CMS-2540-96 Cost Reports

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Overview

S
S2
S3
S-3II
S4
S4-III
S5
S6
S7-I
S7-III
s7-II2
S7-IV
S8
A
A6
A7
A8
A81
A82
A83-1
A83-2
A83-3
A84-1
A84-2
A-8-5
B
B-1
B-II
B-III
B-1-2
B-2
C
D
DII
D-1
D-2
E-I
E-II
E-III
E-V
E1
G
GII
G-1
G-2
G-3
H
H-1
H-2
H-3
H-4
H-5
H-6
H-7
J-1-I
J-1-II
J-1-III
J-1-III2
J-2
J-3
J-3II
J-4
I1
I2
I3
I4
I-5
K
K-1
K-2
K-3
K-4-1
K-4-2
K-5-1
K-5-II
K-5-III
K6

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Sheet 1: S

10-03						FORM CMS 2540-96				3590 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim										FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).										OMB NO. 0938-0463
SKILLED NURSING FACILITY AND						PROVIDER NO.:	PERIOD:
SKILLED NURSING FACILITY HEALTH							FROM ___________________		WORKSHEET S
CARE COMPLEX COST REPORT						______________________	TO ______________________		PARTS I & II
Intermediary		[		]	Audited	Date Received	____________	[ ] Intial	[ ] Re-opened
use only:		[		]	Desk Reviewed	Intermediary No.	____________	[ ] Final
PART I - CERTIFICATION
Check [		[		]	Electronic filed cost report		Date:____________
applicable box [		[		]	Manually submitted cost report		Time:____________
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THE COST REPORT MAY
BE PUNISHABLE BY CRIMINAL, CIVIL AND ANDMINISTRATIVE ACTION, FINE AND / OR IMPRISONMENT
UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED
OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
	I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically
	filed or manually submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by
	______________________________________________________________________ (Provider Names(s) and Number(s)
	for the cost reporting period beginning _________________________ and ending __________________________
	and that to the best of my knowledge and belief, it is a true, correct and complete statement prepared from
	the books and records of the provider in accordance with applicable instructions,except as noted. I further
	certify that I am familiar with the laws and regulations regarding the provision of health care services, and
	that the services identified in this cost report were provided in compliance with such laws and regulations.
	(Signed)_______________________________________________							_________________________________
	Officer or Administrator of Provider(s)								Title
								_________________________________
									Date
PART II - SETTLEMENT SUMMARY
							TITLE XVIII
						TITLE V	A	B	TITLE XIX
						1	2	3	4
1.	SKILLED NURSING FACILITY									1.
2.										2
3.	NURSING FACILITY									3
3.1	I C F / M R									3.1
4.	SNF - BASED H H A									4
5.	SNF - BASED OUTPATIENT									5
	REHABILITATION PROVIDERS
6.	SNF - BASED RHC / FQHC									6
7.	TOTAL									7
The above amounts represent "due to" or "due from" the applicable Program for the element of the above complex indicated.
(Indicate Overpayments in Brackets.)
	According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
	control number. The valid OMB control number for this information collection is 0938-0463. The time required to complete this information collection
	is estimated to average 64 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and
	complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving
	this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FORM CMS-2540-96 ( 7/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB. 15-II, SECTIONS 3506 THROUGH 3506.2 )
Rev. 13										35-303

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Sheet 2: S2

3590 (Cont.)			FORM CMS 2540-96								10-03																						.
SKILLED NURSING FACILITY				PROVIDER NO.:		PERIOD			WORKSHEET
AND SKILLED NURSING FACILITY						FROM_____________			S - 2
COMPLEX IDENTIFICATION DATA				_______________	____________________	TO_______________
Skilled Nursing Facility and Skilled Nursing Facility Complex Address:
1	Street:				P.O Box:						1
2	City:				State:		Zip Code:				2
3	County:				MSA Code:		Urban / Rural:				3
3.1	Facility Specific Rate:			Transition Period - enter 1, 2, 3 or 100							3.1
3.2	Wage Index Adjustment Factor: Before October 1					After Sept 30					3.2
SNF and SNF-Based Component Identification:
								Payment System
						Date		(P, O, or N)
	Component		Component Name		Provider No.	Certified		V	XVIII	XIX
	0		1		2	3		4	5	6
4	S N F										4
5											5
6	Nursing Facility										6
6.1	I C F / M R										6.1
7	SNF-Based O.L.T.C.										7
8	SNF-Based H.H.A.										8
9											9
10	SNF-Based Outpatient										10
	Rehabilitation Providers
11	SNF-Based R.H.C.										11
12	SNF-Based HOSPICE										12
13	Cost Reporting Period (mm/dd/yyyy)			From:		To:					13
14	Type of Control (See Instructions)										14
Type of Freestanding Skilled Nursing Facility										Y / N
15	Is this an Entirely Participating Skilled Nursing Facility?										15
	A notice published in the "Federal Register" Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG
	payments beginning 10/01/2003. Congress expected this increase to be used for direct patient care and related
	expenses. Enter in column 1 the percentage of total expenses for each category to total SNF revenue from
	Worksheet G-2, Part I line 1 column 3. Indicate in column 2 "Y" for yes or "N" for no if the spending reflects
	increases associated with direct patient care andrelated expenses for each category. (See instructions)
15.01	Staffing										15.01
15.02	Recruitment										15.02
15.03	Retention of employees										15.03
15.04	Training										15.04
15.05	Other (Specify)										15.05
16	Is this a Partially Participating Skilled Nursing Facility?										16
17	Is this Skilled Nursing Facility Unit of a Domiciliary Institution?										17
18	Is this Skilled Nursing Facility Unit of a Rehabilitation Center?										18
19	Other ( Specify)										19
Miscellaneous Cost Reporting information
20	If this is a low or no Medicare utilization cost report, enter "L" for Low										20
	Medicare Utilization, or "N" for No Medicare Utilization.
21	If this is an All-Inclusive Provider, enter the method used. (See Instruction)										21
22	Is the difference between total interim payments and the net cost covered										22
	service included in the balance sheet?
FORM CMS-2540-96 ( 10/2003 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB 15-II, SECTION 3508 )
35-304											Rev. 13
10-03			FORM CMS 2540-96								3590 (Cont.)
SKILLED NURSING FACILITY				PROVIDER NO.:		PERIOD			WORKSHEET
AND SKILLED NURSING FACILITY						FROM_____________			S - 2
COMPLEX IDENTIFICATION DATA				_______________	____________________	TO__________			(Continued)
Depreciation Enter the amount of depreciation reported in this SNF for the method indicated.
23	Straight Line										23
24	Declining Balance										24
25	Sum of the Year's Digits										25
26	Sum of line 23 thru 25										26
27	If depreciation is funded, enter the balance as of the end of the period.										27
28	Were there any disposal of capital assets during the cost reporting period? (Y/N)										28
29	Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)										29
30	Was accelerated depreciation claimed on assets acquire on or after August 1, 1970 (1) (Y/N)										30
31	Did you cease to participate in the Medicare program at end of the period to which this cost report applies (1)										31
32	Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports (1)										32
If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of
costs or charges enter "Y" for each component and type of service that qualifies for the exemption.								Part A	Part B	Other
33	Skilled Nursing Facility										33
34											34
35	Nursing Facility										35
35.1	I C F / M R										35.1
36	SNF-Based O.L.T.C.										36
37	SNF-Based H.H.A.										37
38											38
39	SNF-Based Outpatient Rehabilitation Providers										39
40	SNF-Based R.H.C.										40
41	Is this Skilled Nursing Facility exempt from the cost limits?										41
42	Is this Nursing Facility exempt from the cost limits?										42
43	Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless										43
	of the level of care given for titles V and XIX patients.
44	Did the provider participate in the NHCMQ Demonstration during the cost reporting period?										44
	(See instructions) If yes, enter Phase #
45	List malpractice premiums and paid losses:			Premiums		Paid Losses		Self insurance
											45
46	Are malpractice premiums and paid losses reported in other than the Administrative and General cost
	center? Enter Y or N. If yes, check box, and submit supporting schedule listing cost centers and amounts										46
47	Are you claiming ambulance costs? Enter Y or N in column 1. If column 1 is Y, enter in column 2										47
	whether this is your first year of operation for rendering ambulance services.
48	If line 47, column 1 is yes, enter in column 1 the payment limit provided from your										48
	intermediary. If your fiscal year is OTHER than a year beginning on October 1st, enter
	in column 1 the payment limit for the period prior to October 1, and enter in column 2 the payment limit for the period
	beginning October 1. NOTE: Ifline 47, column 2 is yes, no entry is required on line 48 (column 1 or 2).
49	Did you operate an Intermediate Care Facility for the Mentally Retarded (ICF/MR) under title XIX?										49
50	Did this facility report less than 1500 Medicare days in its pevious year's cost report? (See instructions.)										50
51	If line 50 is yes, did you file your previous years cost report using the "Simplified" step-down method of cost										51
	finding? See instructions for qualifications to use the simplified step-down method before answering line 52.
52	Is this cost report being filed under 42 CFR 413.321, the "simplified" cost report? Enter "Y" for yes or "N" for no.										52
FORM CMS-2540-96 ( 10/2003 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB, 15-II, SECTION 3508)
Rev. 13											35-305

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Sheet 3: S3

3590 (Cont.)						FORM CMS 2540-96							10-03
SKILLED NURSING FACILITY AND						PROVIDER NO.:			PERIOD			WORKSHEET S-3
SKILLED NURSING FACILITY HEALTH CARE COMPLEX									FROM____________________			PART I
STATISTICAL DATA
		Number	Bed	I n p a t i e n t D a y s					D i s c h a r g e s
		of	Days	Title	Title	Title		Total	Title	Title	Title		Total
	Component	Beds	Available	V	XVIII	XIX	Other		V	XVIII	XIX	Other
		1	2	3	4	5	6	7	8	9	10	11	12
1	Skilled Nursing Facility													1
2														2
3	Nursing Facility													3
3.1	ICF/MR													3.1
4	Other Long Term Care													4
5	Home Health Agency													5
6														6
7	SNF-Based Outpatient													7
	Rehabilitation Providers
8	Hospice													8
9	Total (Sum of lines 1-8)													9
10	Ambulance Trips													10
												Full Time
			Average Length of Stay				A d m i s s i o n s					Equivalent
			Title	Title	Title	Total	Title	Title	Title		Total	Employees	Nonpaid
			V	XVIII	XIX		V	XVIII	XIX	Other		on Payroll	Workers
			13	14	15	16	17	18	19	20	21	22	23
1	Skilled Nursing Facility													1
2														2
3	Nursing Facility													3
3.1	ICF/MR													3.1
4	Other Long Term Care Facility													4
5	Home Health Agency													5
6														6
7	SNF-Based Outpatient													7
	Rehabilitation Providers
8	Hospice													8
9	Total (Sum of lines 1-8)													9
10	Ambulance trips													10
FORM CMS 2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3509 )
35-306														Rev. 13

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Sheet 4: S-3II

08-01			FORM CMS 2540-96					3590(Cont.)
		PROVIDER NO.:		PERIOD:		WORKSHEET S-3
SNF WAGE INDEX INFORMATION				FROM __________		PARTS II & III
		______________		TO _____________
			Reclass.	Adjusted	Paid Hours	Average
			of Salaries	Salaries	Related	Hourly Wage
PART II DIRECT SALARIES		Amount	from Wkst.	(col. 1 ±	to Salary	(col. 3 ÷	Data
		Reported	A-6	col. 2)	in col. 3	col. 4)	Source
		1	2	3	4	5	6
1	Total salary (See Instructions)							1
2	Physician salaries-Part A							2
3	Physician salaries-Part B							3
4	Interns & Residents (approved)							4
5	Home office personnel							5
6	Sum of lines 2 thru 5							6
7	Revised wages (line 1 minus line 6)							7
8	Other Long Term Care							8
9	Other Inpatient Routine Service							9
10	Interns & Residents							10
	(Not In Approved Program)
11	HHA							11
12	Outpatient Rehabilitation Providers							12
13	Hospice							13
14	Non-reimbursable							14
15	Total Excluded salary							15
	(Sum of lines 8 through 14)
16	Subtotal (line 7 minus line 15)							16
17	Contract Labor: Patient Related & Mgmt						CMS 339	17
18	Home office salaries & wage related costs							18
19	Wage related costs (core)						CMS 339	19
20	Wage related costs (other)						CMS 339	20
21	Wage related costs (excluded units)						CMS 339	21
22	Subtotal (see instructions)							22
23	Total (see instructions)							23
24	Contract Labor: Physician services-Part A							24
PART III - OVERHEAD COST - DIRECT SALARIES
			Reclass.	Adjusted	Paid Hours	Average
			of Salaries	Salaries	Related	Hourly Wage
		Amount	from	(col. 1 ±	to Salary	(col. 3 ÷
		Reported	Wkst. A-6	col. 2)	in col. 3	col. 4)
		1	2	3	4	5
1	Employee Benefits							1
2	Administrative & General							2
3	Plant Operation, Maintenance & Repairs							3
4	Laundry & Linen Service							4
5	Housekeeping							5
6	Dietary							6
7	Nursing Administration							7
8	Central Services and Supply							8
9	Pharmacy							9
10	Medical Records &							10
	Medical Records Library
11	Social Service							11
12	Interns & Records (Apprvd Tching Prog)							12
13	Other General Service (specify)							13
14	Total (sum lines 1 thru 13)							14
FORM CMS-2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3509.1 - 3509.2)
Rev. 11								35-307

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Sheet 5: S4

3590 (Cont.)					FORM CMS 2540-96							08-01
						PROVIDER NO.:		PERIOD:
	SNF - BASED HOME HEALTH AGENCY STATISTICAL DATA						_	FROM ____________		WORKSHEET S-4
						HHA NO.: _______________		TO _______________		PARTS I & II
Check One:		[ ]	Title V	[ ]	Title XVIII	[ ]	Title XIX
	PART I - HOME HEALTH AGENCY VISITS
				Program			Non-Program Data			Total
	DESCRIPTION	Hours		Visits	Patients	Hours	Visits	Patients	Hours	Visits	Patients
		1		2	3	4	5	6	7	8	9
1	Skilled Nursing											1
2	Physical Therapy											2
3	Occupational Therapy											3
4	Speech Pathology											4
5	Medical Social Services											5
6	Home Health Aide											6
7	All Other Services											7
8	Total Visits ( Sum of lines 1 - 7)											8
9	Unduplicated Census Count											9
	Full Cost Repoting Period
9.01	Unduplicated Census Count											9.01
	Pre 10/01/2000
9.02	Unduplicated Census Count											9.02
	Post 09/30/2000
					HHA NO. OF FTE EMPLOYEES 2080 HRS			Footnotes:
	PART II - EMPLOYMENT DATA						(Sum of
					Staff	Contract	Cols. 1+2)	1. This category includes all nurses, i.e., RNs, LPNs, LVNs.
	Enter the number of hours in your normal work week.				1	2	3	A nurse supervisor (if part of her time is spent performing
1	Nurses - RNs		(1)					visits) should be included in this category.
2	Nurses - LPN							2. Includes administrators, assistant administrators, directors,
3	Nurses - LVN							assistant directors, and supervisors (if sole function is
4	Physical Therapists							administrative).
5	Occupational Therapists							3. Includes accountants, internal auditiors, statisticians
6	Speech Pathologists							and other professional financial personnel.
7	Medical Social Workers							4. Includes categories such as billing, payroll clerks, secretaries,
8	Home Health Aides							telephone operators, personnel specialists, security personnel,
9	Homemaker							maintenance staff, and other administrative employees.
10	Executive Administrative Personnel		(2)					5. All other employee classifications. These include, but are
11	Financial Administrative Personnel		(3)					not limited to respiratory therapists, nutritionists, and
12	General Administrative Personnel		(4)					any other employees not included in any of the other
13	Other		(5)					employee classifications.
14
15
16	How many MSAs did you provide services to during this cost reporting period.											16
17	List the MSA code(s) serviced during this cost reporting period (line 17 contains the first code).											17
	(Subscript this line for each MSA code being reported.)
FORM CMS - 2540-96 ( 08/2001 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3511 - 3511.2 )
35-308												Rev. 11

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Sheet 6: S4-III

08-01				FORM CMS 2540-96						3590 (Cont.)
				PROVIDER NO.:		PERIOD:
SNF - BASED HOME HEALTH AGENCY					_	FROM ____________		WORKSHEET S-4
STATISTICAL DATA				HHA NO.: _______________		TO _______________		PART III
	PART III PPS ACTIVITY DATA - Applicable for Services Rendered on and after October 1, 2000
			Full Episodes		L U P A	P E P only	S C I C Within	S C I C Only
	DESCRIPTION		Without Outliers	With Outliers	Episodes	Episodes	a P E P	Episodes	Totals
			1	2	3	4	5	6	7
1	Skilled Nursing Visits									1
2	Skilled Nursing Visit Charges									2
3	Physical Therapy Visits									3
4	Physical Therapy Visit Charges									4
5	Occupational Therapy Visits									5
6	Occupational Therapy Visit Charges									6
7	Speech Pathology Visits									7
8	Speech Pathology Visit Charges									8
9	Medical Social Service Visits									9
10	Medical Social Service Visit Charges									10
11	Home Health Aide Visits									11
12	Home Health Aide Visit Charges									12
13	Total Visits									13
	(Sum of lines 1, 3, 5, 7, 9, & 11)
14	Other Charges									14
15	Total Charges									15
	(Sum of lines 2, 4, 6, 8, 10, 12 & 14)
16	Total Number of Episodes									16
17	Total Number of Outlier Episodes									17
18	Total Non-Routine Medical Supply Charges									18
FORM CMS - 2540-96 ( 08/2001 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3511 - 3511.3 )
Rev. 11										35-308.1

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Sheet 7: S5

11-98							FORM CMS 2540-96										3590 (Cont.)
SNF - BASED RURAL HEALTH CLINIC						PROVIDER NO:				PERIOD:
FEDERALLY QUALIFIED HEALTH						_______________________________				FROM____________________					WORKSHEET
CENTER STATISTICAL DATA						COMPONANT NO:				TO_______________________					S - 5
						________________________
Check applicable box:					[ ] RHC		[ ] FQHC
PART I - STATISTICAL DATA
1	Street:												County:				1
2	City:								State:				Zip Code:				2
3	Designation (for FQHC's only) - Enter "R" for rural or "U" for urban																3
Source of Federal funds:													Grant Award		Date
4	Community Health Center (Section 330(d), PHS Act)																4
5	Migrant Health Center (Section 329(d), PHS Act)																5
6	Health Services for the Homeless (Section 340(d), PHS Act)																6
7	Appalachian Regional Commission																7
8	Look - Alikes																8
9	Other (specify)																9
										Physician Name					Billing #
10	Physician(s) furnishing services at the clinic or under agreement (See instructions)																10
										Physician Name					Hours
11	Supervisory physician(s) and hours of supervision during period. (See instructions)																11
12	Does the facility operate as other than an RHC or FQHC? If yes, indicate the number of other operations in column 2.														1	2
	List other type(s) of operation(s) and hours on subscripts of line 13 below.																12
	NOTE: line 13 (Clinic) is to be completed reguardless of the response to line 12.
	Facility hours of operations (1)
			Sunday		Monday		Tuesday		Wednesday		Thursday		Friday		Saturday
			from	to	from	to	from	to	from	to	from	to	from	to	from	to
	0		1	2	3	4	5	6	7	8	9	10	11	12	13	14
13	Clinic																13
13.01																	13.01
13.02																	13.02
13.03																	13.03
	(1) List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400.
14	Have you received an approval for an exception to the productivity standard?																14
15	Is this a consolidated cost report in accordance with CMS Pub 27, section 508D. If yes, enter in column 2 the number of																15
	providers included in this report. List the names of all providers and numbers on subscripted lines below.
15.01	Provider Name										Provider Number						15.01
15.02	Provider Name										Provider Number						15.02
16	Have you provided all or substantially all GME cost. If yes, enter in column 2 the number of Medicare visits performed by I&R																16
FORM CMS-2540-96 ( 10/98 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3512)
Rev. 4																	35-309

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Sheet 8: S6

3590 (Cont.)						FORM CMS 2540-96					11-98
								PROVIDER NO.:	PERIOD:
SKILLED NURSING FACILITY BASED									FROM ____________	WORKSHEET S-6
OUTPATIENT REHABILITATION STATISTICAL DATA								REHAB NO.: _______________	TO _______________
Check Applicable Box:		[ ]	C.M.H.C.	[ ]	OPT	[ ]	OSP
		[ ]	C.O.R.F.	[ ]	OOT
	NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
	Employment Category: Enter the number of hours							Staff	Contract	Total
	in your normal work week ( ).							1	2	3
1	Administrator and Assistant Administrators										1
2	Directors and Assistant Directors										2
3	Other Administrative Personnel										3
4	Directing Nursing Service										4
5	Nursing Supervisor										5
6	Physical Therapy Service										6
7	Physical Therapy Supervisor										7
8	Occupational Therapy Service										8
9	Occupational Therapy Supervisor										9
10	Speech Pathology Service										10
11	Speech Pathology Supervisor										11
12	Medical Social Service										12
13	Medical Social Service Supervisor										13
14	Respiratory Therapy Service										14
15	Respiratory Therapy Supervisor										15
16	Psychological Service										16
17	Psychological Service Supervisor										17
18											18
19											19
FORM CMS - 2540-96 ( 10/98 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3513 )
35-310											Rev. 4

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Sheet 9: S7-I

11-98				FORM CMS 2540-96				3590 (Cont.)
NHCMQ DEMONSTRATION			PROVIDER NO.		PERIOD:		WORKSHEET S-7
AND					FROM ____________		PART I
PPS STATISTICAL DATA			________________		TO
PART I - NHCMQ DEMONSTRATION STATISTICAL DATA
	> > FOR COST REPORTING PERIODS BEGINNING PRIOR TO JULY 1, 1998 < <
		M3PI	SERVICES PRIOR TO		SERVICES ON OR AFTER
	GROUP	REVENUE	JANUARY 1ST (1)		JANUARY 1ST (1)		TOTAL
		CODE	RATE	DAYS	RATE	DAYS	(See Instructions)
	1	2	3	3.01	4	4.01	5
1	RVC	9044						1
2	RVB	9043						2
3	RVA	9042						3
4	RHD	9041						4
5	RHC	9040						5
6	RHB	9039						6
7	RHA	9038						7
8	RMC	9037						8
9	RMB	9036						9
10	RMA	9035						10
11	RLB	9034						11
12	RLA	9033						12
13	SE3	9032						13
14	SE2	9031						14
15	SE1	9030						15
16	SSC	9029						16
17	SSB	9028						17
18	SSA	9027						18
19	CD2	9026						19
20	CD1	9025						20
21	CC2	9024						21
22	CC1	9023						22
23	CB2	9022						23
24	CB1	9021						24
25	CA2	9020						25
26	CA1	9019						26
27	IB2	9018						27
28	IB1	9017						28
29	IA2	9016						29
30	IA1	9015						30
31	BB2	9014						31
32	BB1	9013						32
33	BA2	9012						33
34	BA1	9011						34
35	PE2	9010						35
36	PE1	9009						36
37	PD2	9008						37
38	PD1	9007						38
39	PC2	9006						39
40	PC1	9005						40
41	PB2	9004						41
42	PB1	9003						42
43	PA2	9002						43
44	PA1	9001						44
45	Other Group	9000						45
46	TOTAL							46
(1)	Calendar Year Providers: Complete columns 1, 2, 4, 4.01, and 5
	Fiscal Year Providers - Rate change as of January 1st: Complete ALL columns.
	Fiscal Year Providers - Rate DOES NOT change as of January 1st: Complete columns 1, 2, 3, 3.01, and 5.
FORM CMS-2540-96 ( 10/98 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3514)
Rev. 4								35-311
A
{APP1}/PCOPQ
/PRCRSA1.H84~G
/PRCRSK1.S84~G

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Sheet 10: S7-III

12-99											FORM CMS 2540-96								3590 (Cont.)
									PROVIDER NO.				PERIOD:
	PPS STATISTICAL DATA												FROM ____________				WORKSHEET S-7
									________________				TO _______________				PART III
TRANSITION PERIOD:			[ ]	YEAR # 1		[ ]	YEAR # 2		[ ]	YEAR # 3		[ ]	YEAR # 4 - 100% Federal Case Mix Rate
	HIPPS	FACILITY		SERVICES PRIOR TO 10/01				SERVICES AFTER 9/30				SUBTOTAL				YR 1: Col. 9 = Col. 7 X 25%
	CODE	SPECIFIC		FEDERAL		DAYS		FEDERAL		DAYS		FEDERAL		FACILITY		Col. 10 = Col. 8 X 75%
	GROUP	RATE		CASE MIX				CASE MIX				CASE MIX		SPECIFIC		YR 2: Col. 9 = Col. 7 X 50%
				RATE				RATE				(Col. 3 X 4,		(Col. 4 + 6 X		Col. 10 = Col. 8 X 50%
												PLUS		Col. 2)		YR 3: Col. 9 = Col. 7 X 75%
												Col . 5 X 6)				Col. 10 = Col. 8 X 25%
	1	2		3		4		5		6		7		8		9		10
1	RUC																		1
2	RUB																		2
3	RUA																		3
4	RVC																		4
5	RVB																		5
6	RVA																		6
7	RHC																		7
8	RHB																		8
9	RHA																		9
10	RMC																		10
11	RMB																		11
12	RMA																		12
13	RLB																		13
14	RLA																		14
15	SE3																		15
16	SE2																		16
17	SE1																		17
18	SSC																		18
19	SSB																		19
20	SSA																		20
21	CC2																		21
22	CC1																		22
FORM CMS-2540-96 ( 12/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3514.3)
Rev. 7																			35-312.1
3590 (Cont.)											FORM CMS 2540-96								12-99
									PROVIDER NO.				PERIOD:
	PPS STATISTICAL DATA												FROM ____________				WORKSHEET S-7
									________________				TO _______________				PART III
TRANSITION PERIOD:			[ ]	YEAR # 1		[ ]	YEAR # 2		[ ]	YEAR # 3		[ ]	YEAR # 4 - 100% Federal Case Mix Rate
	HIPPS	FACILITY		SERVICES PRIOR TO 10/01				SERVICES AFTER 9/30				SUBTOTAL				YR 1: Col. 9 = Col. 7 X 25%
	CODE	SPECIFIC		FEDERAL		DAYS		FEDERAL		DAYS		FEDERAL		FACILITY		Col. 10 = Col. 8 X 75%
	GROUP	RATE		CASE MIX				CASE MIX				CASE MIX		SPECIFIC		YR 2: Col. 9 = Col. 7 X 50%
				RATE				RATE				(Col. 3 X 4,		(Col. 4 + 6 X		Col. 10 = Col. 8 X 50%
												PLUS		Col. 2)		YR 3: Col. 9 = Col. 7 X 75%
												Col . 5 X 6)				Col. 10 = Col. 8 X 25%
	1	2		3		4		5		6		7		8		9		10
23	CB2																		23
24	CB1																		24
25	CA2																		25
26	CA1																		26
27	IB2																		27
28	IB1																		28
29	IA2																		29
30	IA1																		30
31	BB2																		31
32	BB1																		32
33	BA2																		33
34	BA1																		34
35	PE2																		35
36	PE1																		36
37	PD2																		37
38	PD1																		38
39	PC2																		39
40	PC1																		40
41	PB2																		41
42	PB1																		42
43	PA2																		43
44	PA1																		44
45	Default Rate																		45
75	TOTAL																		75
FORM CMS-2540-96 ( 12/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3514.3 )
35-312.2																			Rev. 7

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Sheet 11: s7-II2

3590 (Cont.)					FORM CMS 2540-96					11-98
NHCMQ DEMONSTRATION					PROVIDER NO.		PERIOD:
AND							FROM ____________		WORKSHEET S-7
PPS STATISTICAL DATA					________________		TO _______________		PART II
PART II - PPS STATISTICAL DATA
	> > FOR COST REPORTING PERIODS BEGINNING ON AND AFTER JULY 1, 1998 < <
		GROUP		REVENUE		MEDICARE
				CODE		DAYS
		1		2		3
	1	RUC		9044				1
	2	RUB		9043				2
	3	RUA		9042				3
	4	RVC		9041				4
	5	RVB		9040				5
	6	RVA		9039				6
	7	RHC		9038				7
	8	RHB		9037				8
	9	RHA		9036				9
	10	RMC		9035				10
	11	RMB		9034				11
	12	RMA		9033				12
	13	RLB		9032				13
	14	RLA		9031				14
	15	SE3		9030				15
	16	SE2		9029				16
	17	SE1		9028				17
	18	SSC		9027				18
	19	SSB		9026				19
	20	SSA		9025				20
	21	CC2		9024				21
	22	CC1		9023				22
	23	CB2		9022				23
	24	CB1		9021				24
	25	CA2		9020				25
	26	CA1		9019				26
	27	IB2		9018				27
	28	IB1		9017				28
	29	IA2		9016				29
	30	IA1		9015				30
	31	BB2		9014				31
	32	BB1		9013				32
	33	BA2		9012				33
	34	BA1		9011				34
	35	PE2		9010				35
	36	PE1		9009				36
	37	PD2		9008				37
	38	PD1		9007				38
	39	PC2		9006				39
	40	PC1		9005				40
	41	PB2		9004				41
	42	PB1		9003				42
	43	PA2		9002				43
	44	PA1		9001				44
	45	Other Group		9000				45
	46	TOTAL						46
FORM CMS-2540-96 ( 10/98 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3514.2 )
35-312										Rev. 4
A
{APP1}/PCOPQ
/PRCRSA1.H84~G
/PRCRSK1.S84~G

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Sheet 12: S7-IV

01-01			FORM CMS 2540-96						3590 (Cont.)
PROSPECTIVE PAYMENT FOR SNF				PROVIDER NO.:		PERIOD:		WORKSHEET S-7
STATISTICAL DATA						FROM:		PART IV
						TO:
		M3PI	SERVICES PRIOR TO		SERVICES ON OR AFTER		HIGH COST	TOTAL
		REVENUE	October 1		October 1		RUGs (2)	(see
	GROUP (1)	CODE	RATE	DAYS	RATE	DAYS	DAYS	instructions)
	1	2	3	3.01	4	4.01	4.05	5
1	RUC								1
2	RUB								2
3	RUA								3
4	RVC								4
5	RVB								5
6	RVA								6
7	RHC								7
8	RHB								8
9	RHA								9
10	RMC								10
11	RMB								11
12	RMA								12
13	RLB								13
14	RLA								14
15	SE3								15
16	SE2								16
17	SE1								17
18	SSC								18
19	SSB								19
20	SSA								20
21	CC2								21
22	CC1								22
23	CB2								23
24	CB1								24
25	CA2								25
26	CA1								26
27	IB2								27
28	IB1								28
29	IA2								29
30	IA1								30
31	BB2								31
32	BB1								32
33	BA2								33
34	BA1								34
35	PE2								35
36	PE1								36
37	PD2								37
38	PD1								38
39	PC2								39
40	PC1								40
41	PB2								41
42	PB1								42
43	PA2								43
44	PA1								44
45	Default rate								45
46	TOTAL								46
(1) The RUG III category represents the PPS period. Enter in column 3.01 the days prior to October 1st and in column 4.01 the days on or after October 1st.
(2) Enter in column 4.05 those days which are contained in either column 3.01 or 4.01 which cover the period of 4/1/2000 through 9/30/2000.
These RUGs receive a 20% payment increase added to the total in column 5.
FORM CMS-2540-96 (01/2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3508)
Rev. 10									35-312.3

---

Sheet 13: S8

3590 (Cont.)

FORM CMS-2540-96

12-00

PROVIDER NO.:

PERIOD:

HOSPICE IDENTIFICATION DATA

FROM _____________

WORKSHEET S - 8

HOSPICE NO.:

_____________

TO ________________

PART I

Title XVIII

Title XIX

Title XVIII

Title XIX

Unduplicated

Unduplicated

Other

Total

Unduplicated

Unduplicated

Skilled Nursing

Nursing

Unduplicated

Unduplicated

Enrollment Days

Medicare Days

Medicaid Days

Facility Days

Facility Days

Days

Days

1

2

3

4

5

6

1

Continuous Home Care

1

2

Routine Home Care

2

3

Inpatient Respite Care

3

4

General Inpatient Care

4

HCFA Software Control:

5

Total Hospice Days

5

PART II

Title XVIII

Title XIX

Skilled

Title XVIII

Title XIX

Nursing facility

Nursing Facility

Other

Total

1

2

3

4

5

6

6

Number of Patients Receiving Hospice Care

6

7

Total Number of Unduplicated Continuous

Care Hours Billable to Medicare

7

8

Average Length of Stay

8

9

Unduplicated Census Count

9

FORM CMS-2540-96 ( 12/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3515 )

35-312.4

Rev. 10

---

Sheet 14: A

01-01					FORM CNS 2540-96						3590 (Cont.)
					PROVIDER NO.:		PERIOD:					.
RECLASSIFICATION AND ADJUSTMENT							FROM ________________		WORKSHEET A
OF TRIAL BALANCE OF EXPENSES					_________________		TO ________________
							RECLASSI-	RECLASSIFIED	ADJUSTMENTS	NET EXPENSES
							FICATIONS	TRIAL	TO EXPENSES	FOR COST
			COST CENTER	SALARIES	OTHER	TOTAL	Increase/Decrease	BALANCE	Increase/Decrease	ALLOCATION
			(Omit Cents)			( Col 1 + Col 2 )	( Fr Wkst A-6 )	( Col 3 +/- Col 4 )	( Fr Wkst A-8 )	( Col 5 +/- Col 6 )
A	B	C	D	1	2	3	4	5	6	7
GENERAL SERVICE COST CENTERS
1	0100	x	Captial-Related Costs - Building & Fixture								1
2	0200	x	Capital-Related Costs - Moveable Equipment								2
3	0300	x	Employee Benefits								3
4	0400	x	Administrative and General								4
5	0500	x	Plant Operation, Maintenance and Repairs								5
6	0600	x	Laundry and Linen Service								6
7	0700	x	Housekeeping								7
8	0800	x	Dietary								8
9	0900	x	Nursing Administration								9
10	1000		Central Services and Supply								10
11	1100		Pharmacy								11
12	1200		Medical Records and Library								12
13	1300		Social Service								13
14	1400		Intern & Residents (Apprvd Tchng Prog.)								14
15			Other General Service Cost								15
INPATIENT ROUTINE SERVICE COST CENTERS
16	1600	x	Skilled Nursing Facility								16
17											17
18	1800	x	Nursing Facility								18
18.1	1810	x	Intermediate Care Facility - Mentally Retarded								18.1
19	1900	x	Other Long Term Care								19
20			Other Inpatient Routine Cost								20
ANCILLARY SERVICE COST CENTERS
21	2100	x	Radiology								21
22	2200	x	Laboratory								22
23	2300	x	Intravenous Therapy								23
24	2400	x	Oxygen (Inhalation) Therapy								24
25	2500	x	Physical Therapy								25
26	2600	x	Occupational Therapy								26
27	2700	x	Speech Pathology								27
28	2800	x	Electrocardiology								28
29	2900	x	Medical Supplies Charged to Patients								29
30	3000	x	Drugs Charged to Patients								30
31	3100	x	Dental Care - Title XIX only								31
32	3200	x	Support Surfaces								32
33		x	Other Ancillary Service Cost Center								33
		x	Indicates the lines to be used under the Simplified Method
FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3516 )
Rev. 10											35-313
3590 (Cont.)					FORM CMS 2540-96						01-01
					PROVIDER NO.:		PERIOD:					.
RECLASSIFICATION AND ADJUSTMENT							FROM ________________		WORKSHEET A
OF TRIAL BALANCE OF EXPENSES					_________________		TO ________________
			COST CENTER				RECLASSI-	RECLASSIFIED	ADJUSTMENTS	NET EXPENSES
				SALARIES	OTHER	TOTAL	FICATIONS	TRIAL	TO EXPENSES	FOR COST
			(Omit Cents)				Increase/Decrease	BALANCE	Increase /Decrease	ALLOCATION
						( Col 1 + Col 2 )	( Fr Wkst A-6 )	( Col 3 +/- Col 4 )	( Fr Wkst A-8 )	( Col 5 +/- Col 6 )
A	B	C	D	1	2	3	4	5	6	7
OUTPATIENT SERVICE COST CENTERS
34	3400		Clinic								34
35	3500		Rural Health Clinic (RHC)								35
36			Other Outpatient Service Cost								36
OTHER REIMBURSABLE COST CENTERS
37	3700		Administrative and General - HHA								37
38	3800		Skilled Nursing Care - HHA								38
39	3900		Physical Therapy - HHA								39
40	4000		Occupational Therapy - HHA								40
41	4100		Speech Pathology - HHA								41
42	4200		Medical Social Services - HHA								42
43	4300		Home Health Aide - HHA								43
44	4400		Durable Medical Equipment - Rented - HHA								44
45	4500		Durable Medical Equipment - Sold - HHA								45
46	4600		Home Delivered Meals - HHA								46
47	4700		Other Home Health Services - HHA								47
48	4800		Ambulance								48
49	4900		Intern and Resident (Not Apprvd Tchng Prog)								49
50	5000		Outpatient Rehabilitation Provider								50
51			Other Reimbursable Cost								51
SPECIAL PURPOSE COST CENTERS
52	5200		Malpractice Premiums & Paid Losses								52
53	5300		Interest Expense							- 0 -	53
54	5400	x	Utilization Review -- SNF							- 0 -	54
55	5500		Hospice							- 0 -	55
56		x	Other Special Purpose Cost								56
57	5700		Subtotals								57
NON REIMBURSABLE COST CENTERS
58	5800		Gift, Flower, Coffee Shops and Canteen								58
59	5900	x	Barber and Beauty Shop								59
60	6000		Physicians' Private Offices								60
61	6100		Nonpaid Workers								61
62	6200		Patients Laundry								62
63		x	Other Non Reimbursable Cost								63
75		x	TOTAL								75
		x	Indicates the lines to be used under the Simplified Method
FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3516 )
35-314											Rev. 10

---

Sheet 15: A6

11-98					FORM CMS 2540-96						3590 (Cont.)
					PROVIDER NO:		PERIOD:
	RECLASSIFICATIONS						FROM _________________________		WORKSHEET A-6
					__________________________________		TO __________________
	EXPLANATION OF	CODE		I N C R E A S E				D E C R E A S E
	RECLASSIFICATION ENTRY	(1)	COST CENTER	LN NO.	SALARY	NON SALARY	COST CENTER	LN NO.	SALARY	NON SALARY
		1	2	3	4	5	6	7	8	9
1											1
2											2
3											3
4											4
5											5
6											6
7											7
8											8
9											9
10											10
11											11
12											12
13											13
14											14
15											15
16											16
17											17
18											18
19											19
20											20
21											21
22											22
23											23
24											24
25											25
26											26
27											27
28											28
29											29
30											30
31											31
32											32
33											33
34											34
35											35
36	TOTAL RECLASSIFICATIONS (Sum of column 4 and 5 must										36
	equal sum of column 8 and 9, line 36)			(2)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.						(2) Transfer to Worksheet A, column 4, line as appropriate.
FORM CMS-2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3517 )
Rev. 4											35-315

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Sheet 16: A7

3590 (Cont.)			FORM CMS 2540-96					11-98
	ANALYSIS OF CHANGES DURING		PROVIDER NO:		PERIOD:
	COST REPORTING PERIOD IN				FROM ________________________		WORKSHEET A - 7
	CAPITAL ASSET BALANCES		______________________________		TO ______________________
				Acquisitions		Disposals
		Beginning				and	Ending
	Description	Balances	Purchases	Donation	Total	Retirements	Balance
		1	2	3	4	5	6
1	Land					( )		1
2	Land Improvements					( )		2
3	Buildings and Fixtures					( )		3
4	Building Improvements					( )		4
5	Fixed Equipment					( )		5
6	Movable Equipment					( )		6
7	TOTAL					( )		7
FORM CMS-2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3518 )
35-316								Rev. 4

---

Sheet 17: A8

11-98		FORM CMS 2540-96						3590 (Cont.)
		PROVIDER NO.		PERIOD:
	ADJUSTMENTS TO EXPENSES			FROM ____________		WORKSHEET A-8
		________________		TO _____________
		(2)			EXPENSE CLASSIFICATION ON
	(1)	BASIS FOR			WORKSHEET A - TO / FROM WHICH
	DESCRIPTION	ADJUST-			THE AMOUNT IS TO BE ADJUSTED
		MENT	AMOUNT		COST CENTER		LINE NO.
		1	2		3		4
1	Investment income on restricted funds (ch.2)							1
	funds (chapter 2)
2	Trade, quantity and time discounts							2
	on purchases (chapter 8)
3	Refunds and rebates of expenses (Chapter 8)							3
4	Rental of provider space by suppliers (Chapter 8)							4
5	Telephone services (pay stations							5
	excluded) (chapter 21)
6	Television and radio service (Chapter 21)							6
7	Parking lot (chapter 21)							7
8	Remuneration applicable to provider-	Worksheet						8
	based physician adjustment	A-8-2
9	Home office costs (chapter 21)							9
10	Sale of scrap, waste, etc. (chapter 23)							10
11	Nonallowable costs related to certain							11
	Capital expenditures (chapter 24)
12	Adjustment resulting from transactions	Worksheet						12
	with related organizations (chapter 10)	A-8-1
13	Laundry and Linen service							13
14	Revenue - Employee meals							14
15	Cost of meals - Guests							15
16	Sale of medical supplies to other than patients							16
17	Sale of drugs to other than patients							17
18	Sale of medical records and abstracts							18
19	Vending machines							19
20	Income from imposition of interest,							20
	finance or penalty charges (chapter 21)
21	Interest expense on Medicare overpayments							21
	and borrowings to repay Medicare overpayments
22	Other Adjustment	( 3 )						22
23	Other Adjustment	( 3 )						23
24	Adjustment for respiratory therapy	( 3 )			Oxygen (Inhalation)			24
	costs in excess of limitation (chapter 14)				Therapy		24
25	Adjustment for physical therapy	( 3 )						25
	costs in excess of limitation				Physical Therapy		25
26	Adjustment for HHA physical therapy	See						26
	costs in excess of limitation	Instructions			Physical Therapy--HHA		39
27	SUBTOTAL (Sum of lines 1-26)							27
28	Utilization review--physicians'							28
	compensation (chapter 21)				Utilization Review- SNF		54
29	Depreciation--buildings and fixtures				Capital Related Cost- Building		1	29
30	Depreciation--movable equipment				Capital Related Cost-Movable			30
					Equipment		2
31	Other Adjustment							31
32	TOTAL (line 27 plus the sum of lines 28 - 31)							32
	(Transfer to Worksheet A, col. 6, line 75)
(1) Description--all chapter references in this column pertain to CMS Pub. 15-I
(2) Basis for adjustment		A. Costs--if costs, including applicable overhead, can be determined.
		B. Amount Received--if cost cannot be determined.
(3) See Instructions to report therapy services provided on and after April 10, 1998.
FORM CMS-2540-96 ( 10/98 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3519 )
Rev. 4								35-317

---

Sheet 18: A81

3590 (Cont.)				FORM CMS 2540-96						11-98
STATEMENT OF COSTS				PROVIDER NO:		PERIOD:
OF SERVICES FROM						FROM _____________		WORKSHEET A-8-1
RELATED ORGANIZATIONS				___________________		TO ___________
A. Are there any costs included in Worksheet A which resulted from transactions with related
organizations as defined in CMS Pub. 15-I, chapter 10?
		[ ] Yes (If "Yes," complete Parts B and C)				[ ] No
B. Costs incurred and adjustments required as a result of transactions with related
		organizations. Location and amount included on Worksheet A, Column 5					Amount		Adjustments
							Allowable		(Col 4 minus
	Line No.	Cost Center	Expense Items			Amount	In Cost		Col 5)
	1	2	3			4	5		6
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10	TOTALS (Sum of lines 1-9) (Transfer column 6, lines as									10
	applicable, to Worksheet A, column 6, lines as appropriate)
	Transfer column. 6, line 5 to Worksheet A-8, column 2, line 12)
C. Interrelationship to related organization(s):
	The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you
	furnish the information requested under Part C of this worksheet.
	This information is used by the Health Care Financing Administration and its intermediaries in determining that the costs
	applicable to services, facilities and supplies furnished by organizations related to you by common ownership or control,
	represent reasonable costs as determined under section 1861 of the Social Security Act. If you do not provide all or any
	part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming
	reimbursement under title XVIII.
					Related Organization(s)
(1)			Percentage				Percentage
Symbol		Name	of		Name		of		Type of
			Ownership				Ownership		Business
	1	2	3			4	5		6
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
(1) Use the following symbols to indicate interrelationship to related organizations:
	A. Individual has financial interest (stockholder, partner, etc.)				E. Individual is director, officer, administrator or key person of provider
	in both related organization and in provider.				and related organization.
	B. Corporation, partnership or other organization has financial				F. Director, officer, administrator or key person of related organization
	interest in provider.				or relative of such person has financial interest in provider.
	C. Provider has financial interest in corporation, partnership,				G. Other (financial or non-financial) specify ______________________
	or other organization.				_____________________________________________________
	D. Director, officer, administrator or key person of provider or
	relative of such person has financial interest in related
	organization.
FORM CMS - 2540-96 ( 10/98 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II SECTION 3520 )
35-318										Rev. 4

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Sheet 19: A82

07-99				FORM CMS 2540-96						3590 (Cont.)
				PROVIDER NO:		PERIOD:
PROVIDER-BASED PHYSICIANS ADJUSTMENTS						FROM ______________________		WORKSHEET A-8-2
				________________________		TO _________________
		Cost Center /					Physician /		5 Percent of
	Wkst A	Physician	Total	Professional	Provider	R C E	Provider	Unadjusted	Unadjusted
	Line No.	Identifier	Remuneration	Component	Component	Amount	Component Hours	R C E Limit	R C E Limit
	1	2	3	4	5	6	7	8	9
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
75		TOTAL								75
			Cost of	Provider	Physician	Provider
		Cost Center /	Memberships	Component	Cost of	Component	Adjusted	R C E
	Wkst A	Physician	& Continuing	Share of	Malpractice	Share of	R C E Limit	Disallowance	Adjustment
	Line No.	Identifier	Education	Col 12	Insurance	Column 14
	10	11	12	13	14	15	16	17	18
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
75		TOTAL								75
FORM CMS-2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3521 )
Rev. 5										35-319

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Sheet 20: A83-1

3590 (Cont.)				FORM CMS 2540-96							07-99
REASONABLE COST DETERMINATION FOR PHYSICAL					PROVIDER NO:		PERIOD:		WORKSHEET A-8-3
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS							FROM __________________		PARTS I & II
					___________________		TO _______________
	PART I - GENERAL INFORMATION
1	Total number of weeks worked (During which outside suppliers (excluding aides) worked)										1
2	Line 1 multiplied by 15 hours per week										2
3	Number of unduplicated days on which supervisor or therapist was on provider site (See Instructions)										3
4	Number of unduplicated days on which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (See instructions)										4
5	Number of unduplicated HHA visits - supervisors or therapists (See Instructions)										5
6	Number of unduplicated HHA visits - therapy assistants (Include only visits made by therapy assistant and on which supervisor and/or										6
	therapist was not present during the visit(s)) (See Instructions)
7	Standard travel expense rate										7
8	Optional travel expense rate per mile										8
						Supervisors	Therapists	Assistants		Aides
						1	2	3		4
9	Total hours worked										9
10	A H S E A (See Instructions)										10
11	Standard Travel Allowance (Cols. 1 and 2, one-half of col. 2, line 10; col. 3, one-half of col 3, line 10)										11
12	Number of travel hours (HHA only)										12
13	Number of miles driven (HHA only)										13
	PART II - SALARY EQUIVALENCY COMPUTATION
14	Supervisors (Column 1, line 9 times column 1, line 10)										14
15	Therapists (Column 2, line 9 times column 2, line 10)										15
16	Assistants (Column 3, line9 times column 3, line10)										16
17	Subtotal Allowance Amount (Sum of lines 14-16)										17
18	Aides (Column 4, line 9 times column 4, line 10)										18
19	Total Allowance Amount (Sum of lines 17 and 18)										19
	If the sum of columns 1-3, line 9, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the amount from line 19. Otherwise complete lines 20 - 22.
20	Weighted average rate excluding aides (Line 17 divided by the sum of columns 1-3, line 9)										20
21	Weighted allowance excluding aides (Line 2 times line 20)										21
22	Total Salary Equivalency (Line 19 or sum of lines 18 plus 21)										22
FORM CMS-2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3522 THROUGH 3522.07 )
35-320											Rev. 5

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Sheet 21: A83-2

07-99				FORM CMS 2540-96							3590 (Cont.)
REASONABLE COST DETERMINATION FOR PHYSICAL					PROVIDER NO:		PERIOD:		WORKSHEET A-8-3
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS							FROM __________________		PARTS III & IV
					___________________		TO _______________
	PART III - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
	Standard Travel Allowance
23	Therapists (Line 3 times column 2, line 11)										23
24	Assistants (Line 4 times column3, line 11)										24
25	Subtotal (Sum of lines 23 and 24)										25
26	Standard Travel Expense (Line 7 times sum of lines 3 and 4)										26
27	Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (Sum of lines 25 and 26)										27
	PART IV - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION -
	HHA SERVICES OUTSIDE PROVIDER SITE
	Standard Travel Expense
28	Therapists (Line 5 times column 2, line 11)										28
29	Assistants (Line 6 times column 3, line 11)										29
30	Subtotal (Sum of lines 28 and 29)										30
31	Standard Travel Expense (Line 7 times the sum of lines 5 and 6)										31
	Optional Travel Allowance and Optional Travel Expense
32	Therapists (Sum of columns 1 and 2, line 12 times column 2, line 10)										32
33	Assistants (Column 3, line 12 times column 3, line 10)										33
34	Subtotal (Sum of lines 32 and 33)										34
35	Optional Travel Expense (Line 8 times the sum of columns 1-3, line 13)										35
	Total Travel Allowance and Travel Expense - HHA Services; Complete one of the following
	three lines 36, 37, or 38, as appropriate.
36	Standard Travel Allowance and Standard Travel Expense (Sum of lines 30 and 31 - See Instructions)										36
37	Optional Travel Allowance and Standard Travel Expense (Sum of lines 34 and 31 - See Instructions)										37
38	Optional Travel Allowance and Optional Travel Expense (Sum of lines 34 and 35 - See Instructions)										38
FORM CMS-2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3522 THROUGH 3522.7 )
Rev. 5											35-321

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Sheet 22: A83-3

3590 (Cont.)				FORM CMS 2540-96						07-99
REASONABLE COST DETERMINATION FOR PHYSICAL				PROVIDER NO:		PERIOD:		WORKSHEET A-8-3
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS						FROM _________________		PARTS V, VI, & VII
				_____________________		TO _______________
PART V - OVERTIME COMPUTATION
	Description				Therapists	Assistants		Aides	Total
					1	2		3	4
39	Overtime hours worked during cost reporting period (If column 4, line 39, is zero or equal to									39
	or greater than 2,080, do not complete lines 40-47 and enter zero in each column of line 48)
40	Overtime rate (Multiply the amounts in columns 2-4, line 10 ( A H S E A ) times 1.5)									40
41	Total overtime (Including base and overtime allowance) (Multiply line 39 times line 40)									41
	Calculation of Limit
42	Percentage of overtime hours by category (Divide the hours in each column on line 39 by the									42
	total overtime worked - column 4, line 39)
43	Allocation of provider's standard workyear for one full-time employee times the percentages									43
	on line 42. (See Instructions)
	Determination of Overtime Allowance
44	Adjusted hourly salary equivalency amount ( A H S E A ) (From Part I, Columns 2-4, line 10)									44
45	Overtime cost limitation (Line 43 times line 44)									45
46	Maximum overtime cost (Enter the lessor of line 41 or line 45)									46
47	Portion of overtime already included in hourly computation at the A H S E A									47
	(Multiply line 39 times line 44)
48	Overtime allowance (Line 46 minus 47 - if negative enter zero)(Column 4, sum of cols 1-3)									48
	PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
49	Salary equivalency amount (from Part II, line 22)									49
50	Travel allowance and expense - provider site (from Part III, line 27)									50
51	Travel allowance and expense - HHA services (from Part IV, lines 36, 37 or 38)									51
52	Overtime allowance (from Part V, col. 4, line 48)									52
53	Equipment cost (See Instructions)									53
54	Supplies (See Instructions)									54
55	Total allowance (Sum of lines 49-54)									55
56	Total cost of outside supplier services (from your records)									56
57	Excess over limitation (line 56 minus line 55 - if negative, enter zero -- See Instructions)									57
	PART VII - ALLOCATION OF THERAPY EXCESS COST OVER LIMITATION
	FOR NONSHARED THERAPY DEPARTMENT SERVICES
58	Cost of outside supplier services - SNF (from your records)									58
59	Cost of outside supplier services - HHA (from your records)									59
60	Total cost (Sum of lines 58-59) (This line must agree with line 56)									60
61	Ratio of SNF cost of outside supplier services to total cost (Line 58 divided by line 60)									61
62	Ratio of HHA cost of outside supplier services to total cost (Line 59 divided by line 60)									62
63	SNF excess of cost over limitation (Line 57 times line 61) (Transfer to Wkst A-8, line 25)									63
64	HHA excess of cost over limitation (Line 57 times line 62) (Transfer to Wkst A-8, line 26)									64
FORM CMS-2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3522.6 - 3522.7)
35-322										Rev. 5

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Sheet 23: A84-1

07-99				FORM CMS 2540-96						3590 (Cont.)
REASONABLE COST DETERMINATION FOR				PROVIDER NO:		PERIOD:
RESPIRATORY THERAPY SERVICES						FROM ___________________		WORKSHEET A-8-4
FURNISHED BY OUTSIDE SUPPLIERS				_________________________		TO ______________________		PARTS I & II
	PART I - GENERAL INFORMATION
1	Total number of weeks worked (During which outside suppliers (excluding aides and trainees) worked)									1
2	Line 1 multiplied by 15 hours per week									2
.	Number of unduplicated days on which the following category, as appropriate, has the highest A H S E A on the provider site ( See Instructions ):
3	Registered Therapist									3
4	Certified Therapist									4
5	Nonregistered, Noncertified Therapist									5
6	Standard travel expense rate									6
			Supervisors			Therapists
				Nonregistered			Nonregistered
	Description	Registered	Certified	Noncertified	Registered	Certified	Noncertified	Aides	Trainees
		1	2	3	4	5	6	7	8
7	Total Hours Worked									7
8	A H S E A (See Instructions)									8
9	Standard Travel Allowance									9
	(Enter in cols 1, 2, or 3, one-half of the amounts on line 8, columns 4, 5 or 6 respectively.
	Enter in cols. 4, 5 or 6 one-half of the amounts on line 8, columns 4, 5 or 6 respectively.)
	PART II - SALARY EQUIVALENCY COMPUTATION
10	Supervisory Registered Therapist (Col 1, line 7 times col 1, line 8)									10
11	Supervisory Certified Therapist (Col 2, line 7 times col 2, Line 8)									11
12	Supervisory Non-Registered, Non-Certified Therapist (Col 3, line 7 times col 3, line 8)									12
13	Registered Therapists (Col 4, line 7 times col 4, line 8)									13
14	Certified Therapists (Col 5, line 7 times col 5, line 8)									14
15	Non-Registered, Non-Certified Therapists (Col 6, line 7 times col 6, line 8)									15
16	Subtotal Allowance Amount (Sum of lines 10-15)									16
17	Aides (Col 7, line 7 times col 7, line 8)									17
18	Trainees (Col 8, line 7 times col 8, line 8)									18
19	Total Allowance Amount (Sum of lines 16-18)									19
	If the sum of cols 1-6, line 7, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the amount from line 19.
	Otherwise, complete lines 20-22.
20	Weighted average rate excluding aides and trainees (Line 16 divided by the sum of cols 1-6, line 7)									20
21	Weighted allowance excluding aides and trainees (Line 2 times line 20)									21
22	Total Salary Equivalency (Line 19 or sum of lines 17, 18 and 21)									22
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3523 - 3523.5 )
Rev. 5										35-323

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Sheet 24: A84-2

3590 (Cont.)		FORM CMS 2540-96						07-99
REASONABLE COST DETERMINATION		PROVIDER NO:		PERIOD:
FOR RESPIRATORY THERAPY SERVICES				FROM ________________		WORKSHEET A-8-4
FURNISHED BY OUTSIDE SUPPLIERS		_______________________		TO ___________________		PARTS III, IV AND V
	PART III - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION
23	Regeistered Therapists (Line 3 times col 4, line 9)							23
24	Certified Therapists (Line 4 times col 5, line 9)							24
25	Non-Registered, Non-Certified Therapists (Line 5 times col 6, line 9)							25
26	Subtotal (Sum of lines 23-25)							26
27	Standard Travel Expense (Line 6 times sum of lines 3-5)							27
28	Total Standard Travel Allowance and Standard Travel Expense (Sum of lines 26 and 27)							28
	PART IV - OVERTIME COMPUTATION
			Therapists
				Nonregistered
	Description	Registered	Certified	Noncertified	Aides	Trainees	Total
		1	2	3	4	5	6
29	Overtime hours worked during cost reporting period ( If col 6, line 29,							29
	is zero, or equal to or greater than 2,080, do not complete lines 30
	through 37 and enter zero in each column of line 38 )
30	Overtime rate ( Multiply the amounts in cols 4-8, line 8 (the AHSEA)							30
	times 1.5 )
31	Total overtime (Including base and overtime allowance)							31
	(Multiply line 29 times line 30)
	Calculation of Limitation
32	Percentage of overtime hours by category (Divide the hours in each						100%	32
	column on line 29 by the total overtime worked - column 6, line 29)
33	Allocation of provider's standard workyear for one full-time employee							33
	times the percentage on line 32. (See Instructions)
	Determination of Overtime Allowance
34	Adjusted hourly salary equivalency amount (AHSEA)							34
	(From Part I, cols. 4-8, line 8)
35	Overtime cost limitation (Line 33 times line 34)							35
36	Maximum overtime cost (Enter the lessor of line 31 or 35)							36
37	Portion of overtime already included in hourly computation at the							37
	A H S E A. (Multiply line 29 times line 34)
38	Overtime allowance (Line 36 minus line 37 - if negative enter zero)							38
	(Col. 6, sum of cols. 1 - 5)
	PART V - COMPUTATION OF RESPIRATORY THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
39	Salary equivalency amount (from Part II, line 22)							39
40	Travel allowance and expense (from Part III, line 28)							40
41	Overtime allowance (from Part IV, col 6, line 38)							41
42	Equipment cost (See Instructions)							42
43	Supplies (See Instructions)							43
44	Total allowance ( Sum of lines 39 - 43)							44
45	Total cost of outside supplier services (from your records)							45
46	Excess over limitation ( line 45 minus line 44, - if negative, enter zero - See Instructions) (Transfer to Wkst. A-8 line 24)							46
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3523.3 - 3523.5 )
35-324								Rev. 5

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Sheet 25: A-8-5

07-99			FORM CMS 2540-96					3590 (Cont.)
REASONABLE COST DETERMINATION FOR			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-5
THERAPY SERVICES FURNISHED BY OUTSIDE					FROM _____________________		PARTS I & II
SUPPLIERS ON OR AFTER APRIL 10, 1998			___________________________		TO _____________________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART I - GENERAL INFORMATION
1	Total number of weeks worked (during which outside (excluding aides worked)							1
2	Line 1 multiplied by 15 hours per week							2
3	Number of unduplicated days on which supervisor or therapist was on provider site (see instructions)							3
4	Number of unduplicated days on which therapy assistant was on provider site but neither supervisor nor therapist was on provider site ( See instructions.)							4
5	Number of unduplicated HHA visits - supervisors or therapists (see instructions)							5
6	Number of unduplicated HHA visits - therapy assistants (include only visits made by therapy assistant and on which							6
	supervisor and/or therapist was not present during the visit(s)) (see instructions)
7	Standard travel expense rate							7
8	Optional travel expense rate per mile							8
			Supervisors	Therapists	Assistants	Aides	Trainees
			1	2	3	4	5
9	Total hours worked							9
10	AHSEA (see instructions)							10
11	Standard Travel Allowance (columns 1 and 2, one-half of column 2,							11
	line 10; column 3, one-half of column 3, line 10)
12	Number of travel hours - Provider on site - (see instructions)							12
12.01	Number of travel hours - Provider off site - (see instructions)							12.01
13	Number of miles driven - Provider on site - (see instructions)							13
13.01	Number of miles driven - Provider off site - (see instructions)							13.01
PART II - SALARY EQUIVALENCY COMPUTATION
14	Supervisors (column 1, line 9 times column 1, line 10)							14
15	Therapists (column 2, line 9 times column 2, line 10)							15
16	Assistants (column 3, line 9 times column 3, line10)							16
17	Subtotal Allowance Amount (sum of lines 14-16)							17
18	Aides (column 4, line 9 times column 4, line 10)							18
19	Trainees (column 5, line 9 times column 5, line 10)							19
20	Total Allowance Amount (see instructions)							20
	If the sum of columns 1 and 2 for respiratory therapy or columns 1-3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2,
	make no entries on lines 21 and 22 and enter on line 23 the amount from line 20. Otherwise complete lines 21-23.
21	Weighted average rate excluding aides and trainees (see instructions)							21
22	Weighted allowance excluding aides and trainees (see instructions)							22
23	Total salary equivalency (see instructions)							23
FORM CMS-2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3564-3564.6)
Rev. 5								35-325
3590 (Cont.)			FORM CMS 2540-96					07-99
REASONABLE COST DETERMINATION FOR			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-5
THERAPY SERVICES FURNISHED BY OUTSIDE					FROM _____________________		PARTS III & IV
SUPPLIERS ON OR AFTER APRIL 10, 1998			___________________________		TO _____________________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24	Supervisor and Therapists (line 3 times column 2, line 11)							24
25	Assistants (line 4 times column 3, line 11)							25
26	Subtotal (sum of lines 24 and 25)							26
27	Standard Travel Expense (line 7 times sum of lines 3 and 4)							27
28	Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (sum of lines 26 and 27)							28
Optional Travel Allowance and Optional Travel Expense
29	Supervisor and Therapists (sum of columns 1 and 2, line 12, times column 2 line 10)							29
30	Assistants (column 3, line 12 times column 3 line 10)							30
31	Subtotal (sum of lines 29 and 30)							31
32	Optional travel expense (line 8 times the sum of columns 1-3, line 13)							32
33	Standard travel allowance and standard travel expense (line 28)							33
34	Optional travel allowance and standard travel expense (sum of lines 27 and 31)							34
35	Optional travel allowance and optional travel expense (sum of lines 31 and 32)							35
PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER OFF SITE
Standard Travel Expense
36	Therapists (line 5 times column 2, line 11)							36
37	Assistants (line 6 times column 3, line 11)							37
38	Subtotal (sum of lines 36 and 37)							38
39	Standard Travel Expense (line 7 times the sum of lines 5 and 6)							39
Optional Travel Allowance and Optional Travel Expense
40	Therapists (sum of columns 1 and 2, line 12 times column 2, line 10)							40
41	Assistants (column 3, line 12 times column 3, line 10)							41
42	Subtotal (sum of lines 40 and 41)							42
43	Optional Travel Expense (line 8 times the sum of columns 1-3, line 13)							43
Total Travel Allowance and Travel Expense - Complete one of the following three lines 44, 45, or 46, as appropriate.
44	Standard Travel Allowance and Standard Travel Expense (sum of lines 38 and 39 - see instructions)							44
45	Optional Travel Allowance and Standard Travel Expense (sum of lines 39 and 42 - see instructions)							45
46	Optional Travel Allowance and Optional Travel Expense (sum of lines 42 and 43 - see instructions)							46
FORM CMS-2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3564-3564.6)
35-326								Rev. 5
07-99			FORM CMS 2540-96					3590 (Cont.)
REASONABLE COST DETERMINATION FOR			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-5
THERAPY SERVICES FURNISHED BY OUTSIDE					FROM _____________________		PARTS V & VI
SUPPLIERS ON OR AFTER APRIL 10, 1998			___________________________		TO _____________________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART V - OVERTIME COMPUTATION
			Therapists	Assistants	Aides	Trainees	Total
			1	2	3	4	5
47	Overtime hours worked during reporting period (if column 5,							47
	line 47, is zero or equal to or greater than 2,080, do not complete
	lines 48-55 and enter zero in each column of line 56)
48	Overtime rate (see instructions)							48
49	Total overtime (including base and overtime allowance) (multiply							49
	line 47 times line 48)
CALCULATION OF LIMIT
50	Percentage of overtime hours by category (divide the hours in each							50
	column on line 47 by the total overtime worked - column 5, line 47)
51	Allocation of provider's standard workyear for one full-time							51
	employee times the percentages on line 50) (see instructions)
DETERMINATION OF OVERTIME ALLOWANCE
52	Adjusted hourly salary equivalency amount (see instructions)							52
53	Overtime cost limitation (line 51 times line 52)							53
54	Maximum overtime cost (enter the lessor of line 49 or line 53)							54
55	Portion of overtime already included in hourly computation at the							55
	AHSEA (multiply line 47 times line 52)
56	Overtime allowance (line 54 minus line 55 - if negative enter zero)							56
	(Enter in column 5, the sum of columns 1, 3 and 4 for respiratory
	therapy; and columns 1 through 3 for all others.)
PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
57	Salary equivalency amount (from Part II, line 23)							57
58	Travel allowance and expense - provider site (from Part III, lines 33, 34, or 35))							58
59	Travel allowance and expense - HHA services (from Part IV, lines 44, 45, or 46)							59
60	Overtime allowance (from Part V, column 4, line 56)							60
61	Equipment cost (see instructions)							61
62	Supplies (see instructions)							62
63	Total allowance (sum of lines 57-62)							63
64	Total cost of outside supplier services (from your records)							64
65	Excess over limitation (line 64 minus line 63 - if negative, enter zero -- See Instructions)							65
FORM CMS-2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3564-3564.6)
Rev. 5								35-327
3590 (Cont.)			FORM CMS 2540-96					07-99
REASONABLE COST DETERMINATION FOR			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-5
THERAPY SERVICES FURNISHED BY OUTSIDE					FROM _____________________		PARTS VII
SUPPLIERS ON OR AFTER APRIL 10, 1998			___________________________		TO _____________________
Check applicable box:		[ ] Occupational [ ] Physical [ ] Respiratory [ ] Speech Pathology
PART VII - ALLOCATION OF THERAPY EXCESS COST OVER LIMITATION FOR NONSHARED THERAPY DEPARTMENT SERVICES
66	Cost of outside supplier services - SNF (from your records)							66
67	Cost of outside supplier services - CORF (from your records)							67
68	Cost of outside supplier services - CMHC (from your records)							68
69	Cost of outside supplier services - OPT (from your records)							69
70	Cost of outside supplier services - HHA (from your records)							70
71	Total cost (Sum of lines 66 - 70)							71
72	Ratio of SNF cost of outside supplier services to total cost (line 66 divided by line 71)							72
73	Ratio of CORF cost of outside supplier services to total cost (line 67 divided by line 71)							73
74	Ratio of CMHC cost of outside supplier services to total cost (line 68 divided by line 71)							74
75	Ratio of OPT cost of outside supplier services to total cost (line 69 divided by line 71)							75
76	Ratio of HHA cost of outside supplier services to total cost (Line 70 divided by line 71)							76
77	SNF excess of cost over limitation (line 65 times line 72) (Transfer to Worksheet A-8, - see instructions)							77
78	CORF excess of cost over limitation (line 65 times line 73) (Transfer to Worksheet A-8, see instructions)							78
79	CMHC excess of cost over limitation (line 65 times line 74) (Transfer to Worksheet A-8, see instructions)							79
80	OPT excess of cost over limitation (line 65 times line 75) (Transfer to Worksheet A-8, see instructions)							80
81	HHA excess of cost over limitation (line 65 times line 76) (Transfer to Worksheet A-8, see instructions)							81
82	Total excess of cost over limitation ( sum of lines 77 through 81 and subscripts) (This line must agree with line 65)							82
FORM CMS-2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3564-3564.6)
35-328								Rev. 5
#REF!

---

Sheet 26: B

10-99						FORM CMS 2540-96						3590 (Cont.)
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B
						_________________		TO ________________		PART I
						NET EXPENSES	CAP. REL.	CAP. REL.	EMPLOYEE		ADMINIS-
						FOR COST	BUILDINGS	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE
		COST CENTER				ALLOCATION	& FIXTURES	EQUIPMENT		( Sum of	& GENERAL
		(Omit Cents)				Fr. Wkst A, Col 7				Colunms 0 - 3 )
						0	1	2	3	3 A	4
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture											1
2	Capital-Related Costs - Movable Equipment											2
3	Employee Benefits											3
4	Administrative and General											4
5	Plant Operation, Maintenance and Repairs											5
6	Laundry and Linen Service											6
7	Housekeeping											7
8	Dietary											8
9	Nursing Administration											9
10	Central Services and Supply											10
11	Pharmacy											11
12	Medical Records and Library											12
13	Social Service											13
14	Intern & Residents (Approved Teaching Program)											14
15	Other General Service Cost											15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility											16
17												17
18	Nursing Facility											18
18.1	Intermediate Care Facility/ Mentally Retarded											18.1
19	Other Long Term Care											19
20	Other Inpatient Routine Services											20
	ANCILLARY SERVICE COST CENTERS
21	Radiology											21
22	Laboratory											22
23	Intravenous Therapy											23
24	Oxygen (Inhalation) Therapy											24
25	Physical Therapy											25
26	Occupational Therapy											26
27	Speech Pathology											27
28	Electrocardiology											28
29	Medical Supplies Charged to Patients											29
30	Drugs Charged to Patients											30
31	Dental Care - Title XIX only											31
32	Support Surfaces											32
33	Other Ancillary Service Cost											33
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
Rev. 6												35-329
3590 (Cont.)						FORM CMS 2540-96						10-99
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B
						_________________		TO ________________		PART I
						NET EXPENSES	CAP. REL.	CAP. REL.	EMPLOYEE		ADMINIS-
						FOR COST	BUILDINGS	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE
		COST CENTER				ALLOCATION	& FIXTURES	EQUIPMENT		( Sum of	& GENERAL
		(Omit Cents)				Fr. Wkst A, Col 7				Colunms 0 - 3 )
						0	1	2	3	3 A	4
	OUTPATIENT SERVICE COST CENTERS
34	Clinic											34
35	R H C											35
36	Other Outpatient Service Cost											36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA											37
38	Skilled Nursing Care - HHA											38
39	Physical Therapy - HHA											39
40	Occupational Therapy - HHA											40
41	Speech Pathology - HHA											41
42	Medical Social Services - HHA											42
43	Home Health Aide - HHA											43
44	Durable Medical Equipment - Rented - HHA											44
45	Durable Medical Equipment - Sold - HHA											45
46	Home Delivered Meals - HHA											46
47	Other Home Health Services - HHA											47
48	Ambulance											48
49	Interns and Residents (Not in Approved Teaching Program)											49
50	Outpatient Rehabilitation Provider											50
51	Other Reimbursable Cost											51
	SPECIAL PURPOSE COST CENTERS
55	Hospice											55
56	Other Special Purpose Cost											56
57	Subtotals											57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen											58
59	Barber and Beauty Shop											59
60	Physicians' Private Offices											60
61	Nonpaid Workers											61
62	Patients Laundry											62
63	Other Non Reimbursable Cost											63
64	Cross Foot Adjustments											64
65	Negative Cost Center											65
75	TOTAL											75
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
35-330												Rev. 6
10-99						FORM CMS 2540-96						3590 (Cont.)
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B
						_________________		TO ________________		PART I
					PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
					MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER			& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)
					5	6	7	8	9	10	11
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture											1
2	Capital-Related Costs - Movable Equipment											2
3	Employee Benefits											3
4	Administrative and General											4
5	Plant Operation, Maintenance and Repairs											5
6	Laundry and Linen Service											6
7	Housekeeping											7
8	Dietary											8
9	Nursing Administration											9
10	Central Services and Supply											10
11	Pharmacy											11
12	Medical Records and Library											12
13	Social Service											13
14	Intern & Residents (Approved Teaching Program)											14
15	Other General Service Cost											15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility											16
17												17
18	Nursing Facility											18
18.1	Intermediate Care Facility/ Mentally Retarded											18.1
19	Other Long Term Care											19
20	Other Inpatient Routine Services											20
	ANCILLARY SERVICE COST CENTERS
21	Radiology											21
22	Laboratory											22
23	Intravenous Therapy											23
24	Oxygen (Inhalation) Therapy											24
25	Physical Therapy											25
26	Occupational Therapy											26
27	Speech Pathology											27
28	Electrocardiology											28
29	Medical Supplies Charged to Patients											29
30	Drugs Charged to Patients											30
31	Dental Care - Title XIX only											31
32	Support Surfaces											32
33	Other Ancillary Service Cost											33
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
Rev. 6												35-331
3590 (Cont.)						FORM CMS 2540-96						10-99
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B
						_________________		TO ________________		PART I
					PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
					MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER			& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)
					5	6	7	8	9	10	11
	OUTPATIENT SERVICE COST CENTERS
34	Clinic											34
35	R H C											35
36	Other Outpatient Service Cost											36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA											37
38	Skilled Nursing Care - HHA											38
39	Physical Therapy - HHA											39
40	Occupational Therapy - HHA											40
41	Speech Pathology - HHA											41
42	Medical Social Services - HHA											42
43	Home Health Aide - HHA											43
44	Durable Medical Equipment - Rented - HHA											44
45	Durable Medical Equipment - Sold - HHA											45
46	Home Delivered Meals - HHA											46
47	Other Home Health Services - HHA											47
48	Ambulance											48
49	Interns and Residents (Not in Approved Teaching Program)											49
50	Outpatient Rehabilitation Provider											50
51	Other Reimbursable Cost											51
	SPECIAL PURPOSE COST CENTERS
55	Hospice											55
56	Other Special Purpose Cost											56
57	Subtotals											57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen											58
59	Barber and Beauty Shop											59
60	Physicians' Private Offices											60
61	Nonpaid Workers											61
62	Patients Laundry											62
63	Other Non Reimbursable Cost											63
64	Cross Foot Adjustments											64
65	Negative Cost Center											65
75	TOTAL											75
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
35-332												Rev. 6
10-99						FORM CMS 2540-96						3590 (Cont.)
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B
						_________________		TO ________________		PART I
					MEDICAL	SOCIAL	INTERNS &	OTHER		POST
		COST CENTER			RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEPDOWN	TOTAL
		(Omit Cents)			& LIBRARY			SERVICE		ADJUSTMENTS
								COST
					12	13	14	15	16	17	18
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture											1
2	Capital-Related Costs - Movable Equipment											2
3	Employee Benefits											3
4	Administrative and General											4
5	Plant Operation, Maintenance and Repairs											5
6	Laundry and Linen Service											6
7	Housekeeping											7
8	Dietary											8
9	Nursing Administration											9
10	Central Services and Supply											10
11	Pharmacy											11
12	Medical Records and Library											12
13	Social Service											13
14	Intern & Residents (Approved Teaching Program)											14
15	Other General Service Cost											15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility											16
17												17
18	Nursing Facility											18
18.1	Intermediate Care Facility/ Mentally Retarded											18.1
19	Other Long Term Care											19
20	Other Inpatient Routine Services											20
	ANCILLARY SERVICE COST CENTERS
21	Radiology											21
22	Laboratory											22
23	Intravenous Therapy											23
24	Oxygen (Inhalation) Therapy											24
25	Physical Therapy											25
26	Occupational Therapy											26
27	Speech Pathology											27
28	Electrocardiology											28
29	Medical Supplies Charged to Patients											29
30	Drugs Charged to Patients											30
31	Dental Care - Title XIX only											31
32	Support Surfaces											32
33	Other Ancillary Service Cost											33
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
Rev. 6												35-333
3590 (Cont.)						FORM CMS 2540-96						10-99
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B
						_________________		TO ________________		PART I
					MEDICAL	SOCIAL	INTERNS &	OTHER		POST
					RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEPDOWN	TOTAL
		COST CENTER			& LIBRARY			SERVICE		ADJUSTMENTS
		(Omit Cents)						COST
					12	13	14	15	16	17	18
	OUTPATIENT SERVICE COST CENTERS
34	Clinic											34
35	R H C											35
36	Other Outpatient Service Cost											36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA											37
38	Skilled Nursing Care - HHA											38
39	Physical Therapy - HHA											39
40	Occupational Therapy - HHA											40
41	Speech Pathology - HHA											41
42	Medical Social Services - HHA											42
43	Home Health Aide - HHA											43
44	Durable Medical Equipment - Rented - HHA											44
45	Durable Medical Equipment - Sold - HHA											45
46	Home Delivered Meals - HHA											46
47	Other Home Health Services - HHA											47
48	Ambulance											48
49	Interns and Residents (Not in Approved Teaching Program)											49
50	Outpatient Rehabilitation Provider											50
51	Other Reimbursable Cost											51
	SPECIAL PURPOSE COST CENTERS
55	Hospice											55
56	Other Special Purpose Cost											56
57	Subtotals											57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen											58
59	Barber and Beauty Shop											59
60	Physicians' Private Offices											60
61	Nonpaid Workers											61
62	Patients Laundry											62
63	Other Non Reimbursable Cost											63
64	Cross Foot Adjustments											64
65	Negative Cost Center											65
75	TOTAL											75
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
35-334												Rev. 6

---

Sheet 27: B-1

07-99						FORM CMS 2540-96						3590 (Cont.)
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B - 1
						_________________		TO ________________
							CAP. REL.	CAP. REL.	EMPLOYEE	RECONCIL-	ADMINIS-
							BUILDINGS	MOVABLE	BENEFITS	IATION	TRATIVE
		COST CENTER					& FIXTURES	EQUIPMENT			& GENERAL
		(Omit Cents)					( Square	( Square	(Gross		(Accumulated
							Feet)	Feet)	Salaries)		Cost)
						0	1	2	3	4 A	4
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture											1
2	Capital-Related Costs - Movable Equipment											2
3	Employee Benefits											3
4	Administrative and General											4
5	Plant Operation, Maintenance and Repairs											5
6	Laundry and Linen Service											6
7	Housekeeping											7
8	Dietary											8
9	Nursing Administration											9
10	Central Services and Supply											10
11	Pharmacy											11
12	Medical Records and Library											12
13	Social Service											13
14	Intern & Residents (Approved Teaching Program)											14
15	Other General Service Cost											15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility											16
17												17
18	Nursing Facility											18
18.1	Interrmediate Care Facility/ Mentally Retarded											18.1
19	Other Long Term Care											19
20	Other Inpatient Routine Services											20
	ANCILLARY SERVICE COST CENTERS
21	Radiology											21
22	Laboratory											22
23	Intravenous Therapy											23
24	Oxygen (Inhalation) Therapy											24
25	Physical Therapy											25
26	Occupational Therapy											26
27	Speech Pathology											27
28	Electrocardiology											28
29	Medical Supplies Charged to Patients											29
30	Drugs Charged to Patients											30
31	Dental Care - Title XIX only											31
32	Support Surfaces											32
33	Other Ancillary Service Cost											33
FORM CMS-2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
Rev. 5												35-335
3590 (Cont.)						FORM CMS 2540-96						07-99
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B - 1
						_________________		TO ________________
							CAP. REL.	CAP. REL.	EMPLOYEE		ADMINIS-
							BUILDINGS	MOVABLE	BENEFITS	RECONCIL-	TRATIVE
		COST CENTER					& FIXTURES	EQUIPMENT		IATION	& GENERAL
		(Omit Cents)					( Square	( Square	(Gross		(Accumulated
							Feet)	Feet)	Salaries)		Cost)
						0	1	2	3	4 A	4
	OUTPATIENT SERVICE COST CENTERS
34	Clinic											34
35	R H C											35
36	Other Outpatient Service Cost											36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA											37
38	Skilled Nursing Care - HHA											38
39	Physical Therapy - HHA											39
40	Occupational Therapy - HHA											40
41	Speech Pathology - HHA											41
42	Medical Social Services - HHA											42
43	Home Health Aide - HHA											43
44	Durable Medical Equipment - Rented - HHA											44
45	Durable Medical Equipment - Sold - HHA											45
46	Home Delivered Meals - HHA											46
47	Other Home Health Services - HHA											47
48	Ambulance											48
49	Interns and Residents (Not in Approved Teaching Program)											49
50	Outpatient Rehabilitation Provider											50
51	Other Reimbursable Cost											51
	SPECIAL PURPOSE COST CENTERS
55	Hospice											55
56	Other Special Purpose Cost											56
57	Subtotals											57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen											58
59	Barber and Beauty Shop											59
60	Physicians' Private Offices											60
61	Nonpaid Workers											61
62	Patients Laundry											62
63	Other Non Reimbursable Cost											63
64	Cross Foot Adjustments											64
65	Negative Cost Center											65
66	Cost to be Allocated (Per Wkst. B, Part I)											66
67	Unit Cost Multiplier (Wkst. B, Part I)											67
68	Cost to be Allocated (Per Wkst. B, Part II)											68
69	Unit Cost Multiplier (Wkst. B, Part II)											69
FORM CMS-2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
35-336												Rev. 5
07-99						FORM CMS 2540-96						3590 (Cont.)
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B - 1
						_________________		TO ________________
					PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
					MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER			& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)			(Square	(Pounds of	(Hours of	(Meals	(Direct	(Costed	(Costed
					Feet)	Laundry)	Service)	Served)	Nrsing Hrs.)	Requisitions)	Requisitions)
					5	6	7	8	9	10	11
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture											1
2	Capital-Related Costs - Movable Equipment											2
3	Employee Benefits											3
4	Administrative and General											4
5	Plant Operation, Maintenance and Repairs											5
6	Laundry and Linen Service											6
7	Housekeeping											7
8	Dietary											8
9	Nursing Administration											9
10	Central Services and Supply											10
11	Pharmacy											11
12	Medical Records and Library											12
13	Social Service											13
14	Intern & Residents (Approved Teaching Program)											14
15	Other General Service Cost											15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility											16
17												17
18	Nursing Facility											18
18.1	Interrmediate Care Facility/ Mentally Retarded											18.1
19	Other Long Term Care											19
20	Other Inpatient Routine Services											20
	ANCILLARY SERVICE COST CENTERS
21	Radiology											21
22	Laboratory											22
23	Intravenous Therapy											23
24	Oxygen (Inhalation) Therapy											24
25	Physical Therapy											25
26	Occupational Therapy											26
27	Speech Pathology											27
28	Electrocardiology											28
29	Medical Supplies Charged to Patients											29
30	Drugs Charged to Patients											30
31	Dental Care - Title XIX only											31
32	Support Surfaces											32
33	Other Ancillary Service Cost											33
FORM CMS-2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
Rev. 5												35-337
3590 (Cont.)						FORM CMS 2540-96						07-99
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B - 1
						_________________		TO ________________
					PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
					MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER			& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)			(Square	(Pounds of	(Hours of	(Meals	(Direct	(Costed	(Costed
					Feet)	Laundry)	Service)	Served)	Nrsing Hrs.)	Requisitions)	Requisitions)
					5	6	7	8	9	10	11
	OUTPATIENT SERVICE COST CENTERS
34	Clinic											34
35	R H C											35
36	Other Outpatient Service Cost											36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA											37
38	Skilled Nursing Care - HHA											38
39	Physical Therapy - HHA											39
40	Occupational Therapy - HHA											40
41	Speech Pathology - HHA											41
42	Medical Social Services - HHA											42
43	Home Health Aide - HHA											43
44	Durable Medical Equipment - Rented - HHA											44
45	Durable Medical Equipment - Sold - HHA											45
46	Home Delivered Meals - HHA											46
47	Other Home Health Services - HHA											47
48	Ambulance											48
49	Interns and Residents (Not in Approved Teaching Program)											49
50	Outpatient Rehabilitation Provider											50
51	Other Reimbursable Cost											51
	SPECIAL PURPOSE COST CENTERS
55	Hospice											55
56	Other Special Purpose Cost											56
57	Subtotals											57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen											58
59	Barber and Beauty Shop											59
60	Physicians' Private Offices											60
61	Nonpaid Workers											61
62	Patients Laundry											62
63	Other Non Reimbursable Cost											63
64	Cross Foot Adjustments											64
65	Negative Cost Center											65
66	Cost to be Allocated (Per Wkst. B, Part I)											66
67	Unit Cost Multiplier (Wkst. B, Part I)											67
68	Cost to be Allocated (Per Wkst. B, Part II)											68
69	Unit Cost Multiplier (Wkst. B, Part II)											69
FORM CMS-2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
35-338												Rev. 5
07-99						FORM CMS 2540-96						3590 (Cont.)
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B - 1
						_________________		TO ________________
					MEDICAL	SOCIAL	INTERNS &	OTHER		POST
		COST CENTER			RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEPDOWN	TOTAL
		(Omit Cents)			& LIBRARY			SERVICE		ADJUSTMENTS
					(Time	(Time	(Assigned	COST
					Spent)	Spent)	Time)
					12	13	14	15	16	17	18
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture											1
2	Capital-Related Costs - Movable Equipment											2
3	Employee Benefits											3
4	Administrative and General											4
5	Plant Operation, Maintenance and Repairs											5
6	Laundry and Linen Service											6
7	Housekeeping											7
8	Dietary											8
9	Nursing Administration											9
10	Central Services and Supply											10
11	Pharmacy											11
12	Medical Records and Library											12
13	Social Service											13
14	Intern & Residents (Approved Teaching Program)											14
15	Other General Service Cost											15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility											16
17												17
18	Nursing Facility											18
18.1	Interrmediate Care Facility/ Mentally Retarded											18.1
19	Other Long Term Care											19
20	Other Inpatient Routine Services											20
	ANCILLARY SERVICE COST CENTERS
21	Radiology											21
22	Laboratory											22
23	Intravenous Therapy											23
24	Oxygen (Inhalation) Therapy											24
25	Physical Therapy											25
26	Occupational Therapy											26
27	Speech Pathology											27
28	Electrocardiology											28
29	Medical Supplies Charged to Patients											29
30	Drugs Charged to Patients											30
31	Dental Care - Title XIX only											31
32	Support Surfaces											32
33	Other Ancillary Service Cost											33
FORM CMS-2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
Rev. 5												35-339
3590 (Cont.)						FORM CMS 2540-96						07-99
						PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS								FROM ________________		WORKSHEET B - 1
						_________________		TO ________________
					MEDICAL	SOCIAL	INTERNS &	OTHER		POST
					RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEPDOWN	TOTAL
		COST CENTER			& LIBRARY			SERVICE		ADJUSTMENTS
		(Omit Cents)			(Time	(Time	(Assigned	COST
					Spent)	Spent)	Time)
					12	13	14	15	16	17	18
	OUTPATIENT SERVICE COST CENTERS
34	Clinic											34
35	R H C											35
36	Other Outpatient Service Cost											36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA											37
38	Skilled Nursing Care - HHA											38
39	Physical Therapy - HHA											39
40	Occupational Therapy - HHA											40
41	Speech Pathology - HHA											41
42	Medical Social Services - HHA											42
43	Home Health Aide - HHA											43
44	Durable Medical Equipment - Rented - HHA											44
45	Durable Medical Equipment - Sold - HHA											45
46	Home Delivered Meals - HHA											46
47	Other Home Health Services - HHA											47
48	Ambulance											48
49	Interns and Residents (Not in Approved Teaching Program)											49
50	Outpatient Rehabilitation Provider											50
51	Other Reimbursable Cost											51
	SPECIAL PURPOSE COST CENTERS
55	Hospice											55
56	Other Special Purpose Cost											56
57	Subtotals											57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen											58
59	Barber and Beauty Shop											59
60	Physicians' Private Offices											60
61	Nonpaid Workers											61
62	Patients Laundry											62
63	Other Non Reimbursable Cost											63
64	Cross Foot Adjustments											64
65	Negative Cost Center											65
66	Cost to be Allocated (Per Wkst. B, Part I)											66
67	Unit Cost Multiplier (Wkst. B, Part I)											67
68	Cost to be Allocated (Per Wkst. B, Part II)											68
69	Unit Cost Multiplier (Wkst. B, Part II)											69
FORM CMS-2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3524 )
35-340												Rev. 5

---

Sheet 28: B-II

10-99				FORM CMS 2540-96						3590 (Cont.)
				PROVIDER NO.:		PERIOD:					.
	ALLOCATION OF CAPITAL - RELATED COSTS					FROM ________________		WORKSHEET B
				_________________		TO ________________		PART II
			DIRECTLY	CAP. REL.	CAP. REL.		EMPLOYEE	ADMINIS-	PLANT OPER.
			ASSIGNED	BUILDINGS	MOVABLE	SUBTOTAL	BENEFITS	TRATIVE	MAINTENANCE
	COST CENTER		CAPITAL	& FIXTURES	EQUIPMENT			& GENERAL	& REPAIRS
	(Omit Cents)		RELATED COSTS
			0	1	2	2 A	3	4	5
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Approved Teaching Program)									14
15	Other General Service cost									15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility									16
17										17
18	Nursing Facility									18
18.1	Intermediate Care Facility/Mentally Retarded									18.1
19	Other Long Term Care									19
20	Other Inpatient Routine Service Cost									20
	ANCILLARY SERVICE COST CENTER
21	Radiology									21
22	Laboratory									22
23	Intravenous Therapy									23
24	Oxygen (Inhalation) Therapy									24
25	Physical Therapy									25
26	Occupational Therapy									26
27	Speech Pathology									27
	Electrocardiology									28
29	Medical Supplies Charged to Patients									29
30	Drugs Charged to Patients									30
31	Dental Care - Title XIX only									31
32	Support Surfaces									32
33	Other Ancillary Service Cost									33
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525 )
Rev. 6										35-341
3590 (Cont.)				FORM CMS 2540-96						10-99
				PROVIDER NO.:		PERIOD:					.
	ALLOCATION OF CAPITAL - RELATED COSTS					FROM ________________		WORKSHEET B
				_________________		TO ________________		PART II
			DIRECTLY	CAP. REL.	CAP. REL.		EMPLOYEE	ADMINIS-	PLANT OPER.
			ASSIGNED	BUILDINGS	MOVABLE	SUBTOTAL	BENEFITS	TRATIVE	MAINTENANCE
	COST CENTER		CAPITAL	& FIXTURES	EQUIPMENT			& GENERAL	& REPAIRS
	(Omit Cents)		RELATED COSTS
			0	1	2	2 A	3	4	5
	OUTPATIENT SERVICE COST CENTERS
34	Clinic									34
35	R H C									35
36	Other Outpatient Service Cost									36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA									37
38	Skilled Nursing Care - HHA									38
39	Physical Therapy - HHA									39
40	Occupational Therapy - HHA									40
41	Speech Pathology - HHA									41
42	Medical Social Services - HHA									42
43	Home Health Aide - HHA									43
44	Durable Medical Equipment - Rented - HHA									44
45	Durable Medical Equipment - Sold - HHA									45
46	Home Delivered Meals - HHA									46
47	Other Home Health Services - HHA									47
48	Ambulance									48
49	Interns and Residents (Not An Approved Teaching Program)									49
50	Outpatient Rehabilitation Provider									50
51	Other Reimbursable Cost									51
	SPECIAL PURPOSE COST CENTERS
55	Hospice									55
56	Other Special Purpose Cost									56
57	Subtotals									57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen									58
59	Barber and Beauty Shop									59
60	Physicians' Private Offices									60
61	Nonpaid Workers									61
62	Patients Laundry									62
63	Other Non Reimbursable Cost									63
64	Cross Foot Adjustments									64
65	Negative Cost Center									65
75	Total									75
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525 )
35-342										Rev. 6
10-99				FORM CMS 2540-96						3590 (Cont.)
				PROVIDER NO.:		PERIOD:					.
	ALLOCATION OF CAPITAL - RELATED COSTS					FROM ________________		WORKSHEET B
				_________________		TO ________________		PART II
				LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
				& LINEN	KEEPING		ADMINIS-	SERVICES
	COST CENTER			SERVICE			TRATION	& SUPPLY
	(Omit Cents)
				6	7	8	9	10	11
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Approved Teaching Program)									14
15	Other General Service cost									15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility									16
17										17
18	Nursing Facility									18
18.1	Intermediate Care Facility/Mentally Retarded									18.1
19	Other Long Term Care									19
20	Other Inpatient Routine Service Cost									20
	ANCILLARY SERVICE COST CENTER
21	Radiology									21
22	Laboratory									22
23	Intravenous Therapy									23
24	Oxygen (Inhalation) Therapy									24
25	Physical Therapy									25
26	Occupational Therapy									26
27	Speech Pathology									27
28	Electrocardiology									28
29	Medical Supplies Charged to Patients									29
30	Drugs Charged to Patients									30
31	Dental Care - Title XIX only									31
32	Support Surfaces									32
33	Other Ancillary Service Cost									33
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525 )
Rev. 6										35-343
3590 (Cont.)				FORM CMS 2540-96						10-99
				PROVIDER NO.:		PERIOD:
	ALLOCATION OF CAPITAL - RELATED COSTS					FROM ________________		WORKSHEET B
				_________________		TO ________________		PART II
				LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
				& LINEN	KEEPING		ADMINIS-	SERVICES
	COST CENTER			SERVICE			TRATION	& SUPPLY
	(Omit Cents)
				6	7	8	9	10	11
	OUTPATIENT SERVICE COST CENTERS
34	Clinic									34
35	R H C									35
36	Other Outpatient Service Cost									36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA									37
38	Skilled Nursing Care - HHA									38
39	Physical Therapy - HHA									39
40	Occupational Therapy - HHA									40
41	Speech Pathology - HHA									41
42	Medical Social Services - HHA									42
43	Home Health Aide - HHA									43
44	Durable Medical Equipment - Rented - HHA									44
45	Durable Medical Equipment - Sold - HHA									45
46	Home Delivered Meals - HHA									46
47	Other Home Health Services - HHA									47
48	Ambulance									48
49	Interns and Residents (Not An Approved Teaching Program)									49
50	Outpatient Rehabilitation Provider									50
51	Other Reimbursable Cost									51
	SPECIAL PURPOSE COST CENTERS
55	Hospice									55
56	Other Special Purpose Cost									56
57	Subtotals									57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen									58
59	Barber and Beauty Shop									59
60	Physicians' Private Offices									60
61	Nonpaid Workers									61
62	Patients Laundry									62
63	Other Non Reimbursable Cost									63
64	Cross Foot Adjustments									64
65	Negative Cost Center									65
75	Total									75
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525 )
35-344										Rev. 6
10-99				FORM CMS 2540-96						3590 (Cont.)
				PROVIDER NO.:		PERIOD:
	ALLOCATION OF CAPITAL - RELATED COSTS					FROM ________________		WORKSHEET B
				_________________		TO ________________		PART II
			MEDICAL	SOCIAL	INTERNS &	OTHER		POST
	COST CENTER		RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEPDOWN	TOTAL
	(Omit Cents)		& LIBRARY			SERVICE		ADJUSTMENTS
						COST
			12	13	14	15	16	17	18
	GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Approved Teaching Program)									14
15	Other General Service cost									15
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility									16
17										17
18	Nursing Facility									18
18.1	Intermediate Care Facility/Mentally Retarded									18.1
19	Other Long Term Care									19
20	Other Inpatient Routine Service Cost									20
	ANCILLARY SERVICE COST CENTER
21	Radiology									21
22	Laboratory									22
23	Intravenous Therapy									23
24	Oxygen (Inhalation) Therapy									24
25	Physical Therapy									25
26	Occupational Therapy									26
27	Speech Pathology									27
28	Electrocardiology									28
29	Medical Supplies Charged to Patients									29
30	Drugs Charged to Patients									30
31	Dental Care - Title XIX only									31
32	Support Surfaces									32
33	Other Ancillary Service Cost									33
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525 )
Rev. 6										35-345
3590 (Cont.)				FORM CMS 2540-96						10-99
				PROVIDER NO.:		PERIOD:
	ALLOCATION OF CAPITAL - RELATED COSTS					FROM ________________		WORKSHEET B
				_________________		TO ________________		PART II
			MEDICAL	SOCIAL	INTERNS &	OTHER		POST
			RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEPDOWN	TOTAL
	COST CENTER		& LIBRARY			SERVICE		ADJUSTMENTS
	(Omit Cents)					COST
			12	13	14	15	16	17	18
	OUTPATIENT SERVICE COST CENTERS
34	Clinic									34
35	R H C									35
36	Other Outpatient Service Cost									36
	OTHER REIMBURSABLE COST CENTERS
37	Administrative and General - HHA									37
38	Skilled Nursing Care - HHA									38
39	Physical Therapy - HHA									39
40	Occupational Therapy - HHA									40
41	Speech Pathology - HHA									41
42	Medical Social Services - HHA									42
43	Home Health Aide - HHA									43
44	Durable Medical Equipment - Rented - HHA									44
45	Durable Medical Equipment - Sold - HHA									45
46	Home Delivered Meals - HHA									46
47	Other Home Health Services - HHA									47
48	Ambulance									48
49	Interns and Residents (Not An Approved Teaching Program)									49
50	Outpatient Rehabilitation Provider									50
51	Other Reimbursable Cost									51
	SPECIAL PURPOSE COST CENTERS
55	Hospice									55
56	Other Special Purpose Cost									56
57	Subtotals									57
	NON REIMBURSABLE COST CENTERS
58	Gift, Flower, Coffee Shops and Canteen									58
59	Barber and Beauty Shop									59
60	Physicians' Private Offices									60
61	Nonpaid Workers									61
62	Patients Laundry									62
63	Other Non Reimbursable Cost									63
64	Cross Foot Adjustments									64
65	Negative Cost Center									65
75	Total									75
FORM CMS-2540-96 ( 10/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525 )
35-346										Rev. 6

---

Sheet 29: B-III

03-01			FORM CMS 2540-96						3590 (Cont.)
COST ALLOCATION -			PROVIDER NO.:		PERIOD:					.
GENERAL SERVICE COSTS					FROM ________________		WORKSHEET B
WITH LESS THAN 1500 PROGRAM DAYS			_________________		TO ________________		PART III
						LAUNDRY, DIET
			NET EXPENSES	CAP-REL COSTS	EMPLOYEE	NURSE ADMIN.	ADMIN	TOTAL
	COST CENTER		FOR COST	PLANT OPER.	BENEFITS	CENT SER & SUPP	& GENERAL	COSTS
	(Omit Cents)		ALLOCATION	MAINT & REPAIR		PHARM/MED REC	INTEREST
			(Fr. Wkst A, Col 7)	HOUSEKEEPING		SOC SERV
			0	1	2	3	4	5
GENERAL SERVICE COST CENTERS
15.1	Total								15.1
INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility								16
17									17
18	Nursing Facility								18
18.1	Intermediate Care Facility / Mentally Retarded								18.1
19	Other Long Term Care								19
20	Other Inpatient Routine Services								20
ANCILLARY SERVICE COST CENTERS
21	Radiology								21
22	Laboratory								22
23	Intravenous Therapy								23
24	Oxygen (Inhalation) Therapy								24
25	Physical Therapy								25
26	Occupational Therapy								26
27	Speech Pathology								27
28	Electrocardiology								28
29	Medical Supplies Charged to Patients								29
30	Drugs Charged to Patients								30
31	Dental Care - Title XIX only								31
32	Support Surfaces								32
33	Other Ancillary Service Cost								33
56	Other Special Purpose Cost								56
NON REIMBURSABLE COST CENTERS
59	Barber and Beauty Shop								59
63	All Other Non Reimbursable Cost								63
75	TOTAL								75
FORM CMS-2540-96 (03/2001 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525.1 )
Rev. 11									35-346.1
										.
										.

---

Sheet 30: B-1-2

3590 (Cont.)				FORM CMS 2540-96						03-01
COST ALLOCATION -				PROVIDER NO.:		PERIOD:					.
STATISTICAL BASIS						FROM ________________		WORKSHEET B - 1
WITH LESS THAN 1500 PROGRAM DAYS				_________________		TO ________________		PART II
					CAPITAL RELATED		LAUNDRY, DIET
					COSTS		NURSE ADMIN.	ADMIN
	COST CENTER				PLANT OPERATION		CENTRAL SUPPLY	& GENERAL
	(Omit Cents)				MAINTENANCE &	EMPLOYEE	PHARM / MEDICAL	INTEREST
					REPAIR	BENEFITS	RECORDS / SOCIAL
					HOUSEKEEPING		SERVICES
					(Square Feet)	(Gross Salaries)	(Patient Days)
				0	1	2	3	4	5
	INPATIENT ROUTINE SERVICE COST CENTERS
16	Skilled Nursing Facility									16
17										17
18	Nursing Facility									18
18.1	Intermediate Care Facility / Mentally Retarded									18.1
19	Other Long Term Care									19
20	Other Inpatient Routine Services									20
	ANCILLARY SERVICE COST CENTERS
21	Radiology									21
22	Laboratory									22
23	Intravenous Therapy									23
24	Oxygen (Inhalation) Therapy									24
25	Physical Therapy									25
26	Occupational Therapy									26
27	Speech Pathology									27
28	Electrocardiology									28
29	Medical Supplies Charged to Patients									29
30	Drugs Charged to Patients									30
31	Dental Care - Title XIX only									31
32	Support Surfaces									32
33	Other Ancillary Service Cost									33
56	Other Special Purpose Cost									56
	NON REIMBURSABLE COST CENTERS
59	Barber and Beauty Shop									59
63	All Other Non Reimbursable Cost									63
70	Total General Services Costs									70
71	Total Statistics									71
72	Unit Cost Multipliers (Line 70 divided by line 71)									72
FORM CMS-2540-96 (03/2001 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3525.1 )
35-346.2										Rev. 11
											.
											.

---

Sheet 31: B-2

07-99		FORM CMS 2540-96				3590 ( Cont.)
		PROVIDER NO.:	PERIOD																							.
POST STEP DOWN ADJUSTMENTS			FROM_______________		WORKSHEET B-2
		____________________	TO____________
			WORKSHEET B -
	DESCRIPTION		PART NO.	LINE NO.	AMOUNT
	1		2	3	4
1						1
2						2
3						3
4						4
5						5
6						6
7						7
8						8
9						9
10						10
11						11
12						12
13						13
14						14
15						15
16						16
17						17
18						18
19						19
20						20
21						21
22						22
23						23
24						24
25						25
26						26
27						27
28						28
29						29
30						30
31						31
32						32
33						33
34						34
35						35
36						36
37						37
38						38
39						39
40						40
41						41
42						42
43						43
44						44
45						45
46						46
47						47
48						48
49						49
50						50
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II SECTION 3526 )
Rev. 5						35-347

---

Sheet 32: C

3590 ( Cont.)		FORM CMS 2540-96			07-99
RATIO OF COST TO CHARGES		PROVIDER NO. :	PERIOD :
FOR ANCILLARY AND OUTPATIENT			FROM _________________	WORKSHEET C
COST CENTERS		______________________	TO ___________
		TOTAL	Total	Ratio
	Cost Center	(From Wkst B,	Charges	(col. 1 divided
		Pt. I, Col. 18)		by col. 2)
		1	2	3
ANCILLARY SERVICE COST CENTERS
21	Radiology				21
22	Laboratory				22
23	Intravenous Therapy				23
24	Oxygen ( Inhalation ) Therapy				24
25	Physical Therapy				25
26	Occupational Therapy				26
27	Speech Pathology				27
28	Electrocardiology				28
29	Medical Supplies Charged				29
30	Drugs Charged to Patients				30
31	Dental Care - Title XIX only				31
32	Support Surfaces				32
33	Other Ancillary Service Cost				33
OUTPATIENT SERVICE COST CENTERS
34	Clinic				34
35	R H C				35
36	Other Outpatient Service Cost				36
48	Ambulance				48
75	Total				75
FORM CMS-2540-96 ( 07/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15 II, SECTION 3527 )
35-348					Rev. 5

---

Sheet 33: D

12-99

FORM CMS 2540-96

3590 (Cont.)

APPORTIONMENT OF ANCILLARY AND

PROVIDER NO. :

PERIOD :

WORKSHEET D

OUTPATIENT COST AND REDUCTION

FROM ______________

PART I

OF THERAPY COST

______________________

TO ________________

PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST

Check

[ ] Title V

( 1 )

Check One:

[ ] SNF

[ ] NF

[ ] ICF/MR

[ ] Other __________________

One:

[ ] Title XVIII

[ ] PPS (For cost reporting periods beginning before 07/01/98)

[ ] Title XIX

( 1 )

>PPS FISCAL YEARS BEGINNING 07/01/98 MUST ALSO COMPLETE PART III <

RATIO OF

HEALTH CARE

HEALTH CARE

TITLE XVIII

PART B

10%

NET

COST TO

PROGRAM CHARGES

PROGRAM COST

CHARGES

THERAPY

REDUCTION

ALLOWABLE

Cost Center

CHARGES

ON AND

COSTS ON AND

OF THERAPY

PART B

( Fr. Wkst. C

Part A

Part B

Part A

Part B

AFTER

AFTER 1/1/1998

COSTS

Column 3 )

(Col. 1 X Col. 2)

(Col. 1 X Col. 3)

1/1/1998

Col. 1 X 6)

(Col. 7 X 10%)

Col. 5 less Col. 8)

1

2

3

4

5

6

7

8

9

ANCILLARY SERVICE COST CENTERS

ANCILLARY SERVICE COST CENTERS

21

Radiology

21

22

Laboratory

22

23

Intravenous Therapy

23

24

Oxygen ( Inhalation )

24

Therapy

25

Physical Therapy

25

26

Occupational Therapy

26

27

Speech Pathology

27

28

Electrocardiology

28

29

Medical Supplies

29

Charged To Patients

30

Drugs Charged to Patients

30

31

Dental Care - Title XIX

31

32

Support Surfaces

32

33

Other Ancillary Services

33

OUTPATIENT COST CENTERS

34

Clinic

34

35

R H C

35

36

Other Outpatient Services

36

48

Ambulance (2)

48

75

Total (Sum of lines 21 - 48)

75

( 1 ) For titles V and XIX use columns 1, 2 and 4 only.

( 2 ) Line 48 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.

FORM CMS- 2540-96 ( 12/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 3530)

Rev. 7

35-349

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Sheet 34: DII

3590 (Cont.)				FORM CMS 2540-96					12-99
APPORTIONMENT OF ANCILLARY AND				PROVIDER NO. :		PERIOD :		WORKSHEET D
OUTPATIENT COST AND REDUCTION OF						FROM ______________		PARTS II & III
THERAPY COST FOR TITLE XVIII				______________________		TO ________________
Check One:		[ ]	SNF	[ ]	NF	[ ]	ICF/MR
PART II - APPORTIONMENT OF VACCINE COST
1	Drugs charged to patients - ratio of cost to charges ( From Worksheet C, column 3, line 30)								1
2	Program vaccine charges ( From your records, or the P S & R.)								2
3	Program costs ( Line 1 X line 2) ( Title XVIII, PPS providers,								3
	transfer this amount to Worksheet E, Part III, line 20)
PART III - CALCULATION OF PASS THROUGH COSTS FOR INTERNS & RESIDENTS
>> FOR COST REPORTING PERIODS BEGINNING ON AND AFTER 07/01/98 <<
				Total Cost	Intern and	Ratio of	Program	Program
				(From	Residents Costs	Intern & Residents	Part A Cost	Intern & Residents
	Cost Centers			Worksheet B,	(From Wkst. B,	Costs To Total	(From Wkst. D.	Costs for
				Part I, Col 18)	Part I, Column 14)	Costs - Part A	Part 1, Col. 4)	Pass Through
						(Col. 2 / Col.. 1)		(Col. 3 X Col. 4)
				1	2	3	4	5
ANCILLARY SERVICE COST CENTERS
21	Radiology								21
22	Laboratory								22
23	Intravenous Therapy								23
24	Oxygen ( Inhalation ) Therapy								24
25	Physical Therapy								25
26	Occupational Therapy								26
27	Speech Pathology								27
28	Electrocardiology								28
29	Medical Supplies								29
30	Drugs Charged to Patients								30
31	Dental Care - Title XIX only								31
32	Support Surfaces								32
33	Other Ancillary Service Costs								33
75	Total ( Sum of lines 21 - 33)								75
FORM CMS- 2540-96( 12/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 3530)
35-350									Rev. 7

---

Sheet 35: D-1

12-99			FORM CMS 2540-96					3590 (Cont.)
			PROVIDER NO. :	PERIOD :
COMPUTATION OF INPATIENT				FROM ______________		WORKSHEET D-1
ROUTINE COSTS			______________________	TO ____________		PARTS I & II
Check One:		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
Check One:		[ ] SNF	[ ] NF	[ ] ICF/MR
PART I CALCULATION OF INPATIENT ROUTINE COSTS
	INPATIENT DAYS
1	Inpatient days including private room days							1
2	Private room days							2
3	Inpatient days including private room days applicable to the Program							3
4	Medically necessary private room days applicable to the Program							4
5	Total general inpatient routine service cost							5
	PRIVATE ROOM DIFFERENTAL ADJUSTMENT
6	General inpatient routine service charges							6
7	General inpatient routine service cost/charge ratio (Line 5 divided by line 6)							7
8	Enter private room charges from your records							8
9	Average private room per diem charge (Private room charges							9
	line 8 divided by private room days, line 2)
10	Enter semi-private room charges from your records							10
11	Average semi-private room per diem charge (Semi-private room charges							11
	line 10, divided by semi-private room days)
12	Average per diem private room charge differental ( Line 9 minus line 11 )							12
13	Average per diem private room cost differental ( Line 7 times line 12 )							13
14	Private room cost differental adjustment ( Line 2 times line 13 )							14
15	General inpatient routine service cost net of private room cost differential							15
	( Line 5 minus line 14 )
	PROGRAM INPATIENT ROUTINE SERVICE COSTS
16	Adjusted general inpatient service cost per diem							16
	( Line 15 divided by line 1 )
17	Program routine service cost ( Line 3 times line 16 )							17
18	Medically necessary private room cost applicable to program ( line 4 times line 13 )							18
19	Total program general inpatient routine service cost ( Line 17 plus line 18 )							19
20	Capital related cost allocated to inpatient routine service costs ( From Wkst. B,							20
	Part II column 18, - line 16 for SNF; line 18 for NF.
21	Per diem capital related costs ( Line 20 divided by line 1 )							21
22	Program capital related cost ( Line 3 times line 21 )							22
23	Inpatient routine service cost ( Line 19 minus line 22 )							23
24	Aggregate charges to beneficiaries for excess costs ( From provider records )							24
25	Total program routine service costs for comparison to the cost limitation							25
	( Line 23 minus line 24 )
26	Enter the per diem limitation				SEE NOTE BELOW			26
27	Inpatient routine service cost limitation ( Line 3 times the per diem limitation line 26)							27
					SEE NOTE BELOW
28	Reimbursable inpatient routine service costs ( Line 22 plus the lesser of line 25 or line 27 )							28
	( Transfer to Worksheet E, Part I, line 4)( See instructions )
NOTE: Lines 26 and 27 will not be used for cost reporting periods beginning on and after 7/1/98.
PART II CALCULATION OF INPATIENT INTERN AND RESIDENTS COST FOR PPS PASSTHROUGH
>> FOR COST REPORTING PERIODS BEGINNING ON AND AFTER 07/01/98 <<
1	Total inpatient days. ( From Worksheet S-3, Part I, column 7, line 9, less line 8)							1
2	Program inpatient days. ( From Worksheet S-3, Part I, cols. 3, 4, or 5, lines 1 or 2 , as applicable)							2
3	Total intern and residence cost. ( From Worksheet B, Part I, column 14, line 14)							3
4	Intern and residents retio. ( Line 2 divided by line 1)							4
5	Program Intern and resident cost for passthrough. (Line 3 times line 4)							5
FORM CMS-2540-96 ( 12/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3531 )
Rev. 7								35-351

---

Sheet 36: D-2

3590 (Cont.)					FORM CMS 2540-96							12-99
						PROVIDER NO.:		PERIOD
	APPORTIONMENT OF COST OF SERVICES							FROM_____________		WORKSHEET D-2
	RENDERED BY INTERNS AND RESIDENTS					__________________		TO _______________		PARTS I & II
	PART I - NOT IN APPROVED TEACHING PROGRAM
		Percent of		Total	Average Cost	Health Care Program Inpatient Days			Health Care program inpatient cost
		Assigned	Expense	Inpatient Days	Per Day	Title V	Title XVIII	Title XIX	Title V	Title XVIII	Title XIX
	Cost Centers	Time		All Patients	(Col. 2 ÷ 3)		Part B			Part B
		1	2	3	4	5	6	7	8	9	10
1	Total cost of services rendered	100.00										1
	SNF Inpatient Routine Services:
2	SNF											2
3												3
4	Nursing Facility											4
4.1	ICF/MR											4.1
5	Other Long Term Care											5
6	Home Health Agency											6
7												7
8	Outpatient Rehabilitation Provider											8
9	Ambulatory Surgical Center											9
10	Hospice											10
11	Other Inpatient Routine Service Costs											11
12	Subtotal (Sum of lines 2 through 11)											12
				Total Charges	Ratio of	Titles V and XIX Outpatient and			Titles V and XIX Outpatient and
				(From Wkst. C.	Cost to Charges	Title XVIII, Part B Charges			Title XVIII, Part B Costs
				Col. 2, lines	(Col. 2 ÷	Title V	Title XVIII	Title XIX	Title V	Title XVIII	Title XIX
	SNF Outpatient Services:			34 & 35)	by Col. 3)		Part B			Part B
				3	4	5	6	7	8	9	10
13	Clinic											13
14	R H C											14
15	Subtotal (Sum of lines 13 and 14)											15
16	Total (Sum of lines 12 and 15)	100.00										16
	PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
			Exp. allocated	Total	Average	Title XVIII	Expenses	Enter the amounts from		Total title
			to cost centers	Inpatient	Cost	Part B	Applicable	Part I, Column 9,		XVIII Costs
			on Wkst. B,	Days	Per Day	Inpatient	To Title XVIII	lines as indicated		(Sum of
			Part I Col. 14	All Patients	(Col. 1 ÷ Col. 2)	Days	(Col. 4 X Col. 3)			Cols 5 + 7 )
			1	2	3	4	5	6	7	8
17	SNF							2				17
18												18
19												19
20	Total (Sum of lines 17 through 19)											20
FORM CMS 2540-96 (12/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 3532 )
35-352												Rev. 7

---

Sheet 37: E-I

07-99			FORM CMS 2540-96			3590 (Cont.)
			PROVIDER NO.:	PERIOD:																																											.
	CALCULATION OF			FROM __________	WORKSHEET E
	REIMBURSEMENT SETTLEMENT		_________________	TO ______________	PART I
PART I - PART A INPATIENT SERVICES
Check one:		[ ] Title XVIII	[ ] Title V	[ ] Title XIX
Check one:		[ ] SNF	[ ] NF	[ ] ICF/MR
	COMPUTATION OF NET COST OF COVERED SERVICES
1	Inpatient ancillary services (See Instructions)					1
2	Intern and Resident Cost (From Supplemental Worksheet D-2)					2
3	Outpatient services					3
4	Inpatient routine services (See instructions)					4																			Total reasonable costs (sum of lines 1, 2 and 3)
5	Utilization review--physicians' compensation (From provider records)					5																			Cost of covered services (lesser of lines 4 or 5)
6	Cost of covered services (Sum of lines 1 - 5)					6																			Inpatient routine PPS amount (see instructions)
7	Differential in charges between semiprivate accomodations and less					7
	than semiprivate accomodations
8	SUBTOTAL (Line 6 minus line 7)					8																			Reimbursable bad debts
9	Primary payor amounts					9																			Utilization review
10	Total Reasonable Cost (Line 8 minus line 9)					10																			Recovery of unreimbursed cost under the lesser of reasonable cost or customary charges
	REASONABLE CHARGES
11	Inpatient ancillary service charges					11																			Subtotal (Sum of lines 6 through 14)
12	Intern and Resident Charges (From Provider Records)					12																			Sequestration adjustment
13	Outpatient service charges					13																			Interim payments (See instructions)
14	Inpatient routine service charges					14																			Balance due provider/program (Line 15 minus the sum of lines 16 and 17)
15	Differential in charges between semiprivate accomodations and less					15																			(Indicate overpayments in brackets)
	than semiprivate accomodations																								Protested amounts (Nonallowable cost report items in accordance with
16	Total reasonable charges					16																			CMS Pub. 15-II, section 115.2)
	CUSTOMARY CHARGES																								Balance due provider/program (Line 18 plus or minus line 19)
17	Aggregate amount actually collected from patients liable for payment for					17
	services on a charge basis
18	Amounts that would have been realized from patients liable for payment for services					18
	on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
19	Ratio of line 17 to line 18 (not to exceed 1.000000)					19
20	Total customary charges (See instructions)					20
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
21	Cost of covered services (See Instructions)					21
22	Deductibles ( Titles V and XIX only )					22
23	Subtotal (Line 21 minus line 22)					23
24	Coinsurance					24
25	Subtotal (Line 23 minus line 24)					25
26	Reimbursable bad debts ( From your records)					26
27	Subtotal (Sum of lines 25 and 26)					27
28	Unrefunded charges to beneficiaries for excess costs erroneously collected					28
	based on correction of cost limit
29	Recovery of excess depreciation resulting from provider termination or a decrease					29	<<< LINE DELETED
	in program utilization
30	Other Adjustments (See instructions) Specify					30
31	Amounts applicable to prior cost reporting periods resulting from disposition of					31	<<< LINE DELETED
	depreciable assets ( If minus, enter amount in brackets)
32	Subtotal (Line 27 plus or minus lines 30, and 31, minus lines 28 and 29)					32
33	Sequestration amount					33
34	Sub total (Line 32 minus line 33)					34
35	Interim payments					35
36	Balance due provider/program (Line 34 minus line 35)					36
	(Indicate overpayments in brackets) (See Instructions)
37	Protested amounts (Nonallowable cost report items) in accordance with					37
	CMS Pub. 15-II, section 115.2)
FORM CMS 2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
SECTIONS 3534 - 3534.1 )
Rev. 5						35-353

---

Sheet 38: E-II

3590 ( Cont.)		FORM CMS 2540-96			07-99
CALCULATION OF		PROVIDER NO.:	PERIOD:																																										.
REIMBURSEMENT SETTLEMENT			FROM _____________	WORKSHEET E
		_________________	TO ______________	PART II
PART II - PART B - MEDICAL AND OTHER HEALTH SERVICES
COMPUTATION OF NET COST OF COVERED SERVICES
1	Inpatient ancillary services (See Instructions)				1
2	Outpatient services				2
3	Vaccine cost (From Wkst D., Part II, line 3)				3
4	Interns and Residents (From Supp. Wkst. D-2)				4
5	Subtotal (Sum of lines 1, 2, 3 and 4)				5
6	Primary payor amounts				6
7	Total Reasonable Cost ( Line 5 minus line 6)				7
REASONABLE CHARGES
8	Inpatient ancillary service charges				8
9	Outpatient service charges				9
10	Intern & Resident Charges (From Provider Records)				10
11	Total reasonable charges (See Instructions)				11
CUSTOMARY CHARGES
12	Aggregate amount actually collected from patients liable for payment for				12
	services on a charge basis
13	Amounts that would have been realized from patients liable for payment for services				13
	on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
14	Ratio of line 12 to line 13 (not to exceed 1.000000)				14
15	Total customary charges (See instructions)				15
COMPUTATION OF REIMBURSEMENT SETTLEMENT
16	Cost of covered services (Lesser of Cost or Charges) (Lesser of ln 5 or ln 15 minus ln 6)				16
17	Deductibles and coinsurance				17
18	Subtotal (Line 16 minus line 17)				18
19	Reimbursable bad debts ( From your records )				19
20	Subtotal (Sum of lines 18, and 19)				20
21	Recovery of excess depreciation resulting from provider termination				21
	or a decrease in program utilization
22	Other Adjustments (See instructions) Specify				22
23	Amounts applicable to prior cost reporting periods resulting from				23
	disposition of depreciable assets ( If minus, enter amount in brackets)
24	Subtotal (Line 20 minus line 21 plus or minus lines 22 and 23)				24
25	Sequestration amount				25
26	Subtotal (Line 24 minus line 25)				26
27	Interim payments				27
28	Balance due provider/program (Line 26 minus line 27)				28
	(Indicate overpayments in brackets) (See Instructions)
29	Protested amounts (Nonallowable cost report items) in accordance with				29
	CMS Pub. 15-II, section 115.2)
FORM CMS 2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3534.2 )
35-354					Rev. 5
NOTE: THIS FORM WILL NOT BE NEEDED AFTER 6/30/99

---

Sheet 39: E-III

12-99			FORM CMS 2540-96			3590 ( Cont.)
			PROVIDER NO.:	PERIOD:									.																																.
	CALCULATION OF			FROM _____________	WORKSHEET E
	REIMBURSEMENT SETTLEMENT		_________________	TO ______________	PART III
PART III - SNF REIMBURSEMENT UNDER PPS
Check one:		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
	PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT
	LESSER OF COST OR CHARGES
1	Inpatient ancillary services - Part A - ( See Instructions )					1
2	Interns & Residents and Medical Education cost for Title XVIII ( See Instructions )					2
3	Total cost ( Sum of lines 1 and 2)					3
4	Medicare inpatient ancillary charges (see instructions)					4
5	Intern and Resident Charges ( From Provider Records)					5
6	Cost of covered services (lesser of line 3, or the sum of lines 4 and 5)					6
7	Inpatient PPS amount (see instructions)					7
8	Primary payor amounts					8
9	Coinsurance					9
10	Reimbursable bad debts (From your records)					10
11	Utilization review					11
12	Recovery of excess depreciation resulting from provider termination or a decrease					12
	in Program utilization.
13	Amounts applicable to prior cost reporting periods resulting from disposition					13
	of assets. (If minus, enter amount in brackets)
14	Subtotal (Sum of lines 3, 7, 10 and 11, minus lines 12, 8 & 9, plus or minus line 13)					14
15	Sequestration adjustment					15
16	Interim payments (See instructions)					16
17	Balance due provider/program (Line 14 minus the sum of lines 15 and 16)					17
	(Indicate overpayments in brackets) (See Instructions)
18	Protested amounts (Nonallowable cost report items in accordance with					18
	CMS Pub. 15-II, section 115.2)
	PART B - ANCILLARY SERVICES COMPUTATION OF REIMBURSEMENT
	LESSER OF COST OR CHARGES - TITLE XVIII ONLY
19	Ancillary services Part B					19
20	Vaccine cost (From Wkst D, Part II, line 3)					20
21	Intern and Resident Cost ( From Worksheet D-2)					21
22	Total reasonable costs (Sum of lines 19 to 21)					22
23	Medicare Part B ancillary charges (See instructions)					23
24	Intern and Resident Charges ( From Provider Records )					24
25	Cost of covered services (Lesser of line 22, or sum of lines 23 and 24)					25
26	Primary payor amounts					26
27	Coinsurance and deductibles					27
28	Reimbursable bad debts (From your records)					28
29	Recovery of unreimbursed cost under the lesser of reasonable cost or customary charges					29
30	80% of recovery of unreimbursed cost under the lesser of reasonable cost					30
	or customary charges (Line 29 times 0.80)
31	Recovery of excess depreciation resulting from provider termination or a decrease					31
	in Program utilization.
32	Other Adjustments (See instructions) Specify					32
33	Amounts applicable to prior cost reporting periods resulting from disposition					33
	of assets. (If minus, enter amount in brackets)
34	Subtotal (Sum of lines 25, 28, & 30, minus lines 26, 27, and 31,					34
	plus or minus line 32 and 33 )
35	Sequestration adjustment					35
36	Interim payments (See instructions)					36
37	Balance due provider/program (Line 34 minus the sum of lines 35 and 36)					37
	(Indicate overpayments in brackets) (See Instructions)
38	Protested amounts (Nonallowable cost report items) in accordance with					38
	CMS Pub. 15-II, section 115.2)
FORM CMS 2540-96 ( 12/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3534.3 )
Rev. 7						35-355

---

Sheet 40: E-V

3590 ( Cont.)		FORM CMS 2540-96			12-99
		PROVIDER NO.:	PERIOD:																																										.
CALCULATION OF PPS			FROM _____________	WORKSHEET E,
REIMBURSEMENT SETTLEMENT		_________________	TO ______________	PART V
PART V - REIMBURSEMENT UNDER NHCMQ DEMONSTRATION
DO NOT COMPLETE THIS WORKSHEET FOR COST REPORTING PERIODS
BEGINNING ON AND AFTER JULY 1, 1998.
	PART A - INPATIENT SERVICES: PROVIDER COMPUTATION OF REIMBURSEMENT
	INPATIENT DAYS
1	Total Title XVIII Days ( From Wkst. S-3, Part I, col 4, sum of lines 1 and 2)				1
2	Program Days (From Wkst. S-7, Part I, line 46, sum of cols. 3.01 and 4.01)				2
	INPATIENT ANCILLARY SERVICES - PART A
3	Total Part A Ancillary Program Costs (From Wks. D, Col. 4, line 75)				3
4	Less Physical, Occupational and Speech Therapy (Complete this line for Phase 3 only)				4
	(From Wks. D, Col. 4, sum of lines 25 - 27)
5	Net Non-NHCMQ Demonstration Ancillary Services (Line 3 less line 4)				5
	NHCMQ DEMONSTRATION INPATIENT/ANCILLARY SERVICE PPS
	PROVIDER COMPUTATION OF REIMBURSEMENT
6	Inpatient routine/ancillary PPS amount paid (From Supp. Wkst. S-7, Part I, Col 5, line 46)				6																		Reimbursable bad debts
	PROGRAM INPATIENT CAPITAL COSTS																						Sequestration adjustment
7	Capital related cost allocated to inpatient routine service cost				7																		Interim payments (See instructions)
	(From Worksheet B, Part II column 18, sum of lines 16, 17 and 18)																						Balance due provider/program (Line 15 minus the sum of lines 16 and 17)
8	Per diem capital related costs (See instructions)				8																		(Indicate overpayments in brackets)
9	Program capital related cost (Line 8 times line 1)				9
	NHCMQ DEMONSTRATION ANCILLARY SERVICES: INDIRECT COST COMPONENT
	Total general service cost allocation - (Lines 10 through 24 are completed only for Phase 3)																						Protested amounts (Nonallowable cost report items in accordance with
10	Physical Therapy (Wkst. B, Part I, Col 18, line 25)				10																		CMS Pub. 15-II, section 115.2)
11	Occupational Therapy (Wkst B, Part I, Col 18 line 26)				11																		Balance due provider / program (Line 18 plus or minus line 19)
12	Speech Therapy (Wkst B, Part I, Col 18 line 27)				12
	Direct cost -
13	Physical Therapy (Wkst. B, Part I, Col 0, line 25)				13
14	Occupational Therapy (Wkst B, Part I, Col 0 line 26)				14
15	Speech Therapy (Wkst B, Part I, Col 0 line 27)				15
	Indirect Cost -																						#REF!
16	Physical Therapy (Line 10 less line 13)				16
17	Occupational Therapy (Line 11 less line 14)				17
18	Speech Therapy (Line 12 less line 15)				18
	Charge to Charge Ratio -
19	Physical Therapy (Wkst D, col 2, line 25 divided by Wkst C, Col 2, line 25)				19
20	Occupational Therapy (Wkst D, Col 2, line 26 divided by Wkst C, Col 2, line 26)				20
21	Speech Therapy (Wkst D, Col 2, line 27 divided by Wkst C, Col 2, line 27)				21
	Demonstration Indirect Cost -
22	Physical Therapy (Line 16 times line 19)				22
23	Occupational Therapy (Line 17 times line 20)				23
24	Speech Therapy (Line 18 times line 21)				24
	Total Reimbursed NHCMQ Demonstration
25	NHCMQ Demonstration Inpatient/Ancillary Services - Part A - PPS Provider Computation				25
	of Reimbursement (Phase II - enter sum of lines 5,6 and 9)(Phase III - enter the sum of
	lines 5, 6, 9, 22, 23 and 24.) Transfer this amount to Worksheet E, Part III, line 7
FORM CMS 2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3534.4 )
35-356					Rev. 7

---

Sheet 41: E1

11-98			FORM CMS 2540-96					3590 ( Cont.)
ANALYSIS OF PAYMENTS TO PROVIDERS			PROVIDER NO.:		PERIOD:
FOR SERVICES RENDERED					FROM ________________		WORKSHEET E - 1
			________________		TO ________________
				Inpatient Part A		Part B
				Mo / Day / Yr	Amount	Mo / Day / Yr	Amount
	Description			1	2	3	4
1	Total interim payments paid to provider							1
2	Interim payments payable on individual bills, either submitted							2
	or to be submitted to the intermediary for services rendered
	in the cost reporting period. If none, enter zero
3	List separately each retroactive lump sum		.01					3.01
	adjustment amount based on subsequent revision of		.02					3.02
	the interim rate for the cost reporting period	Program to	.03					3.03
	Also show date of each payment.	Provider	.04					3.04
			.05					3.05
	If none, write "NONE," or enter a zero (1)		.50					3.50
			.51					3.51
		Provider to	.52					3.52
		Program	.53					3.53
			.54					3.54
	SUBTOTAL (Sum of lines 3.01 - 3.05 minus sum of lines 3.50 - 3.54)		.99					3.99
4	TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99)							4
	(Transfer to Wkst E, Part I line 35; Wkst E, Part II line 27; or
	Wkst E, Part III, line 16 for Part A, and line 36 for Part B )
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative settlement	Program to	.01					5.01
	payment after desk review. Also show	Provider	.02					5.02
	date of each payment.		.03					5.03
	If none, write "NONE," or enter a zero.(1)		.50					5.50
		Provider to	.51					5.51
		Program	.52					5.52
	SUBTOTAL (Sum of lines 5.01 - 5.03 minus sum of lines 5.50 - 5.52)		.99					5.99
6	Determined net settlement amount (balance	Program to provider	.01					6.01
	due) based on the cost report. (1)	Provider to program	.50					6.50
7	TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)							7
	Name of Intermediary	Intermediary Number			Signature of Authorized Person		Date (Mo/Day/Yr)
(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment even though total repayment is not accomplished until a later date.
FORM CMS-2540-96 ( 10/98 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3535 )
Rev. 4								35-357

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Sheet 42: G

3590 ( Cont.)			FORM CMS 2540-96			07-99
			PROVIDER NO.:	PERIOD:
	BALANCE SHEET			FROM ________	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type				TO ___________
accounting records, complete the "General Fund" column only)
			Specific
	Assets	General	Purpose	Endowment	Plant
	(Omit cents)	Fund	Fund	Fund	Fund
		1	2	3	4
	CURRENT ASSETS
1	Cash on hand and in banks					1
2	Temporary investments					2
3	Notes receivable					3
4	Accounts receivable					4
5	Other receivables					5
6	Less: allowances for uncollectible notes	( )	( )	( )	( )	6
	and accounts receivable
7	Inventory					7
8	Prepaid expenses					8
9	Other current assets					9
10	Due from other funds					10
11	TOTAL CURRENT ASSETS					11
	(Sum of lines 1 - 10)
	FIXED ASSETS
12	Land					12
13	Land improvements					13
14	Less: Accumulated depreciation	( )	( )	( )	( )	14
15	Buildings					15
16	Less Accumulated depreciation	( )	( )	( )	( )	16
17	Leasehold improvements					17
18	Less: Accumulated Amortization	( )	( )	( )	( )	18
19	Fixed equipment					19
20	Less: Accumulated depreciation	( )	( )	( )	( )	20
21	Automobiles and trucks					21
22	Less: Accumulated depreciation	( )	( )	( )	( )	22
23	Major movable equipment					23
24	Less: Accumulated depreciation	( )	( )	( )	( )	24
25	Minor equipment nondepreciable					25
26	Other fixed assets					26
27	TOTAL FIXED ASSETS					27
	(Sum of lines 12 - 26)
	OTHER ASSETS
28	Investments					28
29	Deposits on leases					29
30	Due from owners/officers					30
31	Other assets					31
32	TOTAL OTHER ASSETS					32
	(Sum of lines 28 - 31)
33	TOTAL ASSETS					33
	(Sum of lines 11, 27 and 32)
	( ) = contra amount
FORM CMS 2540 96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3536 )
35-358						Rev. 5

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Sheet 43: GII

11-98			FORM CMS 2540-96			3590 ( Cont.)
			PROVIDER NO.:	PERIOD:
BALANCE SHEET				FROM ________	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type				TO ___________	(Cont.)
accounting records, complete the "General Fund" column only)
	Liabilities and Fund		Specific
	Balances	General	Purpose	Endowment	Plant
	(Omit cents)	Fund	Fund	Fund	Fund
		1	2	3	4
	CURRENT LIABILITIES
34	Accounts payable					34
35	Salaries, wages & fees payable					35
36	Payroll taxes payable					36
37	Notes & loans payable (Short term)					37
38	Deferred income					38
39	Accelerated payments					39
40	Due to other funds					40
41	Other current liabilities					41
42	TOTAL CURRENT LIABILITIES					42
	(Sum of lines 34 - 41)
	LONG TERM LIABILITIES
43	Mortgage payable					43
44	Notes payable					44
45	Unsecured loans					45
46	Loans from owners: a. Prior to 7/1/66					46
	b. On or after 7/1/66
47	Other long term liabilities					47
48						48
49	TOTAL LONG TERM LIABILITIES					49
	(Sum of lines 43 - 48)
50	TOTAL LIABILITIES					50
	(Sum of lines 42 and 49)
	CAPITAL ACCOUNTS
51	General fund balance					51
52	Specific purpose fund					52
53	Donor created - endowment fund					53
	balance - restricted
54	Donor created - endowment fund					54
	balance - unrestricted
55	Governing body created - endowment					55
	fund balance
56	Plant fund balance - invested in plant					56
57	Plant fund balance - reserve for					57
	plant improvement, replacement and
	expansion
58	TOTAL FUND BALANCES					58
	(Sum of lines 51 thru 57)
59	TOTAL LIABILITIES AND					59
	FUND BALANCES
	(Sum of lines 50 and 58)
	( ) = contra amount
FORM CMS-2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3536 )
Rev. 4						35-359

---

Sheet 44: G-1

3590 (Cont.)				FORM CMS 2540-96						11-98
				PROVIDER NO:		PERIOD:
	STATEMENT OF CHANGES IN FUND BALANCES					FROM ___________________		WORKSHEET G - 1
				________________________		TO ________________
		GENERAL FUND		SPECIFIC PURPOSE FUND		ENDOWMENT FUND		PLANT FUND
			1		2		3		4
1	Fund balances at beginning of									1
	period
2	Net income (loss)									2
	(From Wkst. G-3, line 32)
3	Total (Sum of line 1 and line 2)									3
4	Additions (Credit adjustments)									4
5										5
6										6
7										7
8										8
9										9
10	Total additions (Sum of lines 4 - 9)									10
11	Subtotal (Line 3 plus line 10)									11
12	Deductions (Debit adjustments)									12
13										13
14										14
15										15
16										16
17										17
18	Total deductions									18
	(Sum of lines 12 - 17)
19	Fund balance at end of period per									19
	balance sheet (Line 11 - line 18)
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3536.1)
35-360										Rev. 4

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Sheet 45: G-2

11-98		FORM CMS 2540-96			3590 ( Cont.)
		PROVIDER NO:	PERIOD:
	STATEMENT OF PATIENT REVENUES	______________	FROM _________	WORKSHEET G - 2
	AND OPERATING EXPENSES		TO ___________	PARTS I & II
	PART I - PATIENT REVENUES
	Revenue Center	INPATIENT	OUTPATIENT	TOTAL
		1	2	3
	GENERAL INPATIENT ROUTINE CARE SERVICES
1	Skilled Nursing Facility				1
2					2
3	Nursing facility				3
4	Other long term care				4
5	Total general inpatient care services				5
	(Sum of lines 1 - 4)
	All Other Care Service
6	Ancillary services				6
7	Clinic				7
8	Home health agency				8
9					9
10	Ambulance				10
11	Hospice				11
12	Outpatient Rehabilitation Provider				12
13					13
14	Total Patient Revenues ( Sum of lines 5 - 13 )				14
	( Transfer column 3 to Worksheet G-3, Line 1 )
	PART II - OPERATING EXPENSES
1	Operating Expenses ( Per Worksheet A, Col. 3, Line 75 )				1
2	Add ( Specify )				2
3					3
4					4
5					5
6					6
7					7
8	Total Additions ( Sum of lines 2 - 7 )				8
9	Deduct ( Specify )				9
10					10
11					11
12					12
13					13
14	Total Deductions ( Sum of lines 9 - 13 )				14
15	Total Operating Expenses ( Sum of lines 1 and 8, minus line 14 )				15
	( Transfer to Worksheet G-3, Line 4 )
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3536.2 )
Rev. 4					35-361

---

Sheet 46: G-3

3590 ( Cont.)		FORM CMS 2540-96			11-98
	STATEMENT OF REVENUES	PROVIDER NO:	PERIOD:
	AND EXPENSES	______________	FROM _________	WORKSHEET G - 3
			TO ___________
1	Total patient revenues (From Wkst. G - 2, Part I, col. 3, line 14)				1
2	Less: contractual allowances and discounts on patients accounts				2
3	Net patient revenues (Line 1 minus line 2)				3
4	Less: total operating expenses (From Worksheet G-2, Part II, line 15)				4
5	Net income from service to patients (Line 3 minus 4)				5
6	Other income:				6
7	Contributions, donations, bequests, etc				7
8	Income from investments				8
9	Revenues from telephone and telegraph service				9
10	Revenue from television and radio service				10
11	Purchase discounts				11
12	Rebates and refunds of expenses				12
13	Parking lot receipts				13
14	Revenue from laundry and linen service				14
15	Revenue from meals sold to employees and guests				15
16	Revenue from rental of living quarters				16
17	Revenue from sale of medical and surgical supplies to other than patients				17
18	Revenue from sale of drugs to other than patients				18
19	Revenue from sale of medical records and abstracts				19
20	Tuition (fees, sale of textbooks, uniforms, etc.)				20
21	Revenue from gifts, flower, coffee shops, canteen				21
22	Rental of vending machines				22
23	Rental of skilled nursing space				23
24	Governmental appropriations				24
25	Other (specify)				25
26	Total other income (Sum of lines 7 - 25)				26
27	Total (Line 5 plus line 26)				27
28	Other expenses (specify)				28
29					29
30					30
31	Total other expenses (Sum of lines 28 - 30)				31
32	Net income (or loss) for the period (Line 27 minus line 31)				32
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3536.3 )
35-362					Rev. 4

---

Sheet 47: H

11-98			FORM CMS 2540-96					3590 ( Cont.)
			PROVIDER NO.: ________________		PERIOD:
	ANALYSIS OF PROVIDER - BASED				FROM ________________		WORKSHEET
	HOME HEALTH AGENCY COSTS		HHA NO.: _____________________		TO ___________________		H
			EMPLOYEE		CONTRACTED/
		SALARIES	BENEFITS	TRANSPORT-	PURCHASED SRVS		TOTAL
		(FROM	(FROM	ATION (SEE	(FROM	OTHER	HHA
		WKST. H-1)	WKST. H-2)	INSTRUCTIONS)	WKST. H-3)	COSTS	COST
		1	2	3	4	5	6
	GENERAL SERVICE COST CENTER
1	Capital Related - Bldg. and Fixtures							1
2	Capital Related - Movable Equipment							2
3	Plant Operation & Maintenance							3
4	Transportation (See Instructions)							4
5	Administrative - General -HHA							5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care							6
7	Physical Therapy							7
8	Occupational Therapy							8
9	Speech Pathology							9
10	Medical Social Services							10
11	Home Health Aide							11
12	DME - Rented							12
13	DME - Sold							13
14	Supplies (See Instructions)							14
	HHA NONREIMBURSABLE SERVICES
15	Respiratory Therapy							15
16	Private Duty Nursing							16
17	Clinic							17
18	Health Promotion Activities							18
19	Day Care Program							19
20	Home Delivered Meals Program							20
21	Homemaker Service							21
22								22
23								23
24								24
25	Total							25
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3539 )
Rev 4.								35-363
.

---

Sheet 48: H-1

3590 ( Cont.)				FORM CMS 2540-96							11-98
COMPENSATION ANALYSIS		PROVIDER NO.:_____________			PERIOD:
SALARIES AND WAGES					FROM _______________			WORKSHEET H - 1
		HHA NO.:___________________			TO _______________
		ADMINIS-		CONSULT-	SUPER-				ALL	TOTAL
		TRATORS	DIRECTORS	ANTS	VISORS	NURSES	THERAPISTS	AIDES	OTHER	(1)
		1	2	3	4	5	6	7	8	9
GENERAL SERVICE COST CENTER
1	Capital Related - Bldg. and Fixtures										1
2	Capital Related - Movable Equipment										2
3	Plant Operation & Maintenance										3
4	Transportation (See Instructions)										4
5	Administrative - General--HHA										5
HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care										6
7	Physical Therapy										7
8	Occupational Therapy										8
9	Speech Pathology										9
10	Medical Social Services										10
11	Home Health Aide										11
12	DME - Rented										14
13	DME - Sold										13
14	Supplies (See Instructions)										14
TITLE XVIII NONREIMBURSABLE
SERVICES
15	Respiratory Therapy										15
16	Private Duty Nursing										16
17	Clinic										17
18	Health Promotion Activities										18
19	Day Care Program										19
20	Home Delivered Meals Program										20
21	Homemaker Service										21
22											22
23											23
24											24
25	Total										25
(1) See Instructions
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3540 )
35-364											Rev. 4

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Sheet 49: H-2

11-98				FORM CMS 540-96							3590 ( Cont.)
COMPENSATION ANALYSIS		PROVIDER NO.:_____________			PERIOD:
EMPLOYEE BENEFITS					FROM _______________			WORKSHEET H - 2
(PAYROLL RELATED)		HHA NO.:___________________			TO _______________
		ADMINIS-		CONSULT-	SUPER-				ALL	TOTAL
		TRATORS	DIRECTORS	ANTS	VISORS	NURSES	THERAPISTS	AIDES	OTHER	(1)
		1	2	3	4	5	6	7	8	9
GENERAL SERVICE COST CENTER
1	Capital Related - Bldg. and Fixtures										1
2	Capital Related - Movable Equipment										2
3	Plant Operation & Maintenance										3
4	Transportation (See Instructions)										4
5	Administrative - General--HHA										5
HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care										6
7	Physical Therapy										7
8	Occupational Therapy										8
9	Speech Pathology										9
10	Medical Social Services										10
11	Home Health Aide										11
12	DME - Rented										14
13	DME - Sold										13
14	Supplies (See Instructions)										14
TITLE XVIII NONREIMBURSABLE
SERVICES
15	Respiratory Therapy										15
16	Private Duty Nursing										16
17	Clinic										17
18	Health Promotion Activities										18
19	Day Care Program										19
20	Home Delivered Meals Program										20
21	Homemaker Service										21
22											22
23											23
24											24
25	Total										25
(1) See Instructions
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3541 )
Rev. 4											35-365

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Sheet 50: H-3

3590 ( Cont.)					FORM CMS 2540-96						11-98
COMPENSATION ANALYSIS		PROVIDER NO.:_____________			PERIOD:
CONTRACTED SERVICES					FROM _______________			WORKSHEET H - 3
PURCHASED SERVICES		HHA NO.:___________________			TO _______________
		ADMINIS-		CONSULT-	SUPER-				ALL	TOTAL
		TRATORS	DIRECTORS	ANTS	VISORS	NURSES	THERAPISTS	AIDES	OTHER	(1)
		1	2	3	4	5	6	7	8	9
GENERAL SERVICE COST CENTER
1	Capital Related - Bldg. and Fixtures										1
2	Capital Related - Movable Equipment										2
3	Plant Operation & Maintenance										3
4	Transportation (See Instructions)										4
5	Administrative - General--HHA										5
HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care										6
7	Physical Therapy										7
8	Occupational Therapy										8
9	Speech Pathology										9
10	Medical Social Services										10
11	Home Health Aide										11
12	DME - Rented										14
13	DME - Sold										13
14	Supplies (See Instructions)										14
TITLE XVIII NONREIMBURSABLE
SERVICES
15	Respiratory Therapy										15
16	Private Duty Nursing										16
17	Clinic										17
18	Health Promotion Activities										18
19	Day Care Program										19
20	Home Delivered Meals Program										20
21	Homemaker Service										21
22	All Other										22
23											23
24											24
25	Total										25
(1) See Instructions
Form 3569
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3542 )
35-366											Rev. 4

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Sheet 51: H-4

12-99				FORM CMS 2540-96					3590 (Cont. )
ALLOCATION OF H H A		PROVIDER NO.:			PERIOD:																																																																					{APP4}IALLWAYS~/PCOLB1~Q/PGQ/1
ADMINISTRATIVE		___________________			FROM_________________		WORKSHEET H - 4
AND GENERAL COSTS		HHA NO.:____________________			TO___________________		PARTS I & II
	PART I - ALLOCATION OF HHA ADMINISTRATIVE AND GENERAL COSTS
		From Wkst B.		Shared Ancillary Costs,		Subtotal	Allocation	Total H H A
		Part I, Col 18		from Wkst H-4, Part II		(Sum of Cols.	of H H A	Costs
	Cost Center	Lines as Indicated		Lines as Indicated		1 and 2)	A & G Costs	(Col. 3 + Col. 4)
			1		2	3	4	5
1	Administrative and General--HHA	37					( )	-0-	1
2	Skilled Nursing Care--HHA	38							2
3	Physical Therapy--HHA	39		1					3
4	Occupational Therapy--HHA	40		2					4
5	Speech Pathology--HHA	41		3					5
6	Medical Social Services--HHA	42							6
7	Home Health Aide--HHA	43							7
8	Durable Medical Equipment Rented--HHA	44							8
9	Durable Medical Equipment Sold--HHA	45							9
10	Medical Supplies Charged to Patients			4					10
11	Drugs Charged to Patients			5					11
12	Home Delivered Meals--HHA	46							12
13	Other Home Health Services--HHA	47		6 / 7					13
14	TOTAL (Sum of lines 1 thru 13)			8			-0-		14
15	BASIS FOR ALLOCATION (Sum of lines 2 thru 13)								15
16	UNIT COST MULTIPLIER (Line 1 divided by line 15)								16
	PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED S N F DEPARTMENTS
			Total H H A	Cost/Charge Ratio		H H A Shared	Transfer
			Charges - From	Fr. Wkst. C. Col. 3,		Ancillary Costs	Column 3 to
	Cost Center		Provider Records	Lines as indicated		(Col. 1 X Col. 2)	Part I as indicated
			1		2	3	4
1	Physical Therapy			25			Col. 2, line 3		1
2	Occupational Therapy			26			Col. 2, line 4		2
3	Speech Pathology			27			Col. 2, line 5		3
4	Medical Supplies Charged to Patients			29			Col. 2, line 10		4
5	Drugs Charged to Patients			30			Col. 2, line 11		5
6	Dental Care ( Title XIX Only)			31			Col. 2, line 13		6
7	Other Ancillary Service Cost			33			Col. 2, line 13		7
8	TOTAL						Col. 2, line 14		8
FORM CMS 2540-96 ( 07/96 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3543 - 3543.2 )
Rev. 7									35-367

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Sheet 52: H-5

3590 (Cont. )						FORM CMS 2540-96					08-01
APPORTIONMENT OF					PROVIDER NO.:		PERIOD:
PATIENT SERVICE COSTS					______________________		From: ___________________		WORKSHEET H-5															\B
					HHA NO:		To: ____________________		PARTS I & II
Check One:		[ ]	Title V		[ ]	Title XVIII	[ ]	Title XIX
PART I - AGGREGATE AGENCY COST PER VISIT COMPUTATION
							From			Average
Cost Per Visit Computation							Wkst H-4	Total		Cost
							Pt I, Col.	Cost	Visits	Per Visit
	Patient Services						5, Line			(Cols 2 ÷ 3) (1)
							1	2	3	4
1	Skilled Nursing						2			#DIV/0!	1
2	Physical Therapy						3			#DIV/0!	2
3	Occupational Therapy						4			#DIV/0!	3
4	Speech Pathology						5			#DIV/0!	4
5	Medical Social Services						6			#DIV/0!	5
6	Home Health Aide Services						7			#DIV/0!	6
7	Total (Sum of lines 1-6)										7
PART II - COMPUTATION OF THE AGGREGATE MEDICARE COST AND THE AGGREGATE OF THE MEDICARE LIMITATION (2)
								Medicare Program Visits
Total Medicare Patient						Average Cost Per Visit			Part B
Service Cost						From Part I		Part A	Not Subject	Subject
Computation						Column 4			to Deductibles	to Deductibles
						Line ___			& Coinsurance	& Coinsurance
	MSA Code: __________						4	5	6	7
1	Skilled Nursing - pre 10/1/2000					1					1
1.01	Skilled Nursing -post 9/30/2000					1					1.01
2	Physical Therapy - pre 10/1/2000					2					2
2.01	Physical Therapy - post 9/30/2000					2					2.01
3	Occupational Therapy - pre 10/1/2000					3					3
3.01	Occupational Therapy - post 9/30/2000					3					3.01
4	Speech Pathology - pre 10/1/2000					4					4
4.01	Speech Pathology - post 9/1/2000					4					4.01
5	Medical Social Services - pre 10/1/00					5					5
5.01	Medical Social Services - post 9/30/00					5					5.01
6	Home Health Aide Svcs pre 10/1/2000					6					6
6.01	Home Health Aide Svcs - post 9/30/00					6					6.01
7	Total (Sum of lines 1-6)										7
	(1) Compute the average cost per visit one time for each discipline (column 4, lines 1 through 6) for the entire home health agency.
	(2) Complete Part II once for each SMSA where Medicare covered services were furnished during the cost reporting period.
FORM CMS-2540-96 ( 08/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3544)
35-368											Rev 11
08-01						FORM CMS 2540-96					3590 (Cont. )
APPORTIONMENT OF					PROVIDER NO.:		PERIOD:
PATIENT SERVICE COSTS					______________________		From: ___________________		WORKSHEET H-5															\B
					HHA NO:		To: ____________________		PART II (Cont.)
PART II - COMPUTATION OF THE AGGREGATE MEDICARE COST AND THE AGGREGATE OF THE MEDICARE LIMITATION (2)
						Cost of Medicare Services
Total Medicare Patient							Part B		Total	Total
Service Cost						Part A	Not Subject	Subject	(Sum of	(Sum of
Computation							to Deductibles	to Deductibles	Cols 8 & 9	Cols 8 & 9
							& Coinsurance	& Coinsurance	Pre 10/01/2000	Post 9/30/2000
						8	9	10	11	11.01
1	Skilled Nursing - pre 10/1/2000										1
1.01	Skilled Nursing -post 9/30/2000										1.01
2	Physical Therapy - pre 10/1/2000										2
2.01	Physical Therapy - post 9/30/2000										2.01
3	Occupational Therapy - pre 10/1/2000										3
3.01	Occupational Therapy - post 9/30/2000										3.01
4	Speech Pathology - pre 10/1/2000										4
4.01	Speech Pathology - post 9/1/2000										4.01
5	Medical Social Services - pre 10/1/00										5
5.01	Medical Social Services - post 9/30/00										5.01
6	Home Health Aide Svcs pre 10/1/2000										6
6.01	Home Health Aide Svcs - post 9/30/00										6.01
7	Total (Sum of lines 1-6)										7
	(1) Compute the average cost per visit one time for each discipline (column 4, lines 1 through 6) for the entire home health agency.
	(2) Complete Part II once for each SMSA where Medicare covered services were furnished during the cost reporting period.
				Medicare Program Visits			Cost of Medicare Services			Total
Total Medicare Patient			Program		Part B			Part B		(Sum of
Service Cost			Cost	Part A	Deductibles and Coinsurance		Part A	Deductibles and Coinsurance		Cols 8 & 9
Limitation Computation			Limit		(Not Subject to)	(Subject to)		(Not Subject to)	(Subject to)
			4	5	6	7	8	9	10	11
8	Skilled Nursing		44,454				0				8
9	Physical Therapy		6,010		346		0	#REF!			9
10	Occupational Therapy		1,373		194		0	#REF!			10
11	Speech Pathology		1,101		300		0	#REF!			11
12	Medical Social Services		625				0	#REF!			12
13	Home Health Aide Svcs	#REF!	21,041				#REF!	#REF!			13
14	Total (Sum of lines 8-13)				840		#REF!	#REF!			14
FORM CMS-2540-96 ( 08/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3544)
Rev. 11											35-368.1
3590 (Cont. )						FORM CMS 2540-96					08-01
APPORTIONMENT OF					PROVIDER NO.:		PERIOD:
PATIENT SERVICE COSTS					______________________		From: ___________________		WORKSHEET H-5
					HHA NO:		To: ____________________		PART III
PART III - SUPPLIES AND DRUGS COST COMPUTATION
				From		Total			Part B Charges
				Wkst. H-4,	Total	Charges		Part A	Not Subject	Subject
				Part I, Col. 5	HHA	from HHA	Ratio	Covered	to Deductibles	to Deductibles
	Other Patient Services			Line -	Cost	Record)	(Col 2 ÷ 3)	Charges	& Coinsurance	& Coinsurance
				1	2	3	4	5	6	7
15	Cost of Medical Supplies-Pre 10/01/2000			10	0	23,555	0.000000	10,320			15
15.01	Cost of Medical Supplies-Post 10/01/2000			10							15.01
16	Cost of Drugs-Pre 10/01/200			11							16
16.01	Cost of Drugs-Post 10/01/2000			11	0	49,687	0.000000		25,047		16.01
17	Total										17
									Part B
								Part A	Not Subject	Subject
								Cost of	to Deductibles	to Deductibles
								Services	& Coinsurance	& Coinsurance
								8	9	10
15	Cost of Medical Supplies - Pre 10/01/2000							0	0	0	15
15.01	Cost of Medical Supplies - Post 09/30/2000							0	0	0	15.01
16	Cost of Drugs-Pre 10/0/2000								0		16
16.01	Cost of Drugs-Post 10/01/2000										16.01
17	Total										17
FORM CMS-2540-96 ( 08/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3544)
35-369											Rev. 11
08-01						FORM CMS 2540-96					3590 (Cont. )
APPORTIONMENT OF					PROVIDER NO.:		PERIOD:
PATIENT SERVICE COSTS					______________________		From: ___________________		WORKSHEET H-5
					HHA NO:		To: ____________________		PARTS IV & V
PART IV - COMPARISON OF THE LESSER OF THE AGGREGATE MEDICARE COST, THE AGGREGATE OF THE MEDICARE COST PER VISIT LIMITATION
AND THE AGGREGATE PER BENEFICIARY COST LIMITATION
					Medicare	Per Beneficiary	Cost of Medicre Services
					Program	Annual		Part B		Total
					Unduplicated	Limitation Per		Not Subject	Subject to	(Sum of
					Census Count	MSA/Non-MSA	Part A	to Deductibles	Deductibles	Columns
					For Each MSA	(From your FI)		& Coinsurance	& Coinsurance	3 and 4)
					1	2	3	4	5	6
18	Total Cost of Medicare Services (Sum of the amounts for each Whst. H-5										18
	Part II, columns 8, 9 & 11, respectively, line1-6)(exclusive of subscripts)
19	Cost of Medical Supplies (From Part III, columns 8 and 9, line 15)(exclusive of subscripts)										19
20	Total (Sum of lines 18 and 19).										20
21	Total Cost Per Visit Limitation for Medicare Services (Sum of the										21
	amounts from each Wkst. H-5, Pt II, cols. 8 & 9 respectively, line 14)
22	Cost of Medical Supplies (From Part III, cols. 8 & 9, line 15)(exclusive of subscripts)										22
23	Total ( Sum of lines 21 and 22)										23
					Medicare	Per Beneficiary	Cost of Medicare Services
					Program	Annual		Part B		Total
				MSA Code	Unduplicated	Limitation Per		Not Subject	Subject to	(Sum of
					Census Count	MSA/Non-MSA	Part A	to Deductibles	Deductibles	Columns
					For Each MSA	(From your FI)		& Coinsurance	& Coinsurance	3 and 4)
				0	1	2	3	4	5	6
24	Per Beneficiary Cost Limitation for MSA:										24
24.01	Per Beneficiary Cost Limitation for MSA:										24.01
24.02	Per Beneficiary Cost Limitation for MSA:										24.02
24.03	Per Beneficiary Cost Limitation for MSA:										24.03
24.04	Per Beneficiary Cost Limitation for MSA:										24.04
24.05	Per Beneficiary Cost Limitation for MSA:										24.05
24.06	Per Beneficiary Cost Limitation for MSA:										24.06
24.07	Per Beneficiary Cost Limitation for MSA:										24.07
24.08	Per Beneficiary Cost Limitation for MSA:										24.08
24.09	Per Beneficiary Cost Limitation for MSA:										24.09
25	Aggregate Per Beneficiary Cost Limitation										25
	(Sum of lines 24 and subscripts thereof)
PART V - OUTPATIENT THERAPY REDUCTION COMPUTATION
		From			Part B - Subject to Deductibles and Coinsurance
		Part I,	Average	Medicare	Medicare	Medicare	Medicare	Medicare	Application of
		Col. 4	Cost	Program Visits	Program Costs	Program Visits	Program Visits	Program Costs	the Reasonable	Reasonable
		Line:	Per Visit	for Services	for Services	for Services on	for Services on	for Services on	Cost	Costs Net of
	Patient Services			Before 1/1/98	Before 1/1/98	& After 1/1/98	& After 1/1/99	& After 1/1/98	Reduction	Adjustments
		1	2	3	4	5	5.01	6	7	8
26	Physical Therapy	2	#REF!		2,000	#REF!			#REF!	#REF!	26
27	Occupational Therapy	3	#REF!		1,300	#REF!			#REF!	#REF!	27
28	Speech Pathology	4	#REF!		500	#REF!			#REF!	#REF!	28
29	Total (Sum of lines 26-28)				3,800	#REF!				#REF!	29
FORM CMS-2540-96 ( 06/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3544)
Rev 11											35-370

---

Sheet 53: H-6

08-01				FORM CMS 2540-96				3590 (Cont.)
CALCULATION OF H H A				PROVIDER NO.:	PERIOD:		WORKSHEET																			{APP4}IALLWAYS~/LP2~Q/PCOPB1~Q/PGQ/1
REIMBURSEMENT SETTLEMENT				____________________	FROM_________________		H-6
PART A & PART B SERVICES				HHA NO.:	TO____________________		PARTS I & II
Check One:		[ ]	Title V	[ ]	Title XVIII	[ ]	Title XIX
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
						PART B
	Description					Not Subject to	Subject to
					PART A	Deductibles &	Deductibles &
						Coinsurance	Coinsurance
Reasonable Cost of Program					1	2	3
1	Cost of Services (See Instructions)							1
2	Total program charges for title XVIII Part A and Part B							2
	Services - Pre 10/01/2000
2.01	Total program charges for title XVIII Part A and Part B							2
	Services - Post 9/30/2000
Customary Charges
3	Amount actually collected from patients liable for payment							3
	for services on a charge basis (From your records)
4	Amount that would have been realized from patients liable							4
	for payment for services on a charge basis had such
	payment been made in accordance with 42 CFR 413.13(b).
5	Ratio of line 1 to 2 (Not to exceed 1.0000)							5
6	Total customary program charges (Line 5 X line 2 - each column)							6
7	Primary Payor Amounts							7
PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT
						Part A Services	Part B Services
	Description					1	2
8	Lesser of Cost or Charges ( See Instructions)							8
8.01	Total PPS Reimbursement - Full Episodes without Outliers							8.01
8.02	Total PPS Reimbursement - Full Episodes with Outliers							8.02
8.03	Total PPS Reimbursement - LUPA Episodes							8.03
8.04	Total PPS Reimbursement - PEP Episodes							8.04
8.05	Total PPS Reimbursement - SCIC within a PEP Episode							8.05
8.06	Total PPS Reimbursement - SCIC Episodes							8.06
8.07	Total PPS Outlier Reimbursement - Full Episodes with Outliers							8.07
8.08	Total PPS Outlier Reimbursement - PEP Episodes							8.08
8.09	Total PPS Outlier Reimbursement - SCIC within a PEP Episode							8.09
8.10	Total PPS Outlier Reimbursement - SCIC Episodes							8.10
8.11	Total Other Payments							8.11
8.12	DME Payment							8.12
8.13	Oxygen ayment							8.13
8.14	Prosthetics and Orthotic Payment							8.14
9	Part B deductibles billed to Medicare patients (exclude coinsurance)							9
10	Subtotal (Line 8 minus line 9)							10
11	Coinsurance billed to Program patients (From your records)							11
12	Net cost (Line 10 minus line 11)							12
13	Reimbursable bad debts (From your records)							13
14	Total Costs - Current cost reporting period (Line 12 plus line 13)							14
15	Amounts applicable to prior cost reporting periods resulting from							15
	disposition of depreciable assets
16	Recovery of excess depreciation resulting from agencies'							16
	termination or decrease in Program utilization
17	Unrefunded charges to beneficiaries for excess costs erroneously							17
	collected based on correction of cost limit
18	Total cost - before sequestration & other Adjustments (Line 14, minus the sum of lines							18
	16 and 17 plus or minus the amount on line 15)
18.01	Other adjustments (see instructions) (Specify)							18.01
19	Sequestration Adjustment (See Instructions)							19
20	Amount due to you after sequestration adjustment & other adjustments (Line 18 plus line 18.01 minus line 19)							20
21	Total interim payments (From Worksheet H-7, line 4)							21
21.01	Tentative Settlement (For Intermediary Use Only)
22	Balance due HHA/Program (Line 20, Plus Line 20.01, minus line 21)							22
	(Indicate overpayments in brackets)
23	Protested amounts (nonallowable cost report items) in accordance							23
	with CMS Pub. 15-II, section 115.2
FORM CMS 2540-96 ( 08/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB 15-II, SECTIONS 3545 - 3545.2 )
Rev. 11								35-371

---

Sheet 54: H-7

3590 (Cont.)		FORM CMS 2540-96						08-01
ANALYSIS OF PAYMENTS TO		PROVIDER NO.:			PERIOD:																				{APP4}IALLWAYS~/lp2~q/PCOPB1~Q/pGQ/1
PROVIDER - BASED H H A's		______________________			FROM _____________		WORKSHEET
FOR SERVICES RENDERED TO		HHA NO.:			TO ________________		H-7
PROGRAM BENEFICIARIES		______________________
				PART A		PART B
	Description			Mo/Day/Yr	Amount	Mo/Day/Yr	Amount
				1	2	3	4
1	Total interim payments paid to provider							1
2	Interim pymts payable on individual bills either submitted or to							2
	be submitted to the intermediary, for services rendered in the
	cost reporting period. If none, write "NONE" or enter a zero.
3	List separately each retroactive lump sum		.01					3.01
	adjustment amount based on subsequent	Program	.02					3.02
	revision of the interim rate for the cost	to	.03					3.03
	reporting period Also show date of each	Provider	.04					3.04
	payment . If none, write "NONE", or		.05					3.05
	enter a zero, (1)		.50					3.50
		Provider	.51					3.51
		to	.52					3.52
		Program	.53					3.53
			.54					3.54
	SUBTOTAL (Sum of lines 3.01-3.05, minus sum		.99					3.99
	of lines 3.50-3.54)
4	TOTAL INTERIM PAYMENTS (Sum of lines 1, 2							4
	and 3.99) (Transfer to Workseet H-6, Part II,
	column as appropriate, line 21)
TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative settlement	Program	.01					5.01
	payment after desk review. Also show	to	.02					5.02
	date of each payment. If none, write	Provider	.03					5.03
	"NONE", or enter a zero. (1)	Provider	.50					5.50
		to	.51					5.51
		Program	.52					5.52
	SUBTOTAL (Sum of lines 5.01-5.03 minus sum		.99					5.99
	of lines 5.50-5.52)
6	Determine net settlement	Program
	amount (balance due) based	to	.01					6.01
	on the cost report (See	Provider
	Instructions)	Provider
		to	.50					6.50
		Program
7	TOTAL MEDICARE PROGRAM LIABILITY							7
	(See Instructions)
Name of Intermediary					Intermediary Number
Signature of Authorized Person					Date: Month, Day, Year
(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS 2540-96 ( 08/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 3546 )
35-372								Rev. 11

---

Sheet 55: J-1-I

3590 ( Cont. )			FORM CMS 2540-96						07-99
ALLOCATION OF GENERAL SERVICE COSTS			PROVIDER NO.:		PERIOD:
TO OUTPATIENT REHABILITATION PROVIDER					FROM ____________		WORKSHEET J - 1
COST CENTERS			COMPONENT NO.: _______________		TO _______________		PART I
Check Applicable Box:			[ ] C. M. H. C.		[ ] OPT		[ ] OSP
			[ ] C. O. R. F.		[ ] OOT
			NET EXPENSES	CAPITAL REL.	CAPITAL REL.			ADMINIS-
			FOR COST	COST	COST	EMPLOYEE	SUBTOTAL	TRATIVE
	COMPONENT COST CENTER		ALLOCATION	BUILDS. &	MOVABLE	BENEFITS		&
	(Omit Cents)			FIXTURES	EQUIPMENT		(COLS. 0-3)	GENERAL
			0	1	2	3	3a	4
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	Appr. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21) (1)								22
	(1) Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 50, (subscripted line).
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3551 )
35-378									Rev. 5
07-99			FORM CMS 2540-96						3590 ( Cont. )
ALLOCATION OF GENERAL SERVICE COSTS			PROVIDER NO.:		PERIOD:
TO OUTPATIENT REHABILITATION PROVIDER					FROM ____________		WORKSHEET J - 1
COST CENTERS			COMPONENT NO.: _______________		TO _______________		PART I (CONT. )
Check Applicable Box:			[ ] C. M. H. C.		[ ] OPT		[ ] OSP
			[ ] C. O. R. F.		[ ] OOT
				PLANT
				OPERATION	LAUNDRY	HOUSE -		NURSING
	COMPONENT COST CENTER			MAINTENANCE	& LINEN	KEEPING	DIETARY	ADMINIS-
	(Omit Cents)			& REPAIRS	SERVICE			TRATION
				5	6	7	8	9
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	Appr. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21) (1)								22
	(1) Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 50, (subscripted line).
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3551 )
Rev. 4									35-379

---

Sheet 56: J-1-II

3590 (Cont.)				FORM CMS 2540-96					11-98
ALLOCATION OF GENERAL SERVICE COSTS			PROVIDER NO.:		PERIOD:		WORKSHEET J-1
TO OUTPATIENT REHABILITATION PROVIDER					FROM ____________		PART I ( CONT. )
COST CENTERS			COMPONENT NO.: ______		TO _______________
Check Applicable Box			[ ] C. M. H. C.		[ ] OPT		[ ] OSP
			[ ] C. O. R. F.		[ ] OOT
			CENTRAL	PHARMACY	MEDICAL	SOCIAL	INTERNS	OTHER
	COMPONENT COST CENTER		SERVICES		RECORDS &	SERVICES	&	GENERAL
	(Omit Cents)		& SUPPLY		LIBRARY		RESIDENTS	SERVICES
			10	11	12	13	14	15
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	App. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21) (1)								22
	(1) Columns o through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 50, (subscripted line).
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3551.2 )
35-380									Rev. 4
11-98			FORM CMS 2540-96						3590 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS			PROVIDER NO.:		PERIOD:		WORKSHEET J-1
TO OUTPATIENT REHABILITATION PROVIDER					FROM ____________		PART I ( CONT. )
COST CENTERS			COMPONENT NO.: ______		TO _______________		PART II
Check Applicable Box			[ ] C. M. H. C.		[ ] OPT		[ ] OSP
			[ ] C. O. R. F.		[ ] OOT
					POST		ALLOCATED	TOTAL
	COMPONENT COST CENTER			SUBTOTAL	STEPDOWN	SUBTOTAL	A & G	(SUM OF COLS
	(Omit Cents)				ADJUSTMENTS		(SEE PART II)	18 AND 19)
				16	17	18	19	20
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	App. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21)								22
	PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION
	OF COMPONENT ADMINISTRATIVE AND GENERAL COSTS
1	Amount from Part I, column 18, line 22								1
2	Amount from Part I, column 18, line 1								2
3	Line 1 minus line 2								3
4	Unit cost multiplier for A & G costs (Line 2 divided by line 3) (Multiply each amount in column 18, lines 2 through 21, Part I,								4
	by the unit cost multiplier and enter the result on the corresponding line of column 19)
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3551.2 )
Rev. 4									35-381

---

Sheet 57: J-1-III

3590 (Cont.)		FORM CMS 2540-96						11-98
ALLOCATION OF GENERAL SERVICE COSTS		PROVIDER NO.:		PERIOD:
TO OUTPATIENT REHABILITATION PROVIDER				FROM ____________		WORKSHEET J - 1
COST CENTERS		COMPONENT NO.: ______		TO _______________		PART III
Check Applicable Box:		[ ] C. M. H. C.		[ ] OPT		[ ] OSP
		[ ] C. O. R. F.		[ ] OOT
			CAPITAL REL.	CAPITAL REL.			ADMINIS-
			COST BUILDS.	COST MOVABLE	EMPLOYEE		TRATIVE
	COMPONENT COST CENTER		& FIXTURES	EQUIPMENT	BENEFITS		& GENERAL
			(Square Feet)	(Value or	(Gross Salaries)		(Accumulated
				Square Feet			Cost)
	(Omit Cents)	0	1	2	3		4
1	Administrative and General							1
2	Skilled Nursing							2
3	Physical Therapy							3
4	Occupational Therapy							4
5	Speech Pathology							5
6	Medical Social Services							6
7	Respiratory Therapy							7
8	Psychiatric/Psychological Services							8
9	Individual Therapy							9
10	Group Therapy							10
11	Individualized Activity Therapy							11
12	Family Counseling							12
13	Diagnostic Services							13
14	App. Patient Training & Education							14
15	Prosthetic and Orthotic Devices							15
16	Drugs and Biologicals							16
17	Medical Supplies							17
18	Medical Appliances							18
19	Durable Medical Equipment - Rented							19
20	Durable Medical Equipment - Sold							20
21	Other General Service Cost							21
22	Totals ( Sum of lines 1-21)							22
23	Total Cost to be Allocated							23
24	Unit Cost Multiplier							24
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3551.3 )
35-382								Rev. 4
11-98		FORM CMS 2540-96						3590 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS		PROVIDER NO.:		PERIOD:
TO OUTPATIENT REHABILITATION PROVIDER				FROM ____________		WORKSHEET J - 1
COST CENTERS		COMPONENT NO.: ______		TO _______________		PART III (Cont.)
Check Applicable Box:		[ ] C. M. H. C.		[ ] OPT		[ ] OSP
		[ ] C. O. R. F.		[ ] OOT
			PLANT	LAUNDRY			NURSING
			OPERATION	& LINEN	HOUSE -		ADMINIS
			MAINTENANCE	SERVICE	KEEPING	DIETARY	TRATION
	COMPONENT COST CENTER		& REPAIRS	(Pounds of	(Hours of	(Meals	(Direct Nursing
			(Square Feet)	Laundry)	Service)	Served)	Hours of Service)
	(Omit Cents)		5	6	7	8	9
1	Administrative and General							1
2	Skilled Nursing							2
3	Physical Therapy							3
4	Occupational Therapy							4
5	Speech Pathology							5
6	Medical Social Services							6
7	Respiratory Therapy							7
8	Psychiatric/Psychological Services							8
9	Individual Therapy							9
10	Group Therapy							10
11	Individualized Activity Therapy							11
12	Family Counseling							12
13	Diagnostic Services							13
14	App. Patient Training & Education							14
15	Prosthetic and Orthotic Devices							15
16	Drugs and Biologicals							16
17	Medical Supplies							17
18	Medical Appliances							18
19	Durable Medical Equipment - Rented							19
20	Durable Medical Equipment - Sold							20
21	Other General Service Cost							21
22	Totals ( Sum of lines 1-21)							22
23	Total Cost to be Allocated							23
24	Unit Cost Multiplier							24
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3551.3 )
Rev. 4								35-383

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Sheet 58: J-1-III2

3590 (Cont.)		FORM CMS 2540-96						11-98
ALLOCATION OF GENERAL SERVICE COSTS		PROVIDER NO.:		PERIOD:
TO OUTPATIENT REHABILITATION PROVIDER				FROM ______________________		WORKSHEET J - 1
COST CENTERS		COMPONENT NO.: ______		TO ____________________		PART III (Cont.)
Check Applicable Box:		[ ] C. M. H. C.		[ ] OPT		[ ] OSP
		[ ] C. O. R. F.		[ ] OOT
		CENTRAL
		SERVICES		MEDICAL		INTERNS &	OTHER
		& SUPPLY	PHARMACY	RECORDS &	SOCIAL	RESIDENTS	GENERAL
	COMPONENT COST CENTER	(Costed	(Costed	LIBRARY	SERVICES		SERVICE
	(Omit Cents)	Requisitions)	Requisitions)	(Time Spent)	(Time Spent)	(Assigned Time)	( )
		10	11	12	13	14	15
1	Administrative and General							1
2	Skilled Nursing							2
3	Physical Therapy							3
4	Occupational Therapy							4
5	Speech Pathology							5
6	Medical Social Services							6
7	Respiratory Therapy							7
8	Psychiatric/Psychological Services							8
9	Individual Therapy							9
10	Group Therapy							10
11	Individualized Activity Therapy							11
12	Family Counseling							12
13	Diagnostic Services							13
14	App. Patient Training & Education							14
15	Prosthetic and Orthotic Devices							15
16	Drugs and Biologicals							16
17	Medical Supplies							17
18	Medical Appliances							18
19	Durable Medical Equipment - Rented							19
20	Durable Medical Equipment - Sold							20
21	Other General Service Cost							21
22	Totals ( Sum of lines 1-21)							22
23	Total Cost to be Allocated							23
24	Unit Cost Multiplier							24
	`
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3551.3 )
35-384								Rev. 4

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Sheet 59: J-2

11-98				FORM CMS 2540-96						3590 (Cont.)
COMPUTATION OF OUTPATIENT				PROVIDER NO.:		PERIOD:		WORKSHEET J - 2
REHABILITATION PROVIDER COSTS						FROM ____________		PARTS I, II,
				COMPONENT NO.: __________		TO _______________		AND III
Check Applicable Box:				[ ] C.M.H.C.		[ ] C.O.R.F.	[ ] OPT	[ ] OOT	[ ] OSP
			TOTAL COSTS		RATIO OF
PART I - APPORTIONMENT OF			(FR. WKST. J-1	TOTAL	COSTS TO	TITLE V	TITLE V	TITLE XIX	TITLE XIX
REHABILITATION COST CENTERS			PART I, COL. 20)	CHARGES	CHARGES (1)	CHARGES	(COL. 3 X COL 4)	CHARGES	(COL. 3 X COL 6)
			1	2	3	4	5	6	7
1	Administrative and General									1
2	Skilled Nursing Care									2
3	Physical Therapy									3
4	Occupational Therapy									4
5	Speech Pathology									5
6	Medical Social Services									6
7	Respiratory Therapy									7
8	Psychiatric/Psychological Services									8
9	Individual Therapy									9
10	Group Therapy									10
11	Individualized Activity Therapy									11
12	Family Counseling									12
13	Diagnostic Services									13
14	App. Patient Training & Education									14
15	Prosthetic and Orthotic Devices									15
16	Drugs and Biologicals									16
17	Medical Supplies									17
18	Medical Appliances									18
19	Durable Medical Equipment - Rented									19
20	Durable Medical Equipment - Sold									20
21	Other General Service Cost									21
22	Totals ( Sum of lines 2-21)	(2)								22
	PART II - APPORTIONMENT OF COST OF REHAB SERVICES FURNISHED BY SHARED DEPARTMENTS
23	Oxygen (Inhalation) Therapy			(2)						23
24	Physical Therapy			(2)						24
25	Occupational Therapy			(2)						25
26	Speech Pathology			(2)						26
27	Medical Supplies Charged to Patients			(2)						27
28	Drugs Charged to Patients			(2)						28
29	Other Costs Furnished by shared Departments			(2)						29
30	Total (Sum of lines 23 through 29)									30
	PART III - TOTAL REHAB COSTS
31	Total rehab costs - Add Part I, columns 5 , 7 and 9 respectively, line 22, and Part II, columns 5, 7, and 9 line 30.									31
	(Transfer Titles V and XIX amounts to Worksheet J-3, column 1 or 3, line 1)
(1) Ratio of cost to charges: Part I - column 1 divided by column 2; Part II - From Wkst. C, col. 3, lines as applicable						(2) Charges for Part II, col. 2 are obtained from provider records
FORM CMS 2540-96 ( 10/98 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3552- 3552.2 )
Rev. 4										35-385
3590 (Cont.)				FORM CMS 2540-96						11-98
COMPUTATION OF OUTPATIENT				PROVIDER NO.:		PERIOD:		WORKSHEET J - 2
REHABILITATION PROVIDER COSTS						FROM ____________		PARTS I, II,
				COMPONENT NO.: __________		TO _______________		AND III (Cont.)
Check Applicable Box:				[ ] C.M.H.C.		[ ] C.O.R.F.	[ ] OPT	[ ] OOT	[ ] OSP
				TITLE XVIII				REASONABLE	COST, NET OF
PART I - APPORTIONMENT OF						CHARGES	COSTS - ON &	COST	REASONABLE
REHABILITATION COST CENTERS				CHARGES	COSTS	ON & AFTER	AFTER 01/01/98	REDUCTION	COST
					(COL. 3 X COL 8)	1/1/98	(Col. 3 X Col. 10)	AMOUNT	REDUCTION
				8	9	10	11	12	13
1	Administrative and General									1
2	Skilled Nursing Care									2
3	Physical Therapy									3
4	Occupational Therapy									4
5	Speech Pathology									5
6	Medical Social Services									6
7	Respiratory Therapy									7
8	Psychiatric/Psychological Services									8
9	Individual Therapy									9
10	Group Therapy									10
11	Individualized Activity Therapy									11
12	Family Counseling									12
13	Diagnostic Services									13
14	App. Patient Training & Education									14
15	Prosthetic and Orthotic Devices									15
16	Drugs and Biologicals									16
17	Medical Supplies									17
18	Medical Appliances									18
19	Durable Medical Equipment - Rented									19
20	Durable Medical Equipment - Sold									20
21	Other General Service Cost									21
22	Totals ( Sum of lines 2-21)									22
	PART II - APPORTIONMENT OF COST OF REHAB SERVICES FURNISHED BY SHARED DEPARTMENTS
23	Oxygen (Inhalation) Therapy									23
24	Physical Therapy									24
25	Occupational Therapy									25
26	Speech Pathology									26
27	Medical Supplies Charged to Patients									27
28	Drugs Charged to Patients									28
29	Other Costs Furnished by shared Departments									29
30	Total (Sum of lines 23 through 29)									30
	PART III - TOTAL REHAB COSTS
31	Total Rehab costs - Add the amount from Part I, column 13, line 22 and									31
	the amount from Part II, column 13, line 30. Add the amounts from Part I
	line 22 and Part II line 30 for columns 8 through 11, respectively.
FORM CMS 2540-96 ( 10/98 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3552- 3552.2 )
35-386										Rev. 4

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Sheet 60: J-3

12-99		FORM CMS 2540-96			3590 (Cont.)
CALCULATION OF REIMBURSEMENT		PROVIDER NO.:	PERIOD:
SETTLEMENT OF OUTPATIENT			FROM ____________	WORKSHEET J - 3
REHABILITATION SERVICES		COMPONENT NO.:	TO ______________	PART I
Check Applicable Box:		[ ] C. M. H. C.	[ ] OPT	[ ] OSP
		[ ] C. O. R. F. (Title V & XIX)		[ ] OOT
		Title V	Title XVIII	Title XIX
		PROGRAM	PROGRAM	PROGRAM
		COST	COST	COST
		1	2	3
1	Cost of REHAB services (From Wkst. J-2,				1																2
	Part II, ln. 31: Title V - col. 5; Title XIX -
	col 7; Title XVIII - see instructions.)
2	Amounts paid and payable by Worker's				2																5
	Compensation and other primary payers
3	Subtotal (Line 1 minus line 2)				3																7
4	Part B deductible billed to Program				4																9
	patients (Exclude coinsurance amounts)
5	Net Cost (Line 3 minus line 4)				5																11
6	80% of Part B cost (80% X line 5)				6																13
7	Actual coinsurance billed to Program				7																15
	patients (From provider records)
8	Net cost less actual billed coinsurance				8
	(Line 5 minus line 7)
9	Reimbursable bad debts (See Instructions)				9
10	Net reimbursable amount (See Instructions)				10
11	Amounts applicable to prior cost reporting				11
	periods resulting from disposition of
	depreciable assets
12	Recovery of excess depreciation resulting				12
	from facilitie's termination or a decrease
	in Program utilization
13	Total cost - reimbursable to provider				13
	( From line 10 )
14	Sequestration Amount (See instructions)				14
15	Subtotal (Line 13 minus line 14)				15
16	Interim payments				16
17	Balance due Component/Program				17
	(Line 15 minus line 16)
	(Indicate overpayments in brackets)
18	Protested amounts (Nonallowable				18
	cost report items) in accordance with
	CMS Pub. 15-II, section 115.2
FORM CMS 2540-96 ( 07/96 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB 15-II, SECTION 3553 )
Rev. 7					35-387

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Sheet 61: J-3II

3590 (Cont.)		FORM CMS 2540-96			12-99
CALCULATION OF REIMBURSEMENT		PROVIDER NO.:	PERIOD:
SETTLEMENT OF OUTPATIENT			FROM ____________	WORKSHEET J - 3
REHABILITATION SERVICES		COMPONENT NO.:	TO ______________	PARTS II & III
Check Applicable Box:		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
Check Applicable Box:		[ ] C. O. R. F.	[ ] O. S. P.
		[ ] O. S. P.	[ ] O. O. T.
PART II - COMPUTATION OF CUSTOMARY CHARGES FOR REHAB SERVICES
				1
1	Total reasonable cost of REHAB services (From Wkst. J-2, Part II, line 31 ( See instructions)				1
1.1	Total reasonable cost of REHAB services prior to 1/1/98 (See instructions)				1.1
1.2	Total reasonable cost of REHAB services after 1/1/98 (See instructions)				1.2
2	Amounts paid and payable by Worker's Compensation and other primary payers.				2
3	Subtotal (Line 1 minus line 2)				3
4	Total Charges				4
	CUSTOMARY CHARGES
5	Amounts actually collected from patients liable for payments for rehab services on a charge basis				5
	had such payment been made in accordance with (42CFR 413.13(b).
6	Amount that would have been realized from patients liable for payment for rehab services on a				6
	charge basis had such payment been made in accordance with 42CFR 413.13(b)
7	Ratio of line 5 to line 6 (Not to exceed 1.000000)				7
8	Total customary charges - Rehab services (Multiply line 7 X line 4)				8
8.1	Total customary charges - Rehab services prior to 1/1/98				8.1
8.2	Total customary charges - Rehab services on or after 1/1/98				8
	COMPUTATION OF LESSER OF REASONABLE COSTS OR CUSTOMARY CHARGES FOR REHAB
	SERVICES FURNISHED IN CALENDAR YEAR 1998
8.3	Excess of customary charges over reasonable costs. Complete only if line 8.2 exceeds line 1.2.				8.3
	( See instructions)
8.4	Excess of reasonable cost over customary charges. Complete only if line 1.2 exceeds line 8.2.				8.4
	( See instructions)
PART III - COMPUTATION OF REIMBURSEMENT SETTLEMENT OF
OUTPATIENT REHABILITATION SERVICES
9	Cost of Rehab services (From line 3)				9
10	Part B deductible billed to Program patients (exclude coinsurance amounts)				10
11	Net Cost (Line 9 minus line 10)				11
11.1	Excess of reasonable costs over customary charges for services rendered on or after 1/1/98				11.1
11.2	Subtotal (Line 11 minus 11.1)				11.2
12	80% of Part B cost (80% X line 11.2)				12
13	Actual coinsurance billed to Program patients (from provider records)				13
14	Net cost less actual billed coinsurance ( Line 11.2 minus line 13)				14
15	Reimbursable bad debts (See Instructions)				15
16	Net reimbursable amount (Line 15 plus the lesser of line 12 or line 14				16
17	Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets.				17
18	Recovery of excess depreciation resulting from facility's termination or a decrease				18
	in Program utilization
19	Other adjustments				19
20	Total Cost - reimbursable to provider (line 16 minus lines 17 & 18 plus or minus line 19)				20
21	Sequestration Amount (See instructions)				21
22	Amount due provider after sequestration adjustment (Line 20 minus line 21)Amount				22
23	Interim payments				23
24	Balance due provider/Program (Line 22 minus line 23)( Indicate overpayment in brackets)				24
25	Protested amounts (Nonallowable cost report items) in accordance with PRM II, Sec. 115.2(B)				25
26	Balance due provider/Program (Line 24 minus line 25)( Indicate overpayment in brackets)				26
FORM CMS 2540-96 (12/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB 15-II, SECTION 3553 )
35-388					Rev. 7

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Sheet 62: J-4

07-99			FORM CMS 2540-96				3590 (Cont.)
ANALYSIS OF PAYMENTS TO		PROVIDER NO.:		PERIOD:
PROVIDER - BASED COMPONENT		___________________		FROM ______________		WORKSHEET J - 4
FOR SERVICES RENDERED		COMPONENT NO.:
TO PROGRAM BENEFICIARIES		___________________		TO
Check Applicable Box:			[ ] C.M.H.C.	[ ] OPT		[ ] OSP
			[ ] C.O.R.F.	[ ] OOT
					Mo / Day / Yr	Amount
	Description				1	2
1	Total interim payments paid to provider						1
2	Interim payments payable on individual bills, either submitted or to						2
	be submitted to the intermediary, for services rendered in the cost
	reporting period. If none, write "none", or enter zero.
3	List separately each retroactive			.01			3.01
	lump sum adjustment amount			.02			3.02
	based on subsequent revision		Program to	.03			3.03
	of the interim rate for the cost		Provider	.04			3.04
	reporting period.			.05			3.05
				.50			3.50
	Also show date of each payment.			.51			3.51
			Provider to	.52			3.52
	If none, write "NONE," or enter a zero.(1)		Program	.53			3.53
				.54			3.54
	SUBTOTAL (Sum of lines 3.01 - 3.05			.99			3.99
	minus sum of lines 3.50 - 3.55)
4	TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99)						4
	(Transfer to Worksheet J-3: Part I line 16, Part III line 23)
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative		Program to	.01			5.01
	settlement payment after desk review.		Provider	.02			5.02
				.03			5.03
	Also show date of each payment.		Provider to	.50			5.50
	If none, write "NONE," or enter a zero.(1)		Program	.51			5.51
				.52			5.52
	SUBTOTAL (Sum of lines 5.01 - 5.03			.99			5.99
	minus sum of lines 5.50 - 5.52)
6	Determined net settlement		Program to	.01			6.01
	amount (balance due) based		Provider	.02			6.02
	on the cost report. (1)		Provider to	.50			6.50
			Program	.51			6.51
7	TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)						7
Name of Intermediary					Intermediary Number
Signature of Authorized Person					Date (Mo/Day/Yr)
(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the
	provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS 2540-96 ( 10/98 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
	SECTION 3554)
Rev. 5							35-389

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Sheet 63: I1

07-99			FORM CMS 2540-96						3590 ( Cont.)
ANALYSIS OF SNF-BASED RURAL HEALTH			PROVIDER NO:		PERIOD:
CLINIC/FEDERALLY QUALIFIED					FROM___________________		WORKSHEET I-1
HEALTH CENTER COSTS			COMPONENT NO:		TO____________________
Check Applicable Box:		[ ] RHC	[ ] FQHC
						RECLASSIFIED		NEW EXPENSES
		COMPEN-	OTHER	TOTAL	RECLASSIFI-	TRIAL	ADJUSTMENTS	FOR
		SATION	COSTS	(Col. 1 + Col. 2)	CATIONS	BALANCE		ALLOCATION
						(Col. 3 +/- Col. 4)		(Col. 5 +/- Col.6)
		1	2	3	4	5	6	7
FACILITY HEALTH CARE STAFF COSTS
1	Physician								1
2	Physician Assistant								2
3	Nurse Practitioner								3
4	Visiting Nurse								4
5	Other Nurse								5
6	Clinical Psychologist								6
7	Clinical Social Worker								7
8	Laboratory Technician								8
9	Other Facility Health Care Staff Costs								9
10	Subtotal (Sum of lines 1 - 9)								10
COSTS UNDER AGREEMENT
11	Physician Services Under Agreement								11
12	Physician Supervision Under Agreement								12
13	Other Costs Under Agreement								13
14	Subtotal (Sum of lines 11 - 13)								14
OTHER HEALTH CARE COSTS
15	Medical Supplies								15
16	Transportation (Health Care Staff)								16
17	Depreciation - Medical Equipment								17
18	Professional Liability Insurance								18
19	Other Health Care Costs								19
20	Allowable GME Passthrough cost.								20
21	Subtotal (Sum of lines 15 - 19, less line 20)								21
22	Total Cost of Health Care Services								22
	(Sum of lines 10, 14, and 21)
COSTS OTHER THAN RHC/FQHC SERVICES
23	Pharmacy								23
24	Dental								24
27	Nonallowable GME Passthrough cost								27
28	Total nonreimbursable costs (Sum of lines								28
	23 - 26, less line 27)
FACILITY OVERHEAD
29	Facility Costs								29
30	Administrative Costs								30
31	Total Facility Overhead (Sum of lines 29-30)								31
32	Total Facility Costs (Sum of lines 22, 28 and 31)								32
	* 'The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of this worksheet.
FORM CMS 2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II. SECTION 3556)
Rev. 5									35-373

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Sheet 64: I2

3590 ( Cont. )		FORM CMS 2540-96					07-99
		PROVIDER NO:		PERIOD:
ALLOCATION OF OVERHEAD				FROM___________________		WORKSHEET
TO RHC / FQHC SERVICES		COMPONENT NO:				I - 2
				TO____________________
Check Applicable Box:		[ ] RHC	[ ] FQHC
	PART I - VISITS AND PRODUCTIVITY
		Number		Productivity	Minimum	Greater of
		of FTE	Total	Standard	Visits	Column 2 or
		Personnel	Visits	(1)	Col. 1 X Col. 3)	Column 4
		1	2	3	4	5
1	Physicians						1
2	Physician Assistants						2
3	Nurse Practitioners						3
4	Subtotal (Sum of lines 1 - 3)						4
5	Visiting Nurse						5
6	Clinical Psychologist						6
7	Clinical Social Worker						7
8	Total Staff Costs (Sum of lines 4 - 7)						8
9	Physician Services Under Agreements						9
	(1) Productivity standards established by CMS are: 4200 visits for each physician, and 2100 visits for each nonphysician practitioner.
	PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES
10	Total costs of Health Care Services ( From Worksheet I - 1, column 7, line 22)						10
11	Total nonreimbursable costs (From Worksheet I - 1, column 7, line 28)						11
12	Cost of all services - excluding overhead (Sum of lines 10 and 11)						12
13	Ratio of RHC / FQHC services ( Line 10 divided by line 12)						13
14	Total facility overhead (From Worksheet I - 1, column 7, line 31)						14
15	GME Overhead (See instructions)						15
16	Net Facility Overhead						16
17	Parent provider overhead allocated to facility ( See instructions)						17
18	Total overhead (Sum of lines 16 and 17)						18
19	Overhead applicable to RHC / FQHC services (Lines 13 X line 18)						19
20	Total allowable cost of RHC / FQHC services ( Sum of lines 10 and 19)						20
FORM CMS 2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,
SECTION 3558)
35-374							Rev. 5

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Sheet 65: I3

06-01			FORM CMS 2540-96				3590 (Cont.)
CALCULATION OF		PROVIDER NO.:		PERIOD:
REIMBURSEMENT		______________________		FROM__________________		WORKSHEET
SETTLEMENT FOR		COMPONENT NO.:				I - 3
RHC/FQHC SERVICES		_______________		TO_____________________
Check one:		[ ] Title V	[ ] Title XVIII		[ ] Title XIX
Check Applicable Box:		[ ] RHC	[ ] FQHC
	PART I - DETERMINATION OF RATE FOR RHC / FQHC SERVICES
1	Total Allowable Cost of RHC/FQHC Services (From Worksheet I - 2, Part II, line 20)						1
2							2
3	Total Allowable Cost Excluding Vaccine (Line 1 minus line 2)						3
4	Total FTE's and VISITS (From Worksheet I-2, column 5, line 8)						4
5	Physicians Visits Under Agreement (From Worksheet I - 2, column 5, line 9)						5
6	Total Adjusted Visits (line 4 plus line 5)						6
7	Adjusted Cost Per Visit (line 3 divided by line 6)						7
					Calculation of limit (1)
					Prior to	On or after
					January 1	January 1
					1	2
8	Rate per visit limit (From your intermediary)						8
9	Rate for Medicare Covered Visits (See instructions)						9
	PART II - CALCULATION OF SETTLEMENT
10	Medicare Covered Visits Excluding Mental Health Services						10
	(From Intermediary Records)
11	Medicare Cost Excluding Costs for Mental Health Services						11
	(Line 9 x line 10)
12	Medicare Covered Visits for Mental Health Services						12
	(From Intermediary Records)
13	Medicare Covered Cost from Mental Health Services						13
	(Line 9 x line 12)
14	Limit Adjustment for Mental Health Services						14
	(Line 13 x 62 1/2 %)
15	Allowable GME Pass-through Cost (See instructions)						15
16	Total Medicare Cost (Sum of line 11 column 1 and 2, plus line 14 columns 1 and 2,						16
	plus line 15.)
17	Less: Beneficiary Deductible (From intermediary records)						17
18	Net Medicare Cost Excluding Vaccines (Line 16 - line 17)						18
19	Reimbursable Cost of RHC/FQHC Services, Excluding Vaccine (80% of line 18)						19
20							20
21	Total Reimbursable Medicare Cost (Line 19 plus 20)						21
22	Reimbursable Bad Debts						22
23	Other Adjustments						23
24	Net reimbursable amount (Line 21 plus line 22, plus or minus line 23 )						24
25	Interim payments						25
26	Balance due Component/Program (line 24 minus line 25)						26
27	Protested amounts (nonallowable cost report items) in accordance with						27
	CMS Pub. 15-II, section 115.2
	(1) Lines 8 through 14: Fiscal year providers use columns 1 and 2, calendar year providers use column 2 only.
FORM CMS 2540-96 ( 12/99 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
SECTION 3560 )
Rev. 11							35-375

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Sheet 66: I4

3590 (Cont.)		FORM CMS 2540-96			06-01
		PROVIDER NO.:	PERIOD:
COMPUTATION OF PNEUMOCOCCAL		_______________	FROM____________	WORKSHEET
AND INFLUENZA VACCINE COST		COMPONENT NO.:		I - 4
		_______________	TO_______________
Check one:		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
Check Applicable Box:		[ ] RHC	[ ] FQHC
	CALCULATION OF COST		PNEUMOCOCCAL	INFLUENZA
			1	2
1	Health care staff cost (from Worksheet I -1, column 7, line 10)				1
2	Ratio of pneomococcal and influenza vaccine staff time to				2
	total health care staff time
3	Pneumococcal and influenza vaccine health care staff cost				3
	(Line 1 x line 2)
4	Medical supplies cost - pneumococcal and influenza vaccine				4
	(From your records)
5	Direct cost of pneumococcal and influenza vaccine				5
	(Sum of lines 3 and 4)
6	Total direct cost of the facility (From Wkst. I -1, col. 7, line 22)				6
7	Total overhead (From Worksheet I - 2, line 18)				7
8	Ratio of pneumococcal and influenza vaccine direct cost to				8
	Total direct cost (Line 5 divided by Line 6)
9	Overhead cost - pneumococcal and influenza vaccine				9
	(Line 7 x Line 8)
10	Total pneumococcal and influenza vaccine cost and its (their)				10
	administration (Sum of lines 5 and 9)
11	Total number of pneumococcal and influenza vaccine injections				11
	(From your records)
12	Cost per pneumococcal and influenza vaccine injection				12
	(Line 10 divided by Line 11)
13	Number of pneumococcal and influenza vaccine injections				13
	Adminstered to medicare beneficiaries
14	Medicare cost of pneumococcal and influenza vaccine and				14
	its (their) adminstration (Line 12 x line 13)
15	Total Cost of pneumococcal and influenza vaccine and its (their) administration				15
	(Sum of columns 1 and 2, line 10) (Transfer this amount to Worksheet I-3, line 2)
16	Total medicare cost of pneumococcal and influenza vaccine and its (their) administration				16
	(Sum of columns 1 and 2, line 14) (Transfer this amount to Worksheet I-3, line 20)
FORM CMS 2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II,
SECTION 3562 )
35-376					Rev. 11

---

Sheet 67: I-5

07-99			FORM CMS 2540-96				3590 ( Cont. )
ANALYSIS OF PAYMENTS TO		PROVIDER NO.:		PERIOD:
SNF-BASED RURAL HEALTH		___________________		FROM ______________		WORKSHEET I - 5
CLINIC AND FEDERALLY		COMPONENT NO.:
QUALIFIED HEALTH CENTERS		___________________		TO
Check Applicable Box:			[ ] R.H.C.	[ ] F.Q.H.C.
					Mo / Day / Yr	Amount
	Description				1	2
1	Total interim payments paid to provider						1
2	Interim payments payable on individual bills, either submitted or to						2
	be submitted to the intermediary, for services rendered in the cost
	reporting period. If none, write "none", or enter zero.
3	List separately each retroactive			.01			3.01
	lump sum adjustment amount			.02			3.02
	based on subsequent revision		Program to	.03			3.03
	of the interim rate for the cost		Provider	.04			3.04
	reporting period.			.05			3.05
				.50			3.50
	Also show date of each payment.			.51			3.51
			Provider to	.52			3.52
	If none, write "NONE," or enter a zero.(1)		Program	.53			3.53
				.54			3.54
	SUBTOTAL (Sum of lines 3.01 - 3.05			.99			3.99
	minus sum of lines 3.50 - 3.55)
4	TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99)						4
	(Transfer to Worksheet I-3: Part II line 24)
	TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative		Program to	.01			5.01
	settlement payment after desk review.		Provider	.02			5.02
				.03			5.03
	Also show date of each payment.		Provider to	.50			5.50
	If none, write "NONE," or enter a zero.(1)		Program	.51			5.51
				.52			5.52
	SUBTOTAL (Sum of lines 5.01 - 5.03			.99			5.99
	minus sum of lines 5.50 - 5.52)
6	Determined net settlement		Program to	.01			6.01
	amount (balance due) based		Provider	.02			6.02
	on the cost report. (1)		Provider to	.50			6.50
			Program	.51			6.51
7	TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)						7
Name of Intermediary					Intermediary Number
Signature of Authorized Person					Date (Mo/Day/Yr)
(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the
	provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS 2540-96 ( 07/99 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
	SECTION 3563)
Rev. 5							35-377

---

Sheet 68: K

3590 (Cont.)					FORM CMS-2540-96							01-01
				PROVIDER NO:		HOSPICE NO.		PERIOD:
ANALYSIS OF SNF - BASED HOSPICE COST								FROM ________________		WORKSHEET K
								TO _______________
			EMPLOYEE		CONTRACTED			RECLAS-		ADJUST-
		SALARIES	BENEFITS	TRANSPOR-	SERVICES			SIFICATION		MENTS
	COST CENTER DESCRIPTIONS	(From	(From	TATION	(From		TOTAL	(Increase/		(Increase/	TOTAL
		Wkst K-1)	Wkst K-2)	(See inst.)	Wkst K-3)	OTHER	(col. 1-5)	Decrease)	SUBTOTAL	Decrease)	(col.8 ± col.9)
		1	2	3	4	5	6	7	8	9	10
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.											1
2	Capital Related Costs-Moveable Equip.											2
3	Plant Operation and Maintenance											3
4	Transportation - Staff											4
5	Volunteer Service Coordination											5
6	Administrative and General											6
	INPATIENT CARE SERVICE
7	Inpatient - General Care											7
8	Inpatient - Respite Care											8
	VISITING SERVICES
9	Physician Services											9
10	Nursing Care											10
11	Physical Therapy											11
12	Occupational Therapy											12
13	Speech/ Language Pathology											13
14	Medical Social Services											14
15	Spiritual Counseling											15
16	Dietary Counseling											16
17	Counseling - Other											17
18	Home Health Aide and Homemaker											18
19	Other											19
	OTHER HOSPICE SERVICE COSTS
20	Drugs, Biological and Infusion Therapy											20
21	Durable Medical Equipment/Oxygen											21
22	Patient Transportation											22
23	Imaging Services											23
24	Labs and Diagnostics											24
25	Medical Supplies											25
26	Outpatient Services (incl. E/R Dept.)											26
27	Radiation Therapy											27
28	Chemotherapy											28
29	Other											29
	HOSPICE NONREIMBURSABLE SERV.
30	Bereavement Program Costs											30
31	Volunteer Program Costs											31
32	Fundraising											32
33	Other Program Costs											33
34	Total											34
FORM CMS-2540-96 ( 01-2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3565)
35-390												Rev. 10

---

Sheet 69: K-1

01-01					FORM CMS-2540-96						3890 (Cont.)
			PROVIDER NO:		HOSPICE NO:		PERIOD:
HOSPICE COMPENSATION ANALYSIS							FROM ________________		WORKSHEET K-1
SALARIES AND WAGES				_			TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Moveable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Physical Therapy										11
12	Occupational Therapy										12
13	Speech/ Language Pathology										13
14	Medical Social Services										14
15	Spiritual Counseling										15
16	Dietary Counseling										16
17	Counseling - Other										17
18	Home Health Aide and Homemaker										18
19	Other										19
	OTHER HOSPICE SERVICE COSTS
20	Drugs, Biological and Infusion Therapy										20
21	Durable Medical Equipment/Oxygen										21
22	Patient Transportation										22
23	Imaging Services										23
24	Labs and Diagnostics										24
25	Medical Supplies										25
26	Outpatient Services (incl. E/R Dept.)										26
27	Radiation Therapy										27
28	Chemotherapy										28
29	Other										29
	HOSPICE NONREIMBURSABLE SERV.
30	Bereavement Program Costs										30
31	Volunteer Program Costs										31
32	Fundraising										32
33	Other Program Costs										33
34	Total										34
(1) Transfer the amount in column 9 to Wkst K, column 1
FORM CMS-2540-96 ( 01/2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3566)
Rev. 10											35-391

---

Sheet 70: K-2

3590 (Cont.)					FORM CMS-2540-96						01-01
			PROVIDER NO:		HOSPICE NO:		PERIOD:
HOSPICE COMPENSATION ANALYSIS							FROM ____________________		WORKSHEET K-2
EMPLOYEE BENEFITS (PAYROLL RELATED)							TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Moveable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Physical Therapy										11
12	Occupational Therapy										12
13	Speech/ Language Pathology										13
14	Medical Social Services										14
15	Spiritual Counseling										15
16	Dietary Counseling										16
17	Counseling - Other										17
18	Home Health Aide and Homemaker										18
19	Other										19
	OTHER HOSPICE SERVICE COSTS
20	Drugs Biological and Infusion Therapy										20
21	Durable Medical Equipment/ Oxygen										21
22	Patient Transportation										22
23	Imaging Services										23
24	Labs and Diagnostics										24
25	Medical Supplies										25
26	Outpatient Services (incl. E/R Dept.)										26
27	Radiation Therapy										27
28	Chemotherapy										28
29	Other										29
	HOSPICE NONREIMBURSABLE SERV.
30	Bereavement Program Costs										30
31	Volunteer Program Costs										31
32	Fundraising										32
33	Other Program Costs										33
34	Total										34
(1) Transfer the amounts in column 9 to Wkst K, column 2
FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3567)
35-392											Rev. 10

---

Sheet 71: K-3

01-01					FORM CMS-2540-96						3590 (Cont.)
			PROVIDER NO:		HOSPICE NO:		PERIOD:
HOSPICE COMPENSATION ANALYSIS							FROM ___________________		WORKSHEET K-3
CONTRACTED SERVICES / PURCHASED SERVICES				_			TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Moveable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Physical Therapy										11
12	Occupational Therapy										12
13	Speech/ Language Pathology										13
14	Medical Social Services										14
15	Spiritual Counseling										15
16	Dietary Counseling										16
17	Counseling - Other										17
18	Home Health Aide and Homemaker										18
19	Other										19
	OTHER HOSPICE SERVICE COSTS
20	Drugs, Biological and Infusion Therapy										20
21	Durable Medical Equipment/Oxygen										21
22	Patient Transportation										22
23	Imaging Services										23
24	Labs and Diagnostics										24
25	Medical Supplies										25
26	Outpatient Services (incl. E/R Dept.)										26
27	Radiation Therapy										27
28	Chemotherapy										28
29	Other										29
	HOSPICE NONREIMBURSABLE SERV.
30	Bereavement Program Costs										30
31	Volunteer Program Costs										31
32	Fundraising										32
33	Other Program Costs										33
34	Total										34
(1) Transfer the amounts in column 9 to Wkst K, column 4
FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3568)
Rev. 10											35-393

---

Sheet 72: K-4-1

3590 (Cont.)					FORM CMS 2540-96						01-01
			PROVIDER NO:		HOSPICE NO:		PERIOD:
COST ALLOCATION - HOSPICE							FROM ____________		WORKSHEET K-4
GENERAL SERVICE COST					_		TO _______________		PART I
		FR. WKST. K		CAPITAL
		COL. 10: NET	CAPITAL	RELATED			VOLUNTEER
		EXPENSES	RELATED	COST	PLANT		SERV.		ADMINIS-
	COST CENTER DESCRIPTIONS	FOR COST	COST BLDG	MOVABLE	OPERATION		COORDI-	SUBTOTAL	TRATIVE &
		ALLOC. (1)	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	(col. 0 - 5)	GENERAL	TOTAL
		0	1	2	3	4	5	5A	6	7
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Moveable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Physical Therapy										11
12	Occupational Therapy										12
13	Speech/ Language Pathology										13
14	Medical Social Services - Direct										14
15	Spiritual Counseling										15
16	Dietary Counseling										16
17	Counseling - Other										17
18	Home Health Aide and Homemakers										18
19	Other										19
	OTHER HOSPICE SERVICE COSTS
20	Drugs, Biologicals and Infusion										20
21	Durable Medical Equipment/Oxygen										21
22	Patient Transportation										22
23	Imaging Services										23
24	Labs and Diagnostics										24
25	Medical Supplies										25
26	Outpatient Services (incl. E/R Dept.)										26
27	Radiation Therapy										27
28	Chemotherapy										28
29	Other										29
	HOSPICE NONREIMBURSABLE SERV.
30	Bereavement Program Costs										30
31	Volunteer Program Costs										31
32	Fundraising										32
33	Other Program Costs										33
34	Total										34
	(1) Column 0, line 29 must agree with Wkst. A, column 7, line 55.
FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3569)
35-394											Rev. 10

---

Sheet 73: K-4-2

01-01				FORM CMS-2540-96					3590 (Cont.)
		PROVIDER NO:		HOSPICE NO:		PERIOD:
COST ALLOCATION -						FROM ____________		WORKSHEET K-4
HOSPICE STATISTICAL BASIS				_		TO _______________		PART II
			CAPITAL
		CAPITAL	RELATED			VOLUNTEER
		RELATED	COST	PLANT		SERV.		ADMINIS-
		COST BLDG	MOVABLE	OPERATION	TRANS-	COORDI-		TRATIVE &
	COST CENTER DESCRIPTIONS	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	RECONCI-	GENERAL
		(SQ. FT.)	$ VALUE)	(SQ. FT.)	MILEAGE	(HOURS)	LIATION	(ACC. COST)
		1	2	3	4	5	6A	6
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures								1
2	Capital Related Costs-Moveable Equipment								2
3	Plant Operation and Maintenance								3
4	Transportation-staff								5
5	Volunteer Service Coordination								5
6	Administrative and General								6
	INPATIENT CARE SERVICE
7	Inpatient - General Care								7
8	Inpatient - Respite Care								8
	VISITING SERVICES
9	Physician Services								9
10	Nursing Care								10
11	Physical Therapy								11
12	Occupational Therapy								12
13	Speech/ Language Pathology								13
14	Medical Social Services - Direct								14
15	Spiritual Counseling								15
16	Dietary Counseling								16
17	Counseling - Other								17
18	Home Health Aide and Homemakers								18
19	Other								19
	OTHER HOSPICE SERVICE COSTS
20	Drugs, Biologicals and Infusion								20
21	Durable Medical Equipment/Oxygen								21
22	Patient Transportation								22
23	Imaging Services								23
34	Labs and Diagnostics								24
25	Medical Supplies								25
26	Outpatient Services (incl. E/R Dept.)								26
27	Radiation Therapy								27
28	Chemotherapy								28
29	Other								29
	HOSPICE NONREIMBURSABLE SERV.
30	Bereavement Program Costs								30
31	Volunteer Program Costs								31
32	Fundraising								32
33	Other Program Costs								33
34	Cost To be Allocated (per Wkst K-4, Part I)								34
35	Unit Cost Multiplier								35
FORM CMS-2540-96 ( 01/2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3569)
Rev. 10									35-395

---

Sheet 74: K-5-1

3590 (Cont.)				FORM CMS-2540-96						01-01	01-01				FORM CMS-2540-96					3590 (Cont.)	3590 (Cont.)				FORM CMS-2540-96					01-01
				PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD
ALLOCATION OF GENERAL SERVICE						FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS				HOSPICE NO.:		TO: _________________		PART I			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		Part I (Cont.)			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		Part I (Cont.)
			From
			Wkst.	HOSPICE	CAPITAL	CAPITAL							PLANT															ALLOCATED
	HOSPICE COST CENTER		K-4	TRIAL	RELATED	RELATED			ADMINIS-			HOSPICE COST CENTER	OPERATION	LAUNDRY			NURSING	CENTRAL				HOSPICE COST CENTER	MEDICAL			OTHER	SUBTOTAL	HOSPICE	TOTAL
	(omit cents)		Part I,	BALANCE	BLDGS. &	MOVABLE	EMPLOYEE	SUBTOTAL	TRATIVE &			(omit cents)	MAINTENANCE	& LINEN	HOUSE		ADMINIS-	SERVICES &				(omit cents)	RECORDS &	SOCIAL	INTERNS &	GENERAL	(Sum of Columns	A&G (see	HOSPICE
			col. 6,	(1)	FIXTURES	EQUIPMENT	BENEFITS	(cols. 0-3)	GENERAL				& REPAIRS	SERVICE	KEEPING	DIETARY	TRATION	SUPPLY	PHARMACY				LIBRARY	SERVICE	RESIDENTS	SERVICE	4a through 15)	Part II)	COSTS
			line -	0	1	2	3	4a	4				5	6	7	8	9	10	11				12	13	14	15	16	17	18
1	Administrative and General		6							1	1	Administrative and General								1	1	Administrative and General								1
2	Inpatient - General Care		7							2	2	Inpatient - General Care								2	2	Inpatient - General Care								2
3	Inpatient - Respite Care		8							3	3	Inpatient - Respite Care								3	3	Inpatient - Respite Care								3
4	Physician Services		9							4	4	Physician Services								4	4	Physician Services								4
5	Nursing Care		10							5	5	Nursing Care								5	5	Nursing Care								5
6	Physical Therapy		11							6	6	Physical Therapy								6	6	Physical Therapy								6
7	Occupational Therapy		12							7	7	Occupational Therapy								7	7	Occupational Therapy								7
8	Speech/ Language Pathology		13							8	8	Speech/ Language Pathology								8	8	Speech/ Language Pathology								8
9	Medical Social Services - Direct		14							9	9	Medical Social Services - Direct								9	9	Medical Social Services - Direct								9
10	Spiritual Counseling		15							10	10	Spiritual Counseling								10	10	Spiritual Counseling								10
11	Dietary Counseling		16							11	11	Dietary Counseling								11	11	Dietary Counseling								11
12	Counseling - Other		17							12	12	Counseling - Other								12	12	Counseling - Other								12
13	Home Health Aide and Homemakers		18							13	13	Home Health Aide and Homemakers								13	13	Home Health Aide and Homemakers								13
14	Other		19							14	14	Other								14	14	Other								14
15	Drugs, Biologicals and Infusion		20							15	15	Drugs, Biologicals and Infusion								15	15	Drugs, Biologicals and Infusion								15
16	Durable Medical Equipment/Oxygen		21							16	16	Durable Medical Equipment/Oxygen								16	16	Durable Medical Equipment/Oxygen								16
17	Patient Transportation		22							17	17	Patient Transportation								17	17	Patient Transportation								17
18	Imaging Services		23							18	18	Imaging Services								18	18	Imaging Services								18
19	Labs and Diagnostics		24							19	19	Labs and Diagnostics								19	19	Labs and Diagnostics								19
20	Medical Supplies		25							20	20	Medical Supplies								20	20	Medical Supplies								20
21	Outpatient Services (incl. E/R Dept.)		26							21	21	Outpatient Services (incl. E/R Dept.)								21	21	Outpatient Services (incl. E/R Dept.)								21
22	Radiation Therapy		27							22	22	Radiation Therapy								22	22	Radiation Therapy								22
23	Chemotherapy		28							23	23	Chemotherapy								23	23	Chemotherapy								23
24	Other		29							24	24	Other								24	24	Other								24
25	Bereavement Program Costs		30							25	25	Bereavement Program Costs								25	25	Bereavement Program Costs								25
26	Volunteer Program Costs		31							26	26	Volunteer Program Costs								26	26	Volunteer Program Costs								26
27	Fundraising		32							27	27	Fundraising								27	27	Fundraising								27
28	Other Program Costs		33							28	28	Other Program Costs								28	28	Other Program Costs								28
29	Totals (sum of lines 1-28) (2)									29	29	Totals (sum of lines 1-28) (2)								29	29	Totals (sum of lines 1-28) (2)								29
30	Unit Cost Multiplier:									30	30	Unit Cost Multiplier:								30	30	Unit Cost Multiplier:								30
	Column 16, line 1 divided by the sum of column 16, line 29, minus column 16, line 1, rounded to 6 decimal places.											Column 16, line 1 divided by the sum of column 16, line 29, minus column 16, line 1, rounded to 6 decimal places.										Column 16, line 1 divided by the sum of column 16, line 29, minus column 16, line 1, rounded to 6 decimal places.
(2) Columns 0 through 16 , line 29 must agree with the corresponding columns of Wkst. B, Part I, line 55.
FORM CMS-2540-96 ( 01/2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3570.1)											FORM CMS-2540-96 ( 01/2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3570.1)										FORM CMS-2540-96 ( 01/2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3570.1)
35-396										Rev. 10	Rev. 10									35-397	35-398									Rev. 10

---

Sheet 75: K-5-II

01-01					FORM CMS-2540-96					3590 (Cont.)	3590 (Cont.)			FORM CMS-2540-96						01-01	01-01			FORM CMS-2540-96						3590 (Cont.)
				PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD
ALLOCATION OF GENERAL SERVICE						FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS				HOSPICE NO.:		TO: _________________		PART II			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		Part II (Cont.)			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		Part II (Cont.)
					CAPITAL	CAPITAL							PLANT	LAUNDRY			NURSING	CENTRAL
	HOSPICE COST CENTER				RELATED	RELATED			ADMINIS-			HOSPICE COST CENTER	OPERATION	& LINEN	HOUSE		ADMINIS-	SERVICES &				HOSPICE COST CENTER	MEDICAL			OTHER
	(omit cents)				BLDGS. &	MOVABLE	EMPLOYEE	RECONCIL	TRATIVE &			(omit cents)	MAINTENANCE	SERVICE	KEEPING		TRATION	SUPPLY	PHARMACY			(omit cents)	RECORDS &	SOCIAL	INTERNS &	GENERAL
					FIXTURES	EQUIPMENT	BENEFITS	LATION	GENERAL				& REPAIRS	(Pounds of		DIETARY	(Direct Nursing	(Costed	(Costed				LIBRARY	SERVICE	RESIDENTS	SERVICE
					(Square Feet)	(Dollar Value)	(Gross Salaries)		(Accum. Cost)				(Square Feet)	Laundry)	(Hours of Service)	(Meals Served)	Hours)	Requisitions)	Requisitions)				(Time Spent)	(Time Spent)	(Assigned Time)	(Specify)
					1	2	3	4a	4				5	6	7	8	9	10	11				12	13	14	15
1	Administrative and General									1	1	Administrative and General								1	1	Administrative and General								1
2	Inpatient - General Care									2	2	Inpatient - General Care								2	2	Inpatient - General Care								2
3	Inpatient - Respite Care									3	3	Inpatient - Respite Care								3	3	Inpatient - Respite Care								3
4	Physician Services									4	4	Physician Services								4	4	Physician Services								4
5	Nursing Care									5	5	Nursing Care								5	5	Nursing Care								5
6	Physical Therapy									6	6	Physical Therapy								6	6	Physical Therapy								6
7	Occupational Therapy									7	7	Occupational Therapy								7	7	Occupational Therapy								7
8	Speech/ Language Pathology									8	8	Speech/ Language Pathology								8	8	Speech/ Language Pathology								8
9	Medical Social Services - Direct									9	9	Medical Social Services - Direct								9	9	Medical Social Services - Direct								9
10	Spiritual Counseling									10	10	Spiritual Counseling								10	10	Spiritual Counseling								10
11	Dietary Counseling									11	11	Dietary Counseling								11	11	Dietary Counseling								11
12	Counseling - Other									12	12	Counseling - Other								12	12	Counseling - Other								12
13	Home Health Aide and Homemakers									13	13	Home Health Aide and Homemakers								13	13	Home Health Aide and Homemakers								13
14	Other									14	14	Other								14	14	Other								14
15	Drugs, Biologicals and Infusion									15	15	Drugs, Biologicals and Infusion								15	15	Drugs, Biologicals and Infusion								15
16	Durable Medical Equipment/Oxygen									16	16	Durable Medical Equipment/Oxygen								16	16	Durable Medical Equipment/Oxygen								16
17	Patient Transportation									17	17	Patient Transportation								17	17	Patient Transportation								17
18	Imaging Services									18	18	Imaging Services								18	18	Imaging Services								18
19	Labs and Diagnostics									19	19	Labs and Diagnostics								19	19	Labs and Diagnostics								19
20	Medical Supplies									20	20	Medical Supplies								20	20	Medical Supplies								20
21	Outpatient Services (incl. E/R Dept.)									21	21	Outpatient Services (incl. E/R Dept.)								21	21	Outpatient Services (incl. E/R Dept.)								21
22	Radiation Therapy									22	22	Radiation Therapy								22	22	Radiation Therapy								22
23	Chemotherapy									23	23	Chemotherapy								23	23	Chemotherapy								23
24	Other									24	24	Other								24	24	Other								24
25	Bereavement Program Costs									25	25	Bereavement Program Costs								25	25	Bereavement Program Costs								25
26	Volunteer Program Costs									26	26	Volunteer Program Costs								26	26	Volunteer Program Costs								26
27	Fundraising									27	27	Fundraising								27	27	Fundraising								27
28	Other Program Costs									28	28	Other Program Costs								28	28	Other Program Costs								28
29	Totals (sum of lines 1-28) (2)									29	29	Totals (sum of lines 1-28) (2)								29	29	Totals (sum of lines 1-28) (2)								29
30	Unit Cost Multiplier									30	30	Unit Cost Multiplier								30	30	Unit Cost Multiplier								30
FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3570.2)											FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3570.2)										FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3570.2)
Rev. 10										35-399	35-400									Rev. 10	Rev. 10									35-401

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Sheet 76: K-5-III

3590 (Cont.)				FORM CMS-2540-96					01-01
				PROVIDER NO.:		PERIOD:		WORKSHEET
APPORTIONMENT OF HOSPICE SHARED SERVICES				00-5000		From: 05-01-00		K-5
				HOSPICE NO.:		To: 04-30-01		Part III
				14-1590
PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS
Hospice shared cost computation						Total Hospice	Hospice Shared	Total
		Facility Cost		Cost to Charge Ratio		Charges	Ancillary Costs	Hospice
		From Worksheet K-5, Part I		From Worksheet C, Col. 3		(From Provider	(col. 4 x col. 5)	Cost
	COST CENTER	Line:	Amount:	Line :	Ratio	Records)		(col. 2 and 6)
		1	2	3	4	5	6	7
ANCILLARY SERVICE COST CENTERS
1	Physical Therapy	6		25					1
2	Occupational Therapy	7		26					2
3	Speech/ Language Pathology	8		27					3
4	Drugs, Biologicals and Infusion	15		30					4
5	Labs and Diagnostics	19		22					5
6	Medical Supplies	20		29					6
7	Radiation Therapy	22		21					7
8	Other	24		33					8
9	Total (sum of lines 1-8)								9
FORM CMS-2540-96 ( 01/2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3570.3)
35-402									Rev. 10

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Sheet 77: K6

01-01			FORM CMS-2540-96				3590 (Cont.)
	CALCULATION OF	PROVIDER NO.		PERIOD:
	PER DIEM COST			FROM ________________		WORKSHEET K-6
		_________________		TO ________________
	COMPUTATION OF PER DIEM COST		TITLE XVIII	TITLE XIX	OTHER	TOTAL
			1	2	3	4
1	Total cost (Worksheet K, line 34 less line 33, col. 7)						1
2	Total Unduplicated Days (Worksheet S-8, line 5, col. 6)						2
3	Average cost per diem (line 1 divided by line 2)						3
4	Unduplicated Medicare Days (Worksheet S-8, line 5, col. 1)						4
5	Average Medicare cost (line 3 times line 4)						5
6	Unduplicated Medicaid Days (Worksheet S-8, line 5, col. 2)						6
7	Average Medicaid cost (line 3 times line 6)						7
8	Unduplicated SNF days (Worksheet S-8, line 5, col. 3)						8
9	Average SNF cost (line 3 times line 8)						9
10	Unduplicated NF days (Worksheet S-8, line 5, col. 4)						10
11	Average NF cost (line 3 times line 10)						11
12	Other Unduplicated days (Worksheet S-8, line 5, col. 5)						12
13	Average cost for other days (line 3 times line 12)						13
14	Total cost (see instructions)						14
15	Total days (see instructions)						15
FORM CMS-2540-96 ( 01/2001 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3571)
Rev. 10							35-403