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CHECKLIST A REQUIREMENTS FOR MEETING PROVIDER BASED STATUS All Facilities (On Campus & OffCampus1) Dignity Health Hospital (Main Provider): REQUIREMENTS 1. Licensure 2. Clinical Services Integrated
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Checklist A is a form used to report certain financial information related to assets held outside of the United States.
Individuals, entities, or organizations that meet the reporting requirements set by the IRS are required to file Checklist A.
Checklist A can be filled out manually or electronically through the IRS website using the instructions provided by the IRS.
The purpose of checklist A is to ensure that individuals and entities accurately report their foreign financial assets to the IRS.
Checklist A requires information such as the type of foreign financial assets, maximum value during the year, and information about the financial institution where the assets are held.
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