Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106

06-01 FORM CMS-1728-94 3290

EXHIBIT 1 - FORM CMS-1728-94

The following is a listing of the FORM CMS-1728-94 worksheets and the page number location.

Worksheets Page(s)

Wkst. S, Parts I & II 32-303

Wkst. S-2 32-304

Wkst. S-3, Parts I-III 32-305

Wkst. S-3, Part IV 32-305.1

Wkst. S-4 32-305.2

Wkst. S-5 32-306

Wkst. S-6 Parts I & II 32-307

Wkst. A 32-308

Wkst. A-1 32-309

Wkst. A-2 32-310

Wkst. A-3 32-311

Wkst. A-4 32-312

Wkst. A-5 32-313

Wkst. A-6 32-314

Wkst. A-7 32-315

Wkst. A-8-3, Parts I-III 32-316

Wkst. A-8-3, Parts IV & V 32-317

Wkst. B 32-318

Wkst. B-1 32-319

W kst. C, Parts I & II 32-320

W kst. C, Parts III, IV & V 32-321

Wkst. D 32-322

Wkst. D-1 32-323

Wkst. F 32-324

Wkst. F-1 32-325

Wkst. F-2 32-326

Wkst. J-1, Parts I & II 32-327

Wkst. J-1, Part III 32-328

Wkst. J-2 32-329

Wkst. J-3 32-330

Wkst. J-4 32-331

Wkst. K 32-331.1

W kst. K-1 32-331.2

W kst. K-2 32-331.3

W kst. K-3 32-331.4

W kst. K-4, Part I 32-331.5

Wkst. K-4, Part II 32-331.6

Wkst. K-5, Part I 32-331.7

Wkst. K-5, Part II 32-331.8

Wkst. K-5, Part III 32-331.9

Wkst. K-6 32-331.10

Wkst. CM-1, Parts I & II 32-332

Wkst. CM-1, Part III 32-333

Wkst. CM-2 32-334

W kst. CM-3 32-335

W kst. CM-4 32-336

Wkst. RH-1, Parts I & II 32-337

Wkst. RH-1, Part III 32-338

Rev. 10 32-301

3290 (Cont.) FORM CMS-1728-94 06-01

Worksheets Page(s)

Wkst. RH-2 32-339

Wkst. FQ-1, Parts I & II 32-340

Wkst. FQ-1, Part III 32-341

Wkst. FQ-2 32-342

Wkst. RF-1 32-343

Wkst. RF-2 32-344

Wkst. RF-3 32-345

Wkst. RF-4 (Do not complete. See instructions.) 32-346

Wkst. RF-5 32-347

32-302 Rev. 10