Attach a list of the following:

Any entity, person, or activity not identified in this surcharge worksheet may not be included in the hospital's coverage with the Patient's Compensation Fund.

Definitions:

Hospital bed - licensed hospital beds usually on a short-term basis for patients who are need of acute medical treatment and skilled nursing care 24 hours a day (Intensive diagnostic and invasive treatment for acute illness).

Mental Health/Mental and Physical Acute Rehab bed - Care, diagnosis, and treatment for acute psychiatric, emotionally challenged, and physically handicapped patients needing 24 hour supervision, assistance, and treatment.

Extended Care/Intermediate/Residential bed - nonacute occasional incidental medical and emergency assistance to residents living independently in retirement apartments and communities. Facilities provided with security and emergency call boxes. Some contact services are available to residents.

Nursing Home/Critical Extended Care bed - A step-down from acute medical care for patients still needing 24 hour nursing care usually for an extended or long-term basis. Skilled care services needed such as medication administration, tube feeding, injections, catheterizations, and other procedures ordered by a physician.

Health Institution/Assisted Living/Other bed - Subacute minor health care and related personal services to assist residents on an ongoing and regular basis. Minor nursing care and assistance in such activities as laundry, meal preparations, bathing, and social functions.

* Employed physician - A physician is considered an employee for PCF purposes if the hospital withholds and pays Social Security and Medicare taxes and pays unemployment tax on wages paid to the employee. If a physician is treated as an independent contractor for tax purposes, then he/she cannot be considered an employee for PCF purposes.

*Employed Physicians Sharing in Limits

The following rates reflect credits applied to the base rate.