(a) Every clinic holding a license shall, on or before the 15th day of March each year, file with the Department of Health Care Access and Information, upon forms to be furnished by the department, a verified report showing the following information relating to the previous calendar year:

1. (1) Number of patients served and descriptive information, including, but not limited to, age, gender, race, and ethnic background of patients.

2. (2) Number of patient visits by type of service, including all of the following:

   1. (A) Child health and disability prevention screens, treatment, and followup services.
   2. (B) Medical services.
   3. (C) Dental services.
   4. (D) Other health services.
3. (3) Total clinic operating expenses.
4. (4) Gross patient charges by payer category, including Medicare, Medi-Cal, the Child Health Disability Prevention Program, county indigent programs, other county programs, private insurance, self-paying patients, nonpaying patients, and other payers.
5. (5) Deductions from revenue by payer category, bad debts, and charity care charges.
6. (6) Additional information as may be required by the Department of Health Care Access and Information or the State Department of Public Health.