Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

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Sheet 1: A1

08-05				FORM CMS 287-05					3990 (Cont.)
This report is required by law (42 USC 1395g: 42 CFR 413.20(b)).								FORM APPROVED
Failure to report can result in all interim payments made since								OMB NO. 0938-0202
the beginning of the cost report period being deemed overpayments
(42 USC 1395g).
HOME OFFICE COST			Designated Intermediary Use Only				Date Received:		SCHEDULE
STATEMENT				Desk Reviewed					A
				Audited			Intermediary No.		page 1 of 3
GENERAL INFORMATION, CERTIFICATION AND LISTING OF CHAIN COMPONENTS
Part I - General Information
l. Home Office Name:						2. No. Assigned by Designated Intermediary:
						2.01 No. Assigned by CMS:
3. Home Office Address:						4. Chain Operations
						Started On:
5. Contact Person						6. Cost Statement Period:
Name:						From:
Title:						To:
Phone:						7. Was Audited Financial Data used on
						Schedule B?		[ ] Yes [ ] No
8. Type of Chain Organization (check applicable item)
a) voluntary non-profit					b) proprietary/investor-owned			c) governmental
		Church affiliated				Individual			Federal
		Community				Partnership			State
		Private				Corporation			County
		Charitable				Other (specify)			City
		Other (specify)							District
									Other(specify)
9. Key Officers of Home Office (attach listing if necessary)
President
Vice President(s)
Secretary
Treasurer
Controller
Others(specify)
Part II--Certification By Officer of Home Office
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE
BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE,
IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY
OF A KICKBACK OR WHERE 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 statement of allowable Home Office costs
(and equity capital if applicable), the allocation thereof to the chain components, and the other supporting schedules for the period
beginning _______, 20__, and ending ____________, 20__. To the best of my knowledge and belief, they are true and correct statements
from the books and records of the Home Office in accordance with applicable instructions, except as noted (attach
a statement with exception if necessary).
							(signed)
							(title)
							(date)
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 0938-0202. The time required to complete this information collection is estimated 662 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, Baltimore, Maryland 21244-1850.
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3906-3906.2)
Rev. 1									39-103

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Sheet 2: A2

3990 (Cont.)					FORM CMS 287-05						08-05
PART III-- LISTING OF CHAIN HEALTHCARE FACILITY COMPONENTS						Home Office:	Period			SCHEDULE
(Attach additional pages if necessary) (Please indicate all Medicare numbers excluding							From:_____________			A
Sub-Providers, Provider-Based Skilled Nursing Facilities and Home Health Agencies)							To:_________________			page 2 of 3
			Periods Ending During		Date Acquired	Date Sold/Closed	Medicaid	Type of
	Component Name		Home Office Fiscal Year		During the Home	During the Home	Participation	Reimbursement	Medicare	Medicaid
	Health Care Facilities	Medicare No.	From:	To:	Office Fiscal Year	Office Fiscal Year	Yes/No	N, P, T, O	Intermediaries	Intermediaries
	1	2	3	4	5	6	7	8	9	10
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.
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3906.3)
39-104											Rev. 1

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Sheet 3: A3

08-05				FORM CMS 287-05					3990 (Cont.)
PART IV-- LISTING OF OTHER ( NON-PROVIDER)			Home Office:		Period			SCHEDULE
CHAIN COMPONENTS (Attach					From:________________			A
additional pages if necessary)								page 3 of 3
					To:__________________
			Periods Ending During			During the Home Office Fiscal Year
	Component Name		Home Office Fiscal Year			Date		Date
	Other Components		From	To		Acquired		Sold or Closed
	1		2	3		4		5
1									1
2									2
3									3
4									4
5									5
6									6
7									7
8									8
9									9
PART V--LISTING OF REGIONS/DIVISIONS
				Costs Included	Separate Cost			Designated
			Location	in this Cost Statement	Statement Filed			Region/Division
	Name	City	State	Amount	Yes	No		Intermediary
	1	2	3	4	5	6		7
1									1
2									2
3									3
4									4
		DISCLOSURE OF THE HOME OFFICE COST STATEMENT
The home office cost statement is not an integral part of the providers' cost report; therefore,it is not affected by 20 CFR 422.435(c)
which requires disclosure of providers' cost reports. Any request received under the Freedom of Information Act (FOIA) regarding
a home office cost statement will be subjected to a case by case determination of whether to withhold the information in whole or in part.
In most cases, since the home office cost statements contain information the disclosure of which may result in a competitive disadvantage
for many provider chains, the exemption from disclosure provided in 5 USC, Sec. 552(b)(4) will apply.
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 3906.4-3906.5)
Rev. 1									39-105