Form RPD-41323 Gross Receipts Tax Credit For Certain Unpaid Doctor Services

1 at the time the services were provided the person 2 at the time the services were provided the per 3 the charges are not reimbursable under a pro and County Health Care Act at the time the services were provided the person receiving the services had no health insurance at the time the services were provided the person receiving the services was not eligible for Enter the report period as shown on the attached CRS 1 Long Form For a report period beginning But not after Percentage of the value of unpaid for Medicaid; and gram established according to the Indigent Hos had health insurance that did not cover the ser July 1 2007 June 30 2008 33% July 1 2008 June 30 2009 67% July 1 2009 100% licensed osteopathic physician while on call to a hospital; Medicaid; and MM/DD/YY MM/DD/YY Name of doctor or business New Mexico CRS Identification No on or after (See exception) qualified health care services or had health insurance that did not cover the services provided; pital and County Health Care Act receiving the services had no health insurance or services under the Medicaid program administered by the New Mexico Human Services Department; son receiving the services was not eligible the charges are not reimbursable under a program established according to the Indigent Hospital The credit claimed will be applied against the taxpayers subsequent gross receipts tax liability resulting from medical care services performed by a licensed medical doctor or licensed osteopathic physician; The licensed medical doctor licensed osteopathic physician or licensed medical practice has reason to believe the bill for the services will not be paid because: The qualified health care services included in this claim remain unpaid one year after the date of billing; and The qualified health care services included in this claim were performed by a licensed medical doctor or a The value of the qualified health care services does not exceed 130% of the reimbursement rate for the through vices provided; 1 Enter the value of the unpaid qualified health care services included in this claim: 1 performed while on call to a hospital and 2 Enter the percentage rate of the credit applicable to this report period See rate chart and Exception for Delayed Billing in the instructions for this form 2 performed by the licensed medical doctor or licensed osteopathic physician whose previous unpaid services generated the credit being claimed 3 Multiply line 1 by line 2 and enter the product here This is the amount of the credit claimed in this report period This amount cannot exceed the amount of your current period CRS 1 Form Carry forward of the credit is not allowed A licensed medical practice that employs a licensed medical doctor or licensed osteopathic physician may claim the credit but only against the taxpayer s subsequent gross receipts tax liability resulting from medical care services that are: Compute the credit amount on the worksheet below and attach to the New Mexico CRS 1 Long Form Submit the CRS 1 Long Form and Form RPD 41323 Gross Receipts Tax Credit for Certain Unpaid Doctor Services on or before the due date of the return Mail to New Mexico Taxation and Revenue Department P O Box 25128 Santa Fe New Mexico 87504 5128 For assistance call (505) 476 3683 or your local district office Exception for Delayed Billing: If the actual billing date is more than 30 days from the date the services were performed the credit must be claimed at the rate for the report period that includes the one year anniversary of the 30th day follow ing the date the services were performed Use the rate for the applicable report period even though you cannot claim the credit until the report period that includes the one year anniversary of the actual date of billing If multiple rates for the same report period are needed complete lines 1 and 3 of Form RPD 41323 and attach a schedule of the value of unpaid qualified health care services and the applicable rate used to compute the credit GROSS RECEIPTS TAX CREDIT FOR CERTAIN UNPAID DOCTOR SERVICES HOW TO CLAIM THIS CREDIT: I certify that I have examined this return including accompanying returns and statements and to the best of my knowl edge and belief they are true correct and complete If you cannot electronically file you may submit the CRS 1 Long Form and Form RPD 41323 to Taxation and Revenue Department P O Box 25128 Santa Fe New Mexico 87504 5128 For assistance call (505) 476 3683 or your local district office Important: To qualify for the credit the medical services do not need to be performed at a hospital but must be related to being on call to the hospital INSTRUCTIONS Name and phone number of contact Rev 06/07/2011 RPD 41323 Signature of taxpayer or agent State of New Mexico Taxation and Revenue Department Tax credit for certain unpaid doctor services is subject to gross receipts tax The amount of tax credit for certain un paid doctor services is subject to gross receipts tax and must be included in gross receipts (Column D on the CRS 1 Long Form) in the report period during which the benefit of the tax credit is realized For claimants reporting gross receipts on a cash basis the credit is included in the report period in which the benefit of the credit is received For claimants reporting gross receipts on an accrual basis the credit is included in the report period in which the benefit of the credit is earned For example during the report period beginning July 1 2007 and ending July 31 2007 Doctor X qualifies for and claims the gross receipts tax credit for certain unpaid doctor services billed on July 5 2006 Doctor X reports gross receipts on a cash basis and receives benefit from the tax credit against the gross receipts tax due for the July 2007 report period in August 2007 when the tax due is offset by the claim for the tax credit The amount of the tax credit taken against the July 2007 liability is reported in Column D of the CRS 1 Long Form for the report period for August 2007 If Doctor X reports gross receipts on an accrual basis the receipts for the tax credit would be included in the July 2007 report period The amount of the credit for certain unpaid doctor services is: The following constitutes reason to believe the services will not be paid : The value of the health care services provided for which you are claiming the credit cannot exceed 130% of the reimburse ment rate for the health care services provided under the Medicaid program administered by the New Mexico Human Services Department Title To claim a credit for unpaid doctor services you may file your CRS 1 return online using the Department s web site at https://efile state nm us Underpay the tax liability owed for gross receipts by the amount of the credit claimed by making a partial payment If you claimed a credit in a prior report period and did not apply the full amount of the credit because the tax liability was less than the credit available you may not carry the credit forward to future report periods Mail in a copy of your confirmation page along with Form RPD 41323 Gross Receipts Tax Credit For Certain Unpaid Doctors Services to: Taxation and Revenue Department Attention CRS Unit P O Box 630 Santa Fe New Mexico 87504 0630 To claim this credit you must be able to certify all of the following I certify that: WHEN TO CLAIM THIS CREDIT: For qualified health care services billed on or after July 1 2006 the credit must be claimed in the report period that includes the one year an niversary of the date the person receiving the services was billed For qualified health care services billed prior to July 1 2006 the credit must be claimed in the report period begin ning July 1 2007 WHO MUST FILE THIS FORM: A licensed medical doctor licensed osteopathic physician or licensed medical practice may claim a credit against gross receipts taxes due for the value of unpaid bills for medical care services performed while on call to a hospital To qualify a licensed medical doctor or a licensed osteopathic physician must provide the medical services while on call to a hospital; the value of the medical care services must be unpaid one year after the date of bill ing and the licensed medical doctor or licensed osteopathic physician must have reason to believe the services will not be paid Carry forward of the credit is not allowed A licensed medical practice that employs a licensed medical doctor or licensed osteopathic physician may claim the credit but only against the gross receipts tax liability resulting from medical care services that are: 1) performed while on call to a hospital and 2) performed by the licensed medical doctor or licensed osteopathic physician whose previous unpaid services generated the credit being claimed Important: See the instructions for this form for further details regarding which unpaid medical services qualify and for details on what qualifies as reason to believe the services will not be paid