Get Form Hcp 65 Ri

Filling out the Form Hcp 65 Ri online can streamline the process for reporting your imaging services surcharge. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the Form Hcp 65 Ri online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by filling in your personal information in the designated fields, including your name, address, city, state, zip code, and phone number. Ensure that all entries are accurate and up-to-date.
3. Enter your Federal Employer Identification Number (EIN) in the appropriate field. This number is essential for processing your form.
4. Indicate the period for which you are reporting. Fill in the month and year clearly in the specified fields.
5. For Line 1, report your net patient imaging revenue received for the month. This amount should reflect all revenues for imaging services provided during the reporting period.
6. Calculate the imaging services surcharge for Line 2 by multiplying the amount from Line 1 by 2% (0.02). Enter this figure in the provided space.
7. If applicable, provide the interest amount in Line 3, calculated at 1.5% per month for any late submissions. Make sure to include the months late in your calculation.
8. For Line 4, if your remittance is late, apply a 10% penalty to the surcharge from Line 2. Input this total in the appropriate field.
9. In Line 5, add the amounts from Lines 3 and 4 to get the total interest and penalty amount.
10. Determine the total amount due by adding the amounts from Line 2 and Line 5. Enter this sum in Line 6.
11. Review all information for accuracy. After confirming that everything is correct, you have the option to save your changes, download or print the form.
12. Finally, ensure you include the required signatures and dates in the designated areas before submitting the form.

Complete your Form Hcp 65 Ri online and ensure timely submission for accurate handling of your surcharge.