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Are you a Sole Proprietor?

Required documentation on ERS Request

• Request for Extended Repayment Schedule Application Form
• Demand letter copies
• Amortization Schedule - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good faith payment - Equivalent to one-month payment

Required documentation on ERS Request

• Request for Extended Repayment Schedule Application Form
• Demand letter copies
• Amortization Schedule - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good faith payment - Equivalent to one-month payment

Are you a Sole Proprietor?

Required documentation on ERS Request

• Request for Extended Repayment Schedule application form
• Demand Letter Copies
• Amortization - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good Faith Payment - Equivalent to one-month payment
• A completed Form CMS-379 (Financial Statement of Debtor)
• Income Tax Return from the most recent calendar year
• Financial Statements of the debtor

Required documentation on ERS Request

• Request for Extended Repayment Schedule application form
• Demand Letter Copies
• Amortization - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good Faith Payment - Equivalent to one-month payment
• Balance Sheets - Provider's most current balance sheet and balance sheet for last completed balance sheet for most recent fiscal year. Note: If time period between balance sheets is less than 6 months (or provider cannot submit balance sheets prepared by its accountant), must submit balance sheets for last two complete fiscal years
• Income Statements - related to balance sheets. Note: If time period between income statements is less than 6 months (or provider cannot submit income statements prepared by its accountant), must submit income statements for last two complete fiscal years
• Cash Flow Statements - For periods covered by balance sheets. If date of request for an extended repayment plan is more than three (3) months after date of most recent balance sheet, a cash flow statement should be prepared for all months between that date and date of request
• Projected Cash Flow Statement - From date of request and covering remainder of fiscal year. If fewer than six (6) months remain, provider shall include a projected cash flow statement for following year
• List of restricted cash funds - by amounts as of date of request and purpose for which each fund is to be used, if applicable
• List of investments - by type (stock, bond, etc.), amount, and current market value as of date of report, if applicable
• List of notes and mortgages payable - by amounts as of date of report, and their due dates, if applicable
• Schedule showing amounts - due to and from related companies or individuals included in balance sheets. Schedule should show names of related organizations/persons, TIN and NPIs. It shall show where amounts appear on balance sheet, such as Accounts Receivable, Notes Receivable, etc.
• Schedule showing types - amounts of expenses (included in income statements) paid to related organizations. Schedule shall show names of related organizations, TIN and NPIs
• The percentage of occupancy – by type of patient (Medicare, Medicaid, private pay) and total available bed days for the periods the income statements cover, if applicable.
• Note: All financial records must be for the business participating in the program. It should not be for the owner if the business is a partnership or a corporation. If an outside facility manages the financial aspects of the business, the provider shall submit individual financial records as well as the financial records of the outside facility.

Are you a Sole Proprietor?

Required documentation on ERS Request

• Request for Extended Repayment Schedule application form
• Demand Letter Copies
• Amortization - If there are multiple ARs with multiple interest rates, multiple amortization schedules must be done
• Good Faith Payment - Equivalent to one-month payment
• Completed Form CMS-379 (Financial Statement of Debtor)
• Income Tax Return from most recent calendar year
• Financial Statements of debtor

Required documentation on ERS Request

• Request for Extended Repayment Schedule application form
• Demand Letter Copies
• Amortization
• Good Faith Payment - Equivalent to one-month payment
• Balance Sheets - Provider's most current balance sheet and balance sheet for last completed balance sheet for most recent fiscal year. Note: If time period between balance sheets is less than six (6) months (or provider cannot submit balance sheets prepared by its accountant), it must submit balance sheets for last two complete fiscal years
• Income Statements - related to balance sheets (preferably prepared by your accountant) Note: If time period between income statements is less than six (6) months (or provider cannot submit income statements prepared by its accountant), must submit income statements for last two complete fiscal years
• Cash Flow Statements - For periods covered by balance sheets. If date of request for an extended repayment plan is more than three (3) months after date of most recent balance sheet, a cash flow statement should be prepared for all months between that date and date of request
• Projected Cash Flow Statement - From date of request and covering remainder of fiscal year. If fewer than six (6) months remain, provider shall include a projected cash flow statement for following year
• List of restricted cash funds - by amounts as of date of request and purpose for which each fund is to be used, if applicable)
• List of investments - by type (stock, bond, etc.), amount, and current market value as of date of report, if applicable
• List of notes and mortgages payable – by amounts as of date of report, and their due dates, if applicable
• Schedule showing amounts - due to and from related companies or individuals included in balance sheets. Schedule should show names of related organizations/persons, TIN and NPIs. It shall show where amounts appear on balance sheet, such as Accounts Receivable, Notes Receivable, etc.
• Schedule showing types - amounts of expenses (included in income statements) paid to related organizations. Schedule shall show names of related organizations, TIN and NPIs
• Percentage of occupancy - by type of patient (Medicare, Medicaid, private pay) and total available bed days for periods income statements cover, if applicable
• Note: All financial records must be for the business participating in the program. It should not be for the owner if the business is a partnership or a corporation. If an outside facility manages the financial aspects of the business, the provider shall submit individual financial records as well as the financial records of the outside facility.