Accounting Self-Insured Employer Annual Hospital Report Form

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.