Based on the instructions below, some providers who apply for the Provider Relief Fund Phase 4 are required to submit the Annual Revenues Adjustment Worksheet (XLSX - 111 KB)*. The instructions indicate how and where various data elements are to be entered on the worksheet. Providers must upload the completed worksheet during the application process via the PRF Application and Attestation Portal.
For additional assistance with the application process, contact the Provider Support Line at 866-569-3522, for TTY dials 711. Hours of operation are 8 a.m. to 10 p.m. CT, Monday through Friday.
- Applicant Name — Enter the name of the entity applying.
- Applicant's Tax Identification Number — Enter the TIN without dashes.
- Gross Revenues — Enter the applicant's gross revenues minus discounts and allowances as shown on the applicant's federal income tax return or consolidated audited financial statements.
- Total Annual Revenues [Auto-populated] — This amount automatically populates from the sum of Gross Revenues (Cell A7) and the sum of Total Gross Revenues of entity or asset (Cells D17 and below).
Note: This amount must match the amount reported in Field 10 Total Annual Revenues in the application.
- Annual Net Patient Care Revenues — Enter the amount as shown on the applicant's supporting documentation uploaded in Field 15 according to the chart below:
|If the applicant for tax purposes is a…||Supporting documentation (upload in Field 15) is...||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.|
- Adjusted Annual Net Patient Care Revenues [Auto-populated] — This amount automatically populates from the sum of Annual Net Patient Care Revenues (Cell A11) and the sum of Net Patient Care Revenues of entity or asset (Cells E17 and below).
Note: This amount must match the amount reported in Field 12 Total Net Patient Care Revenues in the application.
- Acquisition and Disposition Information
- Subsidiary/Billing TIN — Enter the TIN, if available.
- Acquisition (A) or Disposition (D) — Enter "A" if the applicant acquired the entity or asset and "D" if the applicant disposed of the entity or asset.
- Name — Include name of the entity or asset as it appears in the applicant's federal income tax return.
- Total gross revenues — Enter the gross revenues for the entity or asset.
- Net patient care revenues — Enter the net patient care revenues for the entity or asset.
*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.