Form CMS-R-249 Hospice Medicare Cost Report Forms

Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

Hospice MCR Forms.XLS

Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24 (CMS-R-249)

OMB: 0938-0758

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Overview

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Sheet 1: Cover Page

OMB No. 0938-0758

FORM CMS 1984-99

Hospice Medicare Cost Report Forms

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

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

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

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

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

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

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

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

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

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

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

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

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

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
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