Organization Information | Mission and Key Planning/Assessment Documents | Programs | Expenditures | Optional Information
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FY Community Benefits Report

 mass ago

Organization Information
Organization Name:
Address:
Contact Name:
Contact Title:
Contact Department (Optional):
Address
(Optional, if different from above):
Phone:
Fax (Optional):
Email:
Website:
Organization Type:
For-Profit Status:
Health System:
Community Health Network Area (CHNA):
Regions Served:

Mission and Key Planning/Assessment Documents
Community Benefits Mission Statement:
Target Populations:
Name of Target Population Basis for Selection
Publication of Target Populations:

Community Health Needs Assessment
Date Last Assessment Completed:
Data Sources:
CHNA Document:

Implementation Strategy
Implementation Strategy Document:
Key Accomplishments of Reporting Year:
Plans for Next Reporting Year:

Self-Assessment
File Upload:

Community Benefits Programs

Expenditures
Total CB Program Expenditures:

CB Expenditures by Program Type

Subtotal Provided to Outside Organizations (Grant/Other Funding)
Direct Clinical Services:
Community-Clinical Linkages:
Total Population or Community-Wide Interventions:
Access/Coverage Supports:
Infrastructure to Support CB Collaborations Across Institutions:

CB Expenditures by Health Need
Chronic Disease with a Focus on Cancer, Heart Disease, and Diabetes:
Mental Health/Mental Illness:
Housing/Homelessness:
Substance Use:
Additional Health Needs Identified by the Community:

Other Leveraged Resources:

Net Charity Care Expenditures
HSN Assessment:
Total CB Expenditures:

Additional Information

(*Excluding expenditures that cannot be projected at the time of the report.)
Comments (Optional):

Optional Information
Publication Describing CB Initiatives:
Bad Debt:     
Bad Debt Certification:
Optional Supplement: