prepared financial statements, as applicable.

In general, the Total Annual Revenues may be found in the supporting documents at the location below.

If the applicant for tax purposes is a...	Supporting Documentation (Upload in Field 15)	Total Annual Revenues Location
Sole proprietor or disregarded entity owned by an individual	IRS Form 1040, Schedule C	Enter Line 7
Trust or estate	IRS Form 1041 including Schedule C	Enter Line 7
Partnership	IRS Form 1065	Enter Line 8
C corporation	IRS Form 1120	Enter Line 11
S corporation	IRS Form 1120-S	Enter Line 6
Tax-exempt organization	IRS Form 990	Enter Line 12
Not required to file federal income taxes (e.g. Government entities)	Most recent audited financial statements (or management-prepared financial statements).	Enter a "Total Annual Revenue" number or equivalent

REQUIREMENT: Applicants must complete Field 16 Annual Revenues Adjustments Worksheet (XLSX - 111 KB)* and Documentation if the applicant reports Total Annual Revenues (Field 10) that are more than 5% greater than or 50% less than the revenues on its most recent federal income tax return or financial statement (required in Field 15).

Field 11

Fiscal Year of Revenues

Enter the fiscal year of the source document for the Total Annual Revenues reported in Field 10.

Field 12

Annual Net Patient Care Revenues

Of the Total Annual Revenues entered in Field 10, enter dollar amount of the revenues for the delivery of services to patients. The amount reported must not include non-patient care revenues. In general, the net patient revenues may be found in the supporting documents at the location below.

If the applicant for tax purposes is a...	Supporting Documentation (upload in Field 15)	Annual Net Patient Care Revenues Location
Sole proprietor or disregarded entity owned by an individual	IRS Form 1040 including Schedule C	Enter Line 3, excluding any income reported on W-2.
Trust or estate	IRS Form 1041 including Schedule C	Enter Line 3, excluding any income reported on W-2.
Partnership	IRS Form 1065	Enter Line 1c minus Line 12.
C corporation	IRS Form 1120	Enter Line 1c minus Line 15.
S corporation	IRS Form 1120-S	Enter Line 1c minus Line 10.
Tax-exempt organization	IRS Form 990	Enter Line 9 minus any joint venture and any other non-patient care revenue included in Part VIII lines 2a – 2f.
Not required to file federal income taxes (e.g. state and local governments)	Most recent audited financial statements (or management-prepared financial statements)	Enter the dollar amount of Annual Net Patient Care Revenues
Applicant that files multiple tax returns or audited financial statements	N/A	Enter the dollar amount of annual patient care revenues for the applicant (including subsidiaries) only. See additional requirements at Field 17 Annual Revenues from Patient Care Worksheet and Field 18 Organizational Structure Documentation.
Applicant is part of a consolidated tax return or consolidated audited financial statements	N/A	Enter dollar amount of net patient care revenues for the applicant only. See additional requirements at Field 17 Annual Revenues from Patient Care Worksheet and Field 18 Organizational Structure Documentation.

In calculating Field 12 Annual Net Patient Care Revenues, applicants must eliminate all non-patient care revenues from Field 10 Total Annual Revenues.

REQUIREMENT: Applicants must complete and upload Field 16 Annual Revenues Adjustments Worksheet (XLSX - 111 KB)* if the applicant reports Annual Net Patient Care Revenues (Field 12) that is more than 5% greater than or 50% less than the patient revenues on its most recent federal income tax return or financial statement (required in Field 15).

Field 12.1

Type of Annual Revenues Documentation

From the drop down menu, select the type of federal income tax return, audited financial statements, and/or internally-generated financial statements uploaded in Field 15.

Fields 13.1 – 13.6

Operating Revenues from Patient Care

Enter the applicant’s operating revenues from patient care for each required time period.

By entering data in these fields, the applicant certifies that all operating expenses entered in 13.1 – 13.6 are attributable to patient care according to the definition of patient care revenue.

Fields 14.1 – 14.6

Operating Expenses from Patient Care

Enter the applicants operating expenses from patient care for each required time period.

By entering data in these fields, the applicant certifies that all operating expenses entered in Fields 14.1 – 14.6, are attributable to patient care according to the definition of patient care expenses.

Supporting Documentation: Total Annual Revenues and Annual Net Patient Care Revenues

Failure to submit the correct supporting documentation may result in HRSA deeming your application ineligible for payment.

Field 15

Annual Revenues Documentation

All applicants must upload the supporting documentation from the list below to justify the amounts reported in Field 10 Total Annual Revenues and Field 12 Annual Net Patient Care Revenues.

• If the applicant is required to file a federal income tax return, the applicant’s most recently filed federal income tax return for 2018, 2019, or 2020.
• If the applicant is exempt from filing a federal income tax return (e.g., a state-owned hospital or health care clinic), most recent audited financial statements.
• If the applicant does not have tax filings or audited financial statements, internally-generated financial statements such as:
  • Entities receiving Federal grants, the most recent four quarters of SF-425 forms; or
  • Eligible federal entities, the most recent annual report submitted to Unified Financial
  • Management System (UFMS).

If the applicant for tax purposes is a...	The applicant must submit:
Sole proprietor or disregarded entity owned by an individual	IRS Form 1040 including Schedule C
Trust or estate	IRS Form 1041 including Schedule C
Partnership	IRS Form 1065
C corporation	IRS Form 1120
S corporation	IRS Form 1120-S
Tax-exempt organization	IRS Form 990
Not required to file federal income taxes (e.g. Government entities)	Most recent audited financial statements (or management-prepared financial statements) and a statement explaining why the entity is not required to file a federal income tax form.

In uploading documentation in Field 15, the applicant must ensure:

• The federal income tax return, audited financial statements, or internally-generated financial statements is submitted in its entirety and clearly identifies the total annual revenues and Annual Net Patient Care Revenues attributable to the applicant TIN.
• The applicant TIN matches the TIN in the federal income tax return, audited financial statements, or internally-generated financial statements.

REQUIREMENTS: Failure to meet the following requirements may result in the application being deemed ineligible and HRSA will not make a payment.

The applicant must upload an Annual Revenues Adjustments Worksheet (XLSX - 111 KB)* and associated documentation in Field 16 if:

• The Total Annual Revenues (Field 10) is more than 5% greater than or 50% less than the total annual revenues in the supporting documentation uploaded in this field.
• The Annual Net Patient Care Revenues (Field 12) is more than 5% greater than or 50% less than the annual patient care revenues in the supporting documentation uploaded in this field.

The applicant must upload an Annual Revenues from Patient Care Worksheet (XLSX - 433 KB)* in Field 17 if, based on the supporting documentation uploaded in this field:

• The annual revenues are not entirely related to patient care.
• The Annual Net Patient Care Revenues versus non-patient care are not clearly identifiable.
• The supporting documentation does not identify that revenues are clearly attributable to the applicant.
• The parent entity is a applying on behalf of multiple subsidiaries.
• The applicant TIN does not match the TIN in the federal income tax return, audited financial statements, or internally-generated financial statements.

The applicant must upload Organizational Structure Documentation in Field 18 if the applicant’s TIN does not match TIN in the supporting documentation uploaded in this field.

Field 16

Annual Revenues Adjustments Worksheet

Applicants must complete and upload the Annual Revenues Adjustments Worksheet (XLSX - 111 KB)* if the applicant reports Total Annual Revenues (Field 10) that is more than 5% greater or 50% less than the annual revenues on its most recent federal income tax return or financial statement (uploaded in Field 15).  The applicant must:

1. Complete and upload Annual Revenues Adjustments Worksheet reporting on acquisitions or dispositions from the date of sale through the Phase 4 application deadline;
2. Include supporting documentation for any adjustments reflected on the worksheet (e.g., internally-generated financial statements, valuation reports that would reflect revenue, and budget-to-actual revenues comparisons); and
3. Ensure that Field 10 Total Annual Revenues equals the adjusted revenues amount on line 4 of the Annual Revenues Adjustments Worksheet.

Field 17

Annual Revenues from Patient Care Worksheet

The applicant must complete and upload an Annual Revenues from Patient Care Worksheet (XLSX - 433 KB)* if the information in the Annual Revenues Documentation (uploaded in Field 15):

• Includes revenues that is not completely and clearly related to patient care.
• Does not clearly identify patient care versus non-patient care revenues.
• Does not clearly identify revenues attributable to the applicant.
• Indicates a complex parent entity applying on behalf of multiple subsidiaries.
• The applicant TIN does not match the TIN in the federal income tax return, audited financial statements, or internally-generated financial statements. 

The applicant must ensure that the worksheet:

• Breaks out the proportion of revenues from non-patient and patient care by billing TIN.
• Breaks out the patient care revenues from other revenues such as tuition, prescription sales, etc.
• Equals the total annual revenues reflected in the applicant’s federal income tax return, audited financial statements, or internally-generated financial statements, as applicable.
• Includes subsidiaries that are pharmacies or durable medical equipment (DME) suppliers in order to ensure the applicant is accurately reporting non-patient care revenues and expenses.

Field 18

Organizational Structure Documentation

The applicant must upload documentation to clarify the applicant’s organizational structure if:

• The applicant TIN does not match the TIN in the supporting documentation uploaded in Field 15 Annual Revenues Documentation.
• The applicant believes their organizational structure or supporting documentation may impact their eligibility for payment.

The applicant must submit supporting documentation to clarify the nature of their organizational structure, including but not limited to:

• Documentation of the legal relationship between the applicant and the federal income tax return, audited financial statements, or internally-generated financial statements uploaded in Field 15.
• CMS change of ownership tie-in notification.
• Purchase or disposition documents.

Supporting Documentation: Operating Revenues and Expenses from Patient Care

Guidelines for Supporting Documentation: For Fields 19 and 20, applicants must upload supporting documents substantiating operating revenues and expenses reported in Fields 13.1 – 13.6 and 14.1 – 14.6, respectively.  Examples of supporting documents include internally-generated financial statements or a classified trial balance groupings report. 

The applicant must conform to the guidelines for supporting documentation:

• The applicant verifies that all operating expenses and revenues included in the uploaded supporting documentation is attributable to patient care according to the definition of patient care revenue below.
• Internally-generated financial statements or a classified trial balance groupings report must clearly reconcile themselves to the claimed amounts in the application and include the following:
  • Patient Care Operating Revenues
    • Net patient service revenues (gross charges minus contractual adjustments)
    • Exclude “other operating revenue” and non-operating revenue, such as investment income, joint venture income, etc.
  • Patient Care Operating Expenses:
    • Salaries and benefits
    • Supplies
    • Professional services
    • Administrative
    • Depreciation
    • Interest
  • If support is broken down by individual months within a quarter, applicants must ensure the total is equal to the respective quarterly amount.
• If the applicant is applying on behalf of subsidiaries, the applicant must submit quarterly financial information by TIN:
  • Quarterly net patient revenues and quarterly patient care operating expenses must be clearly identifiable to each individual TIN that is part of the application. 
  • Prescription sales revenues must be identified by quarter by TIN.
• Applicants should not include quarterly payroll reports.

Failure to submit the correct supporting documentation may result in HRSA deeming your application ineligible for payment.

Field 19

Supporting Documents for 2020 Q3 and Q4 and 2021 Q1 Operating Revenues and Expenses from Patient Care

Upload supporting documents substantiating operating revenues and expenses reported in Fields 13.4, 13.5, 13.6, 14.4, 14.5, and 14.6 in accordance with the guidelines for supporting documentation.

Field 20

Supporting Documents for 2019 Q1, Q3, and Q4 Operating Revenues and Expenses from Patient Care

Upload supporting documents substantiating operating revenues and expenses reported in Fields 13.1, 13.2, 13.3, 14.1, 14.2., and 14.3 in accordance with the guidelines for supporting documentation.

Field 21

Rural Provider Application

Select “Yes” if your organization would like to be considered for an ARP Rural payment.

In order to be considered for an ARP Rural payment, you must list all billing entity TINs that may have provided services to rural patients with Medicare, Medicaid, and/or Children’s Health Insurance Program coverage.  HRSA will only review TINs for eligibility that are submitted in the Application Portal.  Please see the Federal Office of Rural Health Policy definition of rural for additional information.

Applicants must also acknowledge the ARP Rural Terms and Conditions (PDF - 221 KB) in the event that the applicant receives ARP Rural Payments.

Fields 22-32 intentionally removed

Field 33 to Field 36

Banking Information

Enter the applicant’s banking information necessary to receive an electronic payment.

TIP: HRSA requires entities receiving payments greater than $100,000 to set up an ACH account.  HRSA recommends that applicants sign up for an Automated Clearing House (ACH) account at the same time they submit an application.  This will prevent delays in issuing payment once an application has been approved.

Field 37

Terms and Conditions Acknowledgement

Applicants must acknowledge the Phase 4 Terms and Conditions (PDF - 213 KB) in the event that the applicant receives funds under this distribution.

*Note: Persons using assistive technology may not be able to fully access information in this file. For assistance, please email the Provider Relief Bureau at PRBInformation@hrsa.gov.