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

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Overview

D1
D2

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Sheet 1: D1

08-05		FORM CMS 287-05				3990 (Cont.)
STATEMENT OF COSTS OF SERVICES					SCHEDULE D
FROM RELATED ORGANIZATIONS					page 1 of 2
			Period
Home
Office:			From:		To:
Part A.		Are there any costs included on Schedule B which resulted
		from transactions with related organizations as defined in
		42 CFR 413.17?
		_________________Yes		___________________	No
		If "YES," complete Parts B and C following.
Part B.
		Costs incurred and adjustment required as a result of
		transactions with related organizations:
		Account and Amount		Amount	Net Adjustment
		(on Schedule B, column 3)		Allowable	(col. 3 minus
	Line	Expense Account	Amount	in Cost	col.4) *
	1	2	3	4	5
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.
100	Total (sum of lines 1-99)					100
	* transfer to column 1 of Schedule C, applicable lines
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3912)
Rev. 1						39-113

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Sheet 2: D2

3990 (Cont.)			FORM CMS 287-05			08-05
	STATEMENT OF COSTS OF SERVICES	Home Office:		Period:	SCHEDULE
	FROM RELATED ORGANIZATIONS			From: ______________________________	D
					page 2 of 2
				To: ________________________________
	Part C. Inter-relationship of chain Home Office to related organization:
	Name of Related Organization	Type of Business	Related Through	Explanation of Relationship
			Ownership or Control
	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
100						100
FORM CMS-287-05(8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3912)
39-114						Rev. 1