Form CMS-R-249 Hospice Medicare Cost Report Forms

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Overview

Cover Page
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Sheet 1: Cover Page

OMB No. 0938-0758

FORM CMS 1984-99

Hospice Medicare Cost Report Forms

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Sheet 2: S

08-06						FORM CMS-1984-99					3890 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Completion of this report is viewed as a condition									FORM APPROVED
of your provider agreement.									OMB NO. 0938-0758
						PROVIDER NO.:	PERIOD:
HOSPICE COST AND DATA REPORT							FROM		WORKSHEET S
							TO
Intermediary		[ ] Audited				Date Received:		[ ] Initial [ ] Reopening
use only		[ ] Desk Reviewed				Intermediary No.		[ ] Final
CERTIFICATION
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 PRODUCED
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 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
						Phone Number: Area Code
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 0938-0758. The time required to complete this information
collection is estimated to average 176 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-1984-99 (4/99) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3806)
Rev. 7											38-103

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Sheet 3: S-1

3890 (Cont.)						FORM CMS-1984-99					08-06
						PROVIDER NO.:		PERIOD:
HOSPICE IDENTIFICATION DATA								FROM:		WORKSHEET S-1
								TO:
PART I
1	Name:				Address:			City:	State:	Zip Code:	1
2	County where the hospice is located										2
										Date
3	Hospice began operation (mm/dd/yyyy)										3
									Dated certified	Dated certified
									Title XVIII	Title XIX
4	Certification date (mm/dd/yyyy)										4
5	Cost Reporting Period (mm/dd/yyyy)						From:		To:		5
6	Provider Identification Number										6
6.01	National Provider Identier (NPI) Number										6.01
7	Type of Control (see instructions)										7
PART II
					Title XVIII	Title XIX	Title XVIII	Title XIX
							Unduplicated	Unduplicated
			Enrollment Days		Unduplicated	Unduplicated	Skilled Nursing	Nursing	Other	Total
					Medicare Days	Medicaid Days	Facility Days	Facility Days	Unduplicated	Unduplicated Days
					1	2	3	4	5	6
8	Continuous Home Care										8
9	Routine Home Care										9
10	Inpatient Respite Care										10
11	General Inpatient Care										11
12	Total Hospice Days										12
PART III
							Title XVIII	Title XIX
							Skilled Nursing	Nursing
					Title XVIII	Title XIX	Facility	Facility	Other	Total
					1	2	3	4	5	6
13	Number of Patients Receiving Hospice Care										13
	Total Number of Unduplicated Countinuous
14	Care Hours Billable to Medicare										14
15	Average Length of Stay										15
16	Unduplicated Census Count										16
	If the hospice componentized (or fragmented) its administrative and general service costs, indicate whether option one
17	or two is being utilized (See PRM-II, Section 3820) (Enter "1"for option one and "2" for option two)										17
	Are there any related organization or home office costs as defined in CMS Pub. 15-I, chapter 10? Enter "Y" for yes or "N" for no
18	in column 1. If yes, enter the chain home office provider number in column 2.										18
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3807)
38-104											Rev. 7

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Sheet 4: A

08-06						FORM CMS-1984-99							3890 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES					PROVIDER NO:		PERIOD:
							FROM					WORKSHEET A
							TO
											ADJUST-
						CON-			RECLAS-		MENTS
				EMPLOYEE		TRACTED			SIFICATION		(Increase/
			SALARIES	BENEFITS	TRANSPOR-	SERVICES			(Increase/		Decrease)
		COST CENTER DESCRIPTIONS	(From	(From	TATION	(From		TOTAL	Decrease)		(Fr Wkst A-8	TOTAL
			Wkst A-1)	Wkst A-2)	(See inst.)	Wkst A-3)	OTHER	(col. 1-5)	(Fr Wkst A-6)	SUBTOTAL	& A-8-1)	(col.8±col.9)
			1	2	3	4	5	6	7	8	9	10
		GENERAL SERVICE COST CENTERS
1	0100	Capital Related Costs-Bldg and Fixtures											1
2	0200	Capital Related Costs-Movable Equipment											2
3	0300	Plant Operation and Maintenance											3
4	0400	Transportation - Staff											4
5	0500	Volunteer Service Coordination											5
6	0600	Administrative and General											6
		INPATIENT CARE SERVICE
10	1000	Inpatient - General Care											10
11	1100	Inpatient - Respite Care											11
		VISITING SERVICES
15	1500	Physician Services											15
16	1600	Nursing Care											16
16.01	1601	Nursing Care -- Continuous Home Care											16.01
17	1700	Physical Therapy											17
18	1800	Occupational Therapy											18
19	1900	Speech/ Language Pathology											19
20	2000	Medical Social Services											20
21	2100	Spiritual Counseling											21
22	2200	Dietary Counseling											22
23	2300	Counseling - Other											23
24	2400	Home Health Aide and Homemaker											24
24.01	2401	HH Aide & Homemaker -- Cont Home Care											24.01
25		Other											25
		HH Aide & Homemaker -- Cont Hm Care
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3810)
Rev. 7													38-105
3890 (Cont.)						FORM CMS-1984-99							08-06
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES					PROVIDER NO:		PERIOD:
							FROM					WORKSHEET A
							TO
						CONT-			RECLAS-		ADJUST-
				EMPLOYEE		RACTED			SIFICATION		MENTS
			SALARIES	BENEFITS	TRANSPOR-	SERVICES			(Increase/		(Increase/
		COST CENTER DESCRIPTIONS	(From	(From	TATION	(From		TOTAL	Decrease)		Decrease)	TOTAL
			Wkst A-1)	Wkst A-2)	(See inst.)	Wkst A-3)	OTHER	(col. 1-5)	(Fr Wkst A-6)	SUBTOTAL	(Fr Wkst A-8)	(col.8±col.9)
			1	2	3	4	5	6	7	8	9	10
		OTHER HOSPICE SERVICE COSTS
30	3000	Drugs, Biological and Infusion Therapy											30
30.01	3001	Analgesics											30.01
30.02	3002	Sedatives / Hypnotics											30.02
30.03	3003	Other -- Specify											30.03
31	3100	Durable Medical Equipment/Oxygen											31
32	3200	Patient Transportation											32
33	3300	Imaging Services											33
34	3400	Labs and Diagnostics											34
35	3500	Medical Supplies											35
36	3600	Outpatient Services (incl. E/R Dept.)											36
37	3700	Radiation Therapy											37
38	3800	Chemotherapy											38
39		Other											39
		HOSPICE NONREIMBURSABLE SERV.
50	5000	Bereavement Program Costs											50
51	5100	Volunteer Program Costs											51
52	5200	Fundraising											52
53		Other Program Costs											53
100		Total											100
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3810)
38-106													Rev. 7

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Sheet 5: A-1

08-06					FORM CMS-1984-99						3890 (Cont.)
COMPENSATION ANALYSIS SALARIES AND WAGES				PROVIDER NO:		PERIOD:
						FROM				WORKSHEET A-1
						TO
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL			TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	SUPERVISORS	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-Movable 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
10	Inpatient - General Care										10
11	Inpatient - Respite Care										11
	VISITING SERVICES
15	Physician Services										15
16	Nursing Care										16
16.01	Nursing Care -- Continuous Home Care										16.01
17	Physical Therapy										17
18	Occupational Therapy										18
19	Speech/ Language Pathology										19
20	Medical Social Services										20
21	Spiritual Counseling										21
22	Dietary Counseling										22
23	Counseling - Other										23
24	Home Health Aide and Homemaker										24
24.01	HH Aide & Homemaker -- Cont Home Care										24.01
25	Other										25
(1) Transfer the amount in column 9 to Wkst A, column 1
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3811)
Rev. 7											38-107
3890 (Cont.)					FORM CMS-1984-99						08-06
COMPENSATION ANALYSIS SALARIES AND WAGES				PROVIDER NO:		PERIOD:
						FROM				WORKSHEET A-1
						TO
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL			TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	SUPERVISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	OTHER HOSPICE SERVICE COSTS
30	Drugs, Biological and Infusion Therapy										30
30.01	Analgesics										30.01
30.02	Sedatives / Hypnotics										30.02
30.03	Other -- Specify										30.03
31	Durable Medical Equipment/Oxygen										31
32	Patient Transportation										32
33	Imaging Services										33
34	Labs and Diagnostics										34
35	Medical Supplies										35
36	Outpatient Services (incl. E/R Dept.)										36
37	Radiation Therapy										37
38	Chemotherapy										38
39	Other										39
	HOSPICE NONREIMBURSABLE SERV.
50	Bereavement Program Costs										50
51	Volunteer Program Costs										51
52	Fundraising										52
53	Other Program Costs										53
100	Total										100
(1) Transfer the amount in column 9 to Wkst A, column 1
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3811)
38-108											Rev. 7

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Sheet 6: A-2

08-06					FORM CMS-1984-99						3890 (Cont.)
COMPENSATION ANALYSIS EMPLOYEE BENEFITS (PAYROLL RELATED)				PROVIDER NO:		PERIOD:
						FROM				WORKSHEET A-2
						TO
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL			TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	SUPERVISORS	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-Movable 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
10	Inpatient - General Care										10
11	Inpatient - Respite Care										11
	VISITING SERVICES
15	Physician Services										15
16	Nursing Care										16
16.01	Nursing Care -- Continuous Home Care										16.01
17	Physical Therapy										17
18	Occupational Therapy										18
19	Speech/ Language Pathology										19
20	Medical Social Services										20
21	Spiritual Counseling										21
22	Dietary Counseling										22
23	Counseling - Other										23
24	Home Health Aide and Homemaker										24
24.01	HH Aide & Homemaker -- Cont Home Care										24.01
25	Other										25
(1) Transfer the amount in column 9 to Wkst A, column 2
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS UB. 15-II, SECTION 3812)
Rev. 7											38-109
3890 (Cont.)					FORM CMS-1984-99						08-06
COMPENSATION ANALYSIS EMPLOYEE BENEFITS (PAYROLL RELATED)				PROVIDER NO:		PERIOD:
						FROM				WORKSHEET A-2
						TO
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL			TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	SUPERVISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	OTHER HOSPICE SERVICE COSTS
30	Drugs, Biological and Infusion Therapy										30
30.01	Analgesics										30.01
30.02	Sedatives / Hypnotics										30.02
30.03	Other -- Specify										30.03
31	Durable Medical Equipment/ Oxygen										31
32	Patient Transportation										32
33	Imaging Services										33
34	Labs and Diagnostics										34
35	Medical Supplies										35
36	Outpatient Services (incl. E/R Dept.)										36
37	Radiation Therapy										37
38	Chemotherapy										38
39	Other										39
	HOSPICE NONREIMBURSABLE SERV.
50	Bereavement Program Costs										50
51	Volunteer Program Costs										51
52	Fundraising										52
53	Other Program Costs										53
100	Total										100
(1) Transfer the amount in column 9 to Wkst A, column 2
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3812)
38-110											Rev. 7

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Sheet 7: A-3

08-06					FORM CMS-1984-99						3890 (Cont.)
COMPENSATION ANALYSIS - CONTRACTED SERVICES/PURCHASED SERVICES				PROVIDER NO:		PERIOD:
						FROM				WORKSHEET A-3
						TO
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL			TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	SUPERVISORS	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-Movable 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
10	Inpatient - General Care										10
11	Inpatient - Respite Care										11
	VISITING SERVICES
15	Physician Services										15
16	Nursing Care										16
16.01	Nursing Care -- Continuous Home Care										16.01
17	Physical Therapy										17
18	Occupational Therapy										18
19	Speech/ Language Pathology										19
20	Medical Social Services										20
21	Spiritual Counseling										21
22	Dietary Counseling										22
23	Counseling - Other										23
24	Home Health Aide and Homemaker										24
24.01	HH Aide & Homemaker -- Cont Home Care										24.01
25	Other										25
(1) Transfer the amount in column 9 to Wkst A, column 4
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3813)
Rev. 7											38-111
3890 (Cont.)					FORM CMS-1984-99						08-06
COMPENSATION ANALYSIS - CONTRACTED SERVICES/PURCHASED SERVICES				PROVIDER NO:		PERIOD:
						FROM				WORKSHEET A-3
						TO
	COST CENTER DESCRIPTIONS	ADMINIS-		SOCIAL			TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	SUPERVISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	OTHER HOSPICE SERVICE COSTS
30	Drugs, Biological and Infusion Therapy										30
30.01	Analgesics										30.01
30.02	Sedatives / Hypnotics										30.02
30.03	Other -- Specify										30.03
31	Durable Medical Equipment/Oxygen										31
32	Patient Transportation										32
33	Imaging Services										33
34	Labs and Diagnostics										34
35	Medical Supplies										35
36	Outpatient Services (incl. E/R Dept.)										36
37	Radiation Therapy										37
38	Chemotherapy										38
39	Other										39
	HOSPICE NONREIMBURSABLE SERV.
50	Bereavement Program Costs										50
51	Volunteer Program Costs										51
52	Fundraising										52
53	Other Program Costs										53
100	Total										100
(1) Transfer the amount in column 9 to Wkst A, column 4
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3813)
38-112											Rev. 7

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Sheet 8: A-6

04-99			FORM CMS-1984-99								3890 (Cont.)
RECLASSIFICATIONS ADJUSTMENTS TO EXPENSES				PROVIDER NO:			PERIOD:			WORKSHEET A-6
							FROM
							TO
				INCREASES				DECREASES
		CODE
	EXPLANATION OF RECLASSIFICATION(S)	(1)	COST CENTER	LINE #	SALARY	OTHER	COST CENTER	LINE #	SALARY	OTHER
		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
100	Total reclassifications (sum of col. 4 and 5
	must equal sum of col. 8 and 9)										100
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 5, lines as appropriate.
FORM CMS-1984-99 (4/99) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3816)
Rev. 1											38-113

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Sheet 9: A-7

3890 (Cont.)			CMS FORM-1984-99					04-99
				PROVIDER NO:		PERIOD:	WORKSHEET A-7
ANALYSIS OF CHANGES IN CAPITAL ASSETS BALANCES						FROM
						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	Subtotal (sum of lines 1-6)							7
8	Reconciling Items							8
9	Total (line 7 minus line 8)							9
FORM CMS-1984-99 (4/99) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3817)
36-114								Rev. 1

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Sheet 10: A-8

09-00		FORM CMS-1984-99						3890 (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							1
	funds (chapter 2)
2	Telephone services (pay stations							2
	excluded) (chapter 21)
3	Adjustment resulting from transactions							3
	with Related Organizations (chapter 10) and	Worksheet
	Home office costs (chapter 21)	A-8-1
4	Revenue - Employee meals, Guests							4
5	Income from imposition of interest,							5
	finance or penalty charges (chapter 21)
6	Bad Debts Included on Trial Balance							6
7	Patient Personal Purchases							7
8	Miscellaneous Adjustments							8
9	Depreciation--buildings and fixtures				Buildings & Fixtures		1	9
10	Depreciation--movable equipment				Movable Equipment		2	10
11	TOTAL (sum of lines 1 - 10)							11
	(Transfer to Worksheet A, col. 9, line 100)
(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.
FORM CMS-1984-99 (09/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3818)
Rev. 2								38-115

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Sheet 11: A-8-1

3890 (Cont.)

FORM CMS-1984-99

09-00

STATEMENT OF COSTS OF SERVICES

PROVIDER NO:

PERIOD:

WORKSHEET A-8-1

FROM RELATED ORGANIZATIONS AND

FROM

HOME OFFICE COSTS

TO

A. Costs incurred and adjustments required as a result of transactions with related organizations or the claiming of home office costs,

and/or related organization:

Amount

Net

Amount

(from

Adjustments

Allowable

Worksheet A,

(col. 4 minus

Line No.

Cost Center

Expense Items

In Cost

col. 5)

col. 5) *

1

2

3

4

5

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet

5

A-8, column 2, line 3.

B. Interrelationship to related organization(s) and/or home office:

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 B of this worksheet.

This information is used by the Centers for Medicare and Medicare Services 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.

* The amounts on lines 1-4 and subscripts as appropriate are transferred in detail to Worksheet A, column 9, lines as appropriate.

Positive amounts increase cost and negative amounts decrease cost. For related organizational or home office cost which has not

been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

Related Organization(s) and/or Home Office

Percentage

Percentage

Type of

Symbol

of

of

(1)

Name

Ownership

Name

Ownership

Business

1

2

3

4

5

6

1

1

2

2

3

3

4

4

5

5

(1) Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related

organization and in provider.

B. Corporation, partnership, or other organization has financial interest in provider.

C. Provider has financial interest in corporation, partnership, or other organization.

D. Director, officer, administrator, or key person of provider or relative of such

person has financial interest in related organization.

E. Individual is director, officer, administrator, or key person of provider and

related organization.

F. Director, officer, administrator, or key person of related organization or relative

of such person has financial interest in provider.

G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-1984-99 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN PUB. 15-II, SECTION 3818.1)

38-116

Rev. 2

---

Sheet 12: B

08-06					FORM CMS 1984-99										3890 (Cont.)
COST ALLOCATION BASED ON SERVICE COST CENTERS					PROVIDER NO:		PERIOD:
							FROM							WORKSHEET B
							TO
				CAPITAL
		NET	CAPITAL	RELATED			VOLUNTEER
		EXPENSES	RELATED	COST	PLANT		SERVICE		A & G		A & G		A & G
	COST CENTER DESCRIPTIONS	FOR COST	COST BLDG	MOVABLE	OPERATION	TRANS-	COORDI-	SUBTOTAL	SHARED	SUBTOTAL	REIMB.	SUBTOTAL	NON-REIMB.
		ALLOC.	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	(col. 0 - 5)	COSTS	(col. 0 - 6.01	COSTS	(col. 0 - 6.02)	COSTS	TOTAL
		0	1	2	3	4	5	5A	6.01	6A.01	6.02	6A.02	6.03	7
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixtures														1
2	Capital Related Costs-Movable Equipment														2
3	Plant Operation and Maintenance														3
4	Transportation - Staff														4
5	Volunteer Service Coordination														5
6	Administrative and General														6
6.01	A & G Shared Costs														6.01
6.02	A & G Reimbursable Costs														6.02
6.03	A & G Nonreimbursable Costs														6.03
	INPATIENT CARE SERVICE
10	Inpatient - General Care														10
11	Inpatient - Respite Care														12
	VISITING SERVICES
15	Physician Services														15
16	Nursing Care														16
16.01	Nursing Care -- Continuous Home Care														16.01
17	Physical Therapy														17
18	Occupational Therapy														18
19	Speech/ Language Pathology														19
20	Medical Social Services														20
21	Spiritual Counseling														21
22	Dietary Counseling														22
23	Counseling - Other														23
24	Home Health Aide and Homemaker														24
24.01	HH Aide & Homemaker -- Cont Home Care														24.01
25	Other														25
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3820)
Rev. 7															38-117
3890 (Cont.)				FORM CMS-1984-99											08-06
COST ALLOCATION BASED ON SERVICE COST CENTERS					PROVIDER NO:		PERIOD:
							FROM							WORKSHEET B
							TO
				CAPITAL
		NET	CAPITAL	RELATED			VOLUNTEER
		EXPENSES	RELATED	COST	PLANT		SERVICE		A & G		A & G		A & G
	COST CENTER DESCRIPTIONS	FOR COST	COST BLDG	MOVABLE	OPERATION	TRANS-	COORDI-	SUBTOTAL	SHARED	SUBTOTAL	REIMB.	SUBTOTAL	NON-REIMB.
		ALLOC.	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	(col. 0 - 5)	COSTS	(col. 0 - 6.01	COSTS	(col. 0 - 6.02)	COSTS	TOTAL
		0	1	2	3	4	5	5A	6.01	6A.01	6.02	6A.02	6.03	7
	OTHER HOSPICE SERVICE COSTS
30	Drugs, Biologicals and Infusion														30
30.01	Analgesics														30.01
30.02	Sedatives / Hypnotics														30.02
30.03	Other -- Specify														30.03
31	Durable Medical Equipment/Oxygen														31
32	Patient Transportation														32
33	Imaging Services														33
34	Labs and Diagnostics														34
35	Medical Supplies														35
36	Outpatient Services (incl. E/R Dept.)														36
37	Radiation Therapy														37
38	Chemotherapy														38
39	Other														39
	HOSPICE NONREIMBURSABLE SERV.
50	Bereavement Program Costs														50
51	Volunteer Program Costs														51
52	Fundraising														52
53	Other Program Costs														53
100	Total														100
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3820)
38-117.1															Rev. 7

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Sheet 13: B-1

08-06				FORM CMS-1984-99								3890 (Cont.)
COST ALLOCATION - STATISTICAL BASIS				PROVIDER NO:		PERIOD:
						FROM					WORKSHEET B-1
						TO
			CAPITAL
		CAPITAL	RELATED			VOLUNTEER
		RELATED	COST	PLANT		SERVICE		ADMINIS-	A & G	A & G	A & G
		COST BLDG	MOVABLE	OPERATION	TRANS-	COORDI-		TRATIVE &	SHARED	REIMB.	NON-REIMB.
	COST CENTER DESCRIPTIONS	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	RECONCI-	GENERAL	COSTS	COSTS	COSTS
		(SQ. FT.)	$ VALUE)	(SQ. FT.)	(MILEAGE)	(HOURS)	LIATION	(ACC. COST)	(ACC. COST)	(ACC. COST)	(ACC. COST)
		1	2	3	4	5	6A	6	6.01	6.02	6.03
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures											1
2	Capital Related Costs-Movable Equipment											2
3	Plant Operation and Maintenance											3
4	Transportation-staff											5
5	Volunteer Service Coordination											5
6	Administrative and General											6
6.01	A & G Shared Costs											6.01
6.02	A & G Reimbursable Costs											6.02
6.03	A & G Nonreimbursable Costs											6.03
	INPATIENT CARE SERVICE
10	Inpatient - General Care											10
11	Inpatient - Respite Care											11
	VISITING SERVICES
15	Physician Services											15
16	Nursing Care											16
16.01	Nursing Care -- Continuous Home Care											16.01
17	Physical Therapy											17
18	Occupational Therapy											18
19	Speech/ Language Pathology											19
20	Medical Social Services											20
21	Spiritual Counseling											21
22	Dietary Counseling											22
23	Counseling - Other											23
24	Home Health Aide and Homemaker											24
24.01	HH Aide & Homemaker -- Cont Home Care											24.01
25	Other											25
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3820)
Rev. 7												38-118
3890 (Cont.)				FORM CMS-1984-99								08-06
COST ALLOCATION - STATISTICAL BASIS				PROVIDER NO:		PERIOD:
						FROM					WORKSHEET B-1
						TO
			CAPITAL
		CAPITAL	RELATED			VOLUNTEER
		RELATED	COST	PLANT		SERVICE		ADMINIS-	A & G	A & G	A & G
		COST BLDG	MOVABLE	OPERATION	TRANS-	COORDI-		TRATIVE &	SHARED	REIMB.	NON-REIMB.
	COST CENTER DESCRIPTIONS	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	RECONCI-	GENERAL	COSTS	COSTS	COSTS
		(SQ. FT.)	$ VALUE)	(SQ. FT.)	MILEAGE	(HOURS)	LIATION	(ACC. COST)	(ACC. COST)	(ACC. COST)	(ACC. COST)
		1	2	3	4	5	6A	6	6.01	6.02	6.03
	OTHER HOSPICE SERVICE COSTS
30	Drugs, Biologicals and Infusion											30
30.01	Analgesics											30.01
30.02	Sedatives / Hypnotics											30.02
30.03	Other -- Specify											30.03
31	Durable Medical Equipment/Oxygen											31
32	Patient Transportation											32
33	Imaging Services											33
34	Labs and Diagnostics											34
35	Medical Supplies											35
36	Outpatient Services (incl. E/R Dept.)											36
37	Radiation Therapy											37
38	Chemotherapy											38
39	Other											39
	HOSPICE NONREIMBURSABLE SERV.
50	Bereavement Program Costs											50
51	Volunteer Program Costs											51
52	Fundraising											52
53	Other Program Costs											53
100	Cost To be Allocated (per Wkst B)											100
101	Unit Cost Multiplier											101
FORM CMS-1984-99 (8/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3820)
38-118.1												Rev. 7

---

Sheet 14: D

09-00			FORM CMS-1984-99				3890 (Cont.)
	CALCULATION OF	PROVIDER NO:		PERIOD:
	PER DIEM COST			FROM		WORKSHEET D
				TO
	COMPUTATION OF PER DIEM COST		TITLE XVIII	TITLE XIX	OTHER	TOTAL
			(1)	(2)	(3)	(4)
1	Total cost (Worksheet B, line 100, col 7, less line 53, col. 7)						1
2	Total Unduplicated Days (Worksheet S-1, line 12, col. 6)						2
3	Average cost per diem (line 1 divided by line 2)						3
4	Unduplicated Medicare Days (Worksheet S-1, line 12, col.1)						4
5	Average Medicare cost (line 3 times line 4)						5
6	Unduplicated Medicaid Days (Worksheet S-1, line 12, col. 2)						6
7	Average Medicaid cost (line 3 times line 6)						7
8	Unduplicated SNF days (Worksheet S-1, line 12, col. 3)						8
9	Average SNF cost (line 3 times line 8)						9
10	Unduplicated NF days (Worksheet S-1, line 12, col. 4)						10
11	Average NF cost (line 3 times line 10)						11
12	Other Unduplicated days (Worksheet S-1, line 12, 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-1984-99 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3830)
Rev. 2							38-119

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Sheet 15: G

3890 (Cont.)		FORM CMS-1984-99				09-00
	BALANCE SHEET		PROVIDER NO:	PERIOD:
(If you are nonproprietary and do not maintain fund-type				FROM	WORKSHEET G
accounting records, complete the "General Fund" column only)				TO
			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
	(Sum of lines 11, 27, and 32)					33
	( ) = contra amount
FORM CMS-1984-99 (4/99) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 3850)
38-120						Rev. 2

---

Sheet 16: GII

04-99				FORM CMS-1984-99			3890 (Cont.)
	BALANCE SHEET			PROVIDER NO:	PERIOD:
(If you are nonproprietary and do not maintain fund-type					FROM	WORKSHEET G
accounting records, complete the "General Fund" column only)					TO	(Cont.)
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 plant						57
	improvement, replacement and expansion
58	TOTAL FUND BALANCES						58
	(Sum of lines 51 thru 57)
59	TOTAL LIABILITIES AND FUND						59
	BALANCES (Sum of lines 50 and 58)
	( ) = contra amount
FORM CMS-1984-99 (4/99) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 3850)
Rev. 1							38-121

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Sheet 17: G-1

3890 (Cont.)		FORM CMS-1984-99					04-99
		PROVIDER NO:		PERIOD:
STATEMENT OF CHANGES IN FUND BALANCES				FROM		WORKSHEET G - 1
				TO
			GENERAL	SPECIFIC	ENDOWMENT	PLANT FUND
			FUND	PURPOSE FUND	FUND
			1	2	3	4
1	Fund balances at beginning of period						1
2	Net income (loss) (From Wkst. G-2, line 16)						2
3	Total (Sum of line 1 and line 2)						3
4	Additions (Credit adjustments) (Specify)						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) (Specify)						12
13							13
14							14
15							15
16							16
17							17
18	Total deductions (Sum of lines 12 - 17)						18
19	Fund balance at end of period per balance						19
	sheet (Line 11 minus line 18)
FORM CMS 1984-99 (4-99) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15 - II, SECTION 3850.1 )
38-122							Rev. 1

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Sheet 18: G-2

09-00		FORM CMS 1984-99			3890 (Cont.)
		PROVIDER NO:	PERIOD:
STATEMENT OF PATIENT REVENUES			FROM	WORKSHEET G - 2
AND NET INCOME			TO	PARTS I & II
	PART I - PATIENT REVENUES
	Revenue Center
				TOTAL
	GENERAL INPATIENT AND HOME CARE SERVICE LOCATION
1	Skilled Nursing Facility based				1
2	Nursing facility based				2
3	Home care				3
4	Other (See Instructions)				4
5	State Medicaid room & board				5
6	Total General Inpatient Revenues ( Sum of lines 1, 2, 3 and 4 )				6
	PART II - OPERATING EXPENSES
1	Operating Expenses ( Per Worksheet A, Col. 6, Line 100 )				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
	Total Operating Expenses
15	( Sum of lines 1 and 8, minus line 14 )				15
16	Net Income (or loss) for the period (Line 6 minus line 15)				16
FORM CMS 1984-99 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3850.2)
Rev. 2					38-123