
Organization name: Corp number/CA SOS file number:__________________________
................................................ 1 □ □
.................................................................... 2a □ □
....................................................................................... 2b □ □
......................................................................................... 3a □ □
......................................... 3b □ □
........................................... 4a □ □
......
4b □ □
.................................................................... 4c □ □
... 5a □ □
. ............... 5e □ □
.................... 6a □ □
............................... 6b
Schedule 2B – Hospitals
Complete Schedule 2B only if the organization answered “Yes” to Specific Section D, Question 6b. Attach a statement to explain any answers.
1 Are all the doctors in the community eligible for staff privileges? Yes No
If “No,” give the reasons why and explain how the medical staff is selected.
2 a Does or will the organization provide medical services to all individuals in the community who can pay for themselves
or have private health insurance? Yes No
If “No,” explain.
b Does or will the organization provide medical services to all individuals in the community who participate in
Medicare? Yes No
If “No,” explain.
3 a Does or will the organization require persons covered by Medicare or Medicaid to pay a deposit before receiving
services? Yes No
If “Yes,” explain.
b Does the same deposit requirement, if any, apply to all other patients? Yes No
If “No,” explain.
4 a Does or will the organization maintain a full-time emergency room? Yes No
If “No,” explain why the organization does not maintain a full-time emergency room. Also, describe any emergency
services provided.
b Does the organization have a policy on providing emergency services to persons without apparent means to pay?
Yes No
If “Yes,” provide a copy of the policy.
c Does the organization have any arrangements with police, fire, and voluntary ambulance services for the delivery
or admission of emergency cases? Yes No
If “Yes,” describe the arrangements, including whether they are written or oral agreements. If written, submit copies of
all such agreements.
5 a Does the organization provide for a portion of the organization’s services and facilities to be used for charity patients? Ye
s No
If “Yes,” answer question 5b through question 5e.
b Explain the organization’s policy regarding charity cases, including how the organization distinguishes between charity
care and bad debts. Submit a copy of the written policy.
c Provide data on the organization’s past experience in admitting charity patients, including the amounts expended for
treating charity care patients and types of services provided to charity care patients.
d Describe any arrangements with federal, state, or local governments or government agencies for paying for the cost
of treating charity care patients. Submit copies of any written agreements.
e Does the organization provide services on a sliding fee schedule depending on financial ability to pay? Yes No
If “Y
es,” submit the sliding fee schedule.
6 a Does or will the organization carry on a formal program of medical training or medical research? Yes No
If “Yes,” describe such programs, including the type of programs offered, the scope of such programs, and affiliations
with other hospitals or medical care providers with which the organization carries on the medical training or research
programs.
b Does or will the organization carry on a formal program of community education? Yes No
If “Yes,” describe such programs, including the type of programs offered, the scope of such programs, and affiliations
with other hospitals or medical care providers with which the organization offers community education programs.
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Schedule 2B Hospitals continued
Side 10 FTB 3500 2021
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