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Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

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    • Commissioners
    • Director's Office
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      • Arizona Rules
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      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • Divisions
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      • Accounting
      • Human Resources, Special Services and MIS
      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
      • Boiler Section
      • Elevator Section
      • Occupational Safety and Health (OSHA / ADOSH)
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
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    • Public Notices
    • News and Events
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  • Self-Insured Employer - Annual Hospital Report Form

Self-Insured Employer - Annual Hospital Report Form

Instructions

All Self-Insured Employers in the State of Arizona on Tax Plan B are required to file the annual Self-Insured Employer - Annual Hospital Report Form on or before February 15. The “Hospital Report” is required of self-insurers that operate a hospital or direct medical care, pursuant to A.R.S. §23-1070.

The annual tax forms required for each tax plan are listed below for your convenience.

plan aplan bplan c and plan r
Self-Insured Payroll ReportSelf-Insured Payroll ReportSelf-Insured Payroll Report
Self-Insured Medical ReportSelf-Insured Medical ReportSelf-Insured Medical Report
Self-Insured Injury Report Self-Insured Injury Report Self-Insured Injury Report
Arizona Substitute W-9 Self-Insured Hospital Report Arizona Substitute W-9 
 Arizona Substitute W-9  

The Self-Insured Employer - Annual Hospital Report Instructions provide information on completing the Self-Insured Employer - Annual Hospital Report Form. See the Self-Insured Employer - Annual Tax Letter for a list of all the forms required for closing out the most recently completed tax year.

Annual Hospital Report Requirements are as follows:

  • Lines 1 – 8             List the total cost of operations of the hospital for the calendar year
  • Lines 9 – 13           List all revenue received by the hospital during the calendar year
  • Lines 14 – 15         List the cash flow beginning of year and total cash available
  • Lines 16 – 19         List the cash flow for the calendar year


Please direct questions regarding the Annual Hospital Report to [email protected] or call (602) 542-1836.

Sign and Submit Form

Self-Insured Employer - Annual Hospital Report Form

Printer-Friendly Form

PDF icon 6613 Accounting_SelfInsEmployer_AnnualHospitalReport2021_Master.pdf

Related Forms

Insurance Carrier - Quarterly Tax Form
Insurance Carrier - Annual Tax Form 200
Self-Insured Employer - Quarterly Tax Form
Self-Insured Employer - Annual Payroll Report Form
Self-Insured Employer - Annual Medical Report Form
Self-Insured Employer - Annual Injury Report Form
Self-Insured Employer - Annual Hospital Report Form
Workers’ Compensation Liability Form
Self-Provider of Medical Benefits Form
Initial Application for Authority to Self-Insure
Notice of Self-Insurer’s Termination of Self-Insurance Form
Initial Pool Application for Authority to Self-Insure
Reversal Form for Reversing Automated Payment Processing
State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions

Official Website of the State of Arizona

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Contact Us:

Phoenix Office
800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

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