CMS-1984-14 Hospice Cost Report

FORM CMS-1984-14

DRAFT

4390 (Cont.)

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Completion of this report is viewed as a condition
of your provider agreement.
HOSPICE COST AND DATA REPORT
PROVIDER CCN:
PERIOD :
FROM:
TO:

FORM APPROVED
OMB NO. 0938-0758
WORKSHEET S
PARTS I & II

PART I - COST REPORT STATUS
1
Provider
use only

Contractor
use only:

1
2
3
4
5

6
7
8
9
10
11
12

Electronic filed cost report
Manually submitted cost report
Amended report
Medicare utilization
Cost report status
[ 1 ] As Submitted
[ 2 ] Reserved
[ 3 ] Reserved
[ 4 ] Reserved
[ 5 ] Amended
Date received
Contractor number
First cost report for this provider CCN
Last cost report for this provider CCN
Reserved
Contractor vendor code
Reserved

2

[
[
[

]
]
]

[

]

[
[

]
]

ECR Date:

3
ECR Time:

1

PART II - 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 THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL, AND
ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDERS
I HEREBY CERTIFY that I have read the above certification 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 Name(s) and Provider CCN(s)} for
the cost reporting period beginning _______________ and ending _______________ and that to the best of my knowledge and belief, this report and statement
are true, correct, complete and 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.
OFFICER OR ADMINISTRATOR OF PROVIDER
Printed Name _________________

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 0938-0758. The time required to complete this information collection is estimated 188 hours per response, including the
time to review instructions, search existing 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 Report Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4306)

Rev. 1

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FORM CMS-1984-14

4390 (Cont.)
HOSPICE IDENTIFICATION DATA

DRAFT
PROVIDER CCN:

PART I - IDENTIFICATION DATA
1 Name
2 Street address
3 City
4 County
5 CCN
6 Date hospice began operation

PERIOD :
FROM:
TO:

1
2
3
4
5
6

P.O. Box:
State:

ZIP Code:

Title XVIII - Medicare

Title XIX - Medicaid

From

To

WORKSHEET S-1
PART I

7 Certification date

7

8 Cost reporting period

8

Malpractice Insurance Information
9 Is this facility legally required to carry malpractice insurance? Enter "Y" for yes or "N" for no.
10 Is the malpractice insurance a claims-made or occurrence policy?
Enter 1 if the policy is claim-made. Enter 2 if the policy is occurrence.

9
10
Premiums

Paid Losses

11 Amounts of malpractice premiums, paid losses, and self-insurance
12 Are malpractice premiums and paid losses reported in a cost center other than A&G?
If yes, submit supporting schedule listing cost centers and amounts contained therein.

Self Insurance
11
12

Home Office Information
Y/N
13 Are home office costs (as defined in CMS Pub. 15-1, §2150ff ) claimed? Enter "Y" for yes or "N" for
no in col. 1. If yes, enter the home office number in col. 2. (see instructions)
14 Home office name
15 Street address
P.O. Box:
16 City
State:
17 Home office contractor name
18 Home office contractor number

Home Office Number
13

ZIP Code:

Other Information
19 Type of control (see instructions)
20 Number of CBSAs where Medicare covered services were provided during the cost reporting period
21 List each CBSA code where Medicare covered hospices services were provided during the cost
reporting period (line 21 contains the first code)

14
15
16
17
18

19
20
21

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4307 - 4307.1)

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DRAFT

FORM CMS-1984-14

HOSPICE IDENTIFICATION DATA

4390 (Cont.)
PROVIDER CCN:

PERIOD :
FROM:
TO:

WORKSHEET S-1
PARTS II and III

PART II - STATISTICAL DATA
Title XVIII - Medicare
1
30
31
32
33
34

UNDUPLICATED DAYS
Title XIX - Medicaid
Other
2
3

Total
4

Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Total Hospice Days

30
31
32
33
34

PART III - CONTRACTED STATISTICAL DATA
Title XVIII - Medicare
1
40 Inpatient Respite Care
41 General Inpatient Care

UNDUPLICATED DAYS
Title XIX - Medicaid
Other
2
3

Total
4
40
41

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4307.2 - 4307.3)

Rev. 1

43-105

4390 (Cont.)

FORM CMS-1984-14

HOSPICE REIMBURSEMENT QUESTIONNAIRE

DRAFT
PROVIDER CCN:

PERIOD :
FROM:
TO:

WORKSHEET S-2

PROVIDER ORGANIZATION AND OPERATION
Y/N
1

DATE
2

V/I
3

1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period? Enter "Y" for yes or "N" for
no in column 1.
If yes, enter the date of the change in column 2. (see instructions)
2 Has the provider terminated participation in the Medicare program? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in column 2 the termination date.
If yes, enter in column 3, "V" for voluntary or "I" for involuntary.
3 Is the provider involved in business transactions, including management contracts, with individuals or entities that were related to
the provider or its officers, medical staff, management personnel, or members of the board of directors through ownership, control, or
family and other similar relationships? Enter "Y" for yes or "N" for no in column 1. (see instructions)

1

2

3

FINANCIAL DATA AND REPORTS
Y/N
1
4 Column 1: Were the financial statements prepared by a certified public accountant? Enter "Y" for yes or "N" for no.
Column 2: If yes, enter in column 2: "A" for audited, "C" for compiled, or "R" for reviewed. Submit complete copy of financial
statements or enter date available in column 3. (see instructions) If no, see instructions.
5 Are the cost report total expenses and total revenues different from those on the filed financial statements?
Enter "Y" for yes or "N" for no in column 1.
If yes, submit reconciliation.

A/C/R
2

DATE
3
4

5

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4308)

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DRAFT

FORM CMS-1984-14

HOSPICE REIMBURSEMENT QUESTIONNAIRE

4390 (Cont.)
PROVIDER CCN:

PERIOD :
FROM:
TO:

WORKSHEET S-2

P S & R REPORT DATA
Y/N
1
6 Was the cost report prepared using the PS&R report only? Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the paid-through date
of the PS&R report used to prepare the cost report. (see instructions.)
7 Was the cost report prepared using the PS&R report for totals and the provider's records for allocation? Enter "Y" for yes or "N" for no in col.1.
If yes, enter in col. 2 the paid-through date of the PS&R report. (see instructions)
8 If line 6 or 7 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included on the PS&R report used to file
the cost report? Enter "Y" for yes or "N" for no. If yes, see instructions.
9 If line 6 or 7 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter "Y" for yes or "N" for no.
If yes, see instructions.
10 If line 6 or 7 is yes, were adjustments made to PS&R report data for Other? Enter "Y" for yes or "N" for no.
If yes, describe the other adjustments: __________________________________________
11 Was the cost report prepared only using the provider's records? Enter "Y" for yes or "N" for no.
If yes, see instructions.

COST REPORT PREPARER CONTACT INFORMATION
12 First name
13 Employer
14 Telephone number

Last name
Email address

DATE
2
6
7
8
9
10
11

Title

12
13
14

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4308)

Rev. 1

43-107

FORM CMS-1984-14

4390 (Cont.)

DRAFT

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

SALARIES
1

PROVIDER CCN:

OTHER
2

SUBTOTAL
( col. 1 plus
col. 2 )
3

GENERAL SERVICE COST CENTERS
1
0100 Cap Rel Costs-Bldg & Fixt*
2
0200 Cap Rel Costs-Mvble Equip*
3
0300 Employee Benefits*
4
0400 Administrative & General *
5
0500 Plant Operation and Maintenance*
6
0600 Laundry & Linen Service*
7
0700 Housekeeping*
8
0800 Dietary*
9
0900 Nursing Administration*
10
1000 Routine Medical Supplies*
11
1100 Medical Records*
12
1200 Staff Transportation*
13
1300 Volunteer Service Coordination*
14
1400 Pharmacy*
15
1500 Physician Administrative Services*
16
1600 Other General Service (specify)*
17
1700 Patient/Residential Care Services
DIRECT PATIENT CARE SERVICE COST CENTERS
25
2500 Inpatient Care-Contracted**
26
2600 Physician Services**
27
2700 Nurse Practitioner**
28
2800 Registered Nurse**
29
2900 LPN/LVN**
30
3000 Physical Therapy**
31
3100 Occupational Therapy**
32
3200 Speech/ Language Pathology**
33
3300 Medical Social Services**
34
3400 Spiritual Counseling**
35
3500 Dietary Counseling**
36
3600 Counseling - Other**
37
3700 Hospice Aide and Homemaker Services**
38
3800 Durable Medical Equipment/Oxygen**
39
3900 Patient Transportation**

RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD :
FROM:
TO:
ADJUSTMENTS
6

WORKSHEET A

TOTAL
( col. 5 ± col. 6 )
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

* Transfer the amounts in column 7 to Wkst. B, col. 0, line as appropriate.
** See instructions. Do not transfer the amounts in col. 7 to Wkst. B.

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4310)

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Rev. 1

DRAFT

FORM CMS-1984-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES

SALARIES
1

4390 (Cont.)
PROVIDER CCN:

OTHER
2

TOTAL
( col. 1 through
col. 5 )
3

DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40
4000 Imaging Services**
41
4100 Labs and Diagnostics**
42
4200 Medical Supplies-Non-routine**
43
4300 Outpatient Services**
44
4400 Palliative Radiation Therapy**
45
4500 Palliative Chemotherapy**
46
Other Patient Care Svc (specify)**
NONREIMBURSABLE COST CENTERS
60
6000 Bereavement Program *
61
6100 Volunteer Program *
62
6200 Fundraising*
63
6300 Hospice/Palliative Medicine Fellows*
64
6400 Palliative Care Program*
65
6500 Other Physician Services*
66
6600 Residential Care *
67
6700 Advertising*
68
6800 Telehealth/Telemonitoring*
69
6900 Thrift Store*
70
7000 Nursing Facility Room & Board*
71
7100 Other Nonreimbursable (specify)*
100
Total

RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD :
FROM:
TO:
ADJUSTMENTS
6

WORKSHEET A

TOTAL
( col. 5 ± col. 6 )
7
40
41
42
43
44
45
46
60
61
62
63
64
65
66
67
68
69
70
71
100

* Transfer the amounts in column 7 to Wkst. B, col. 0, line as appropriate.
** See instructions. Do not transfer the amounts in col. 7 to Wkst. B.

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4310)

Rev. 1

43-109

FORM CMS-1984-14

4390 (Cont.)

DRAFT

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES
CONTINUOUS HOME CARE

SALARIES
1

PROVIDER CCN:

OTHER
2

SUBTOTAL
( col. 1 plus
col. 2 )
3

DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc (specify)
100 Total *

RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD :
FROM:
TO:
ADJUSTMENTS
6

WORKSHEET A-1

TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. B, col. 0, l. 50.

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

43-110

Rev. 1

FORM CMS-1984-14

DRAFT

4390 (Cont.)

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES
ROUTINE HOME CARE

SALARIES
1

PROVIDER CCN:

OTHER
2

SUBTOTAL
( col. 1 plus
col. 2 )
3

DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc (specify)
100 Total *

RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD :
FROM:
TO:
ADJUSTMENTS
6

WORKSHEET A-2

TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

Rev. 1

43-111

FORM CMS-1984-14

4390 (Cont.)

DRAFT

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES
INPATIENT RESPITE CARE

SALARIES
1

PROVIDER CCN:

OTHER
2

SUBTOTAL
( col. 1 plus
col. 2 )
3

DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc (specify)
100 Total *

RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD :
FROM:
TO:
ADJUSTMENTS
6

WORKSHEET A-3

TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

43-112

Rev. 1

FORM CMS-1984-14

DRAFT

4390 (Cont.)

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE EXPENSES
GENERAL INPATIENT CARE

SALARIES
1

PROVIDER CCN:

OTHER
2

SUBTOTAL
( col. 1 plus
col. 2 )
3

DIRECT PATIENT CARE SERVICE COST CENTERS
25 Inpatient Care - Contracted
26 Physician Services
27 Nurse Practitioner
28 Registered Nurse
29 LPN/LVN
30 Physical Therapy
31 Occupational Therapy
32 Speech/ Language Pathology
33 Medical Social Services
34 Spiritual Counseling
35 Dietary Counseling
36 Counseling - Other
37 Hospice Aide and Homemaker Services
38 Durable Medical Equipment/Oxygen
39 Patient Transportation
40 Imaging Services
41 Labs and Diagnostics
42 Medical Supplies-Non-routine
43 Outpatient Services
44 Palliative Radiation Therapy
45 Palliative Chemotherapy
46 Other Patient Care Svc (specify)
100 Total *

RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD :
FROM:
TO:
ADJUSTMENTS
6

WORKSHEET A-4

TOTAL
( col. 5 ± col. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
100

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

Rev. 1

43-113

4390 (Cont.)

FORM CMS-1984-14

RECLASSIFICATIONS

EXPLANATION OF RECLASSIFICATION(S)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100 Total reclassifications
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4 and 7 to Wkst. A, col. 5, lines as appropriate.

DRAFT
PROVIDER CCN:

Code
(1)
1

INCREASES
Cost Center
Line #
2
3

Amount
4

4

PERIOD :
FROM:
TO:

DECREASES
Cost Center
Line #
5
6

WORKSHEET A-6

Amount
7

7

LOC WS
Indicator
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
100

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4316)

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DRAFT

FORM CMS-1984-14

ADJUSTMENTS TO EXPENSES

PROVIDER CCN:

Basis for
Adjustment
DESCRIPTION (1)

(2)

1
1 Investment income on restricted funds
(chapter 2)
2 Telephone services (pay stations excluded)
(chapter 21)
3 Adjustment resulting from transactions with related organizations (chapter 10) and home office costs (chapter 21)
4 Revenue - employee and guest meals
5 Income from imposition of interest, finance or penalty
charges (chapter 21)
6 Bad debts included on trial balance

AMOUNT
2

4390 (Cont.)
PERIOD :
FROM:
TO:

WORKSHEET A-8

EXPENSE CLASSIFICATION ON
WKST. A TO / FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
Cost Center
Line No.
3
4

LOC WS
Indicator
5
1
2

Wkst.
A-8-1
B
B

3
Dietary

8

4

Administrative and General

4

5

A

6

7 Patient personal purchases

7

8 Depreciation - buildings and fixtures

Buildings & Fixtures

1

8

9 Depreciation - movable equipment

Movable Equipment

2

9

70

10

10 Revenue - State-redirected room and board

B

Nursing Facility Room & Board

(3)
11 Other adjustments (specify)

11

50 TOTAL (sum of lines 1 through 49)
(transfer to Wkst. A, col. 9, line 100)

50

(1)
(2)

(3)

Description - all chapter references in this column pertain to CMS Pub. 15-1
Basis for adjustment (see instructions)
A. Costs - if cost, including applicable overhead, can be determined
B. Amount Received - if cost cannot be determined
Additional adjustments may be made on lines 10 thru 49 and subscripts thereof.

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4318)

Rev. 1

43-115

4390 (Cont.)

FORM CMS-1984-14

STATEMENT OF COSTS OF SERVICES FROM
RELATED ORGANIZATIONS AND HOME OFFICE COSTS

DRAFT

PROVIDER CCN:

PERIOD :
FROM:
TO:

WORKSHEET A-8-1

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR
CLAIMED HOME OFFICE COSTS
Net
Wkst. A
Amount
Amount
Adjustments
Line
Allowable
Included
(col. 4 minus
Number
Cost Center
Expense Items
In Cost
in Wkst. A, col. 5
col. 5) *
1
2
3
4
5
6
1
2
3
4
5
6
7
8
9
10 TOTALS (sum of lines 1 through 9)
(transfer col. 6, line 5 to Wkst. A-8, col. 2, line 3)

LOC WS
Indicator
7
2

1
2
3
4
5
6
7
8
9
10

* Transfer amounts in col. 6, lines 1 through 4 (and subscripts as appropriate) to Wkst. A, col. 9, lines as indicated in col. 1. Positive amounts increase cost and
negative amounts decrease cost. For related organizational or home office cost which has not been posted to Wkst. A, col. 1 and/or col. 2, report the amount
allowable in col. 4 above.

PART II - 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 II 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.

Symbol(1)
1

Name
2

Percentage
of
Ownership
3

Name
4

Related Organization(s) and/or Home Office
Percentage
of
Type of
Ownership
Business
5
6

1
2
3
4
5
6
7
8
9
10
(1)

1
2
3
4
5
6
7
8
9
10

Use the followings 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 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-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4319)

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FORM CMS-1984-14

DRAFT
COST ALLOCATION

Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service (specify)
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care

4390 (Cont.)
PROVIDER CCN:

NET
EXPENSES
FOR ALLOC.
0

CAP REL
BLDG
& FIX
1

CAP REL
MVBLE
EQUIP
2

EMPLOYEE
BENEFITS
3

SUBTOTAL
( sum of col. 0
through col. 3)
3A

ADMINISTRATIVE &
GENERAL
4

PLANT
OP &
MAINT
5

PERIOD :
FROM:
TO:
LAUNDRY
& LINEN
6

WORKSHEET B

HOUSEKEEPING

DIETARY

7

8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 1

43-117

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION

Cost Center Descriptions
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable (specify)
99 Negative Cost Center
100 Total

DRAFT
PROVIDER CCN:

NET
EXPENSES
FOR ALLOC.
0

CAP REL
BLDG
& FIX
1

CAP REL
MVBLE
EQUIP
2

EMPLOYEE
BENEFITS
3

SUBTOTAL
( sum of col. 0
through col. 3)
3A

ADMINISTRATIVE &
GENERAL
4

PLANT
OP &
MAINT
5

PERIOD :
FROM:
TO:
LAUNDRY
& LINEN
6

WORKSHEET B

HOUSEKEEPING

DIETARY

7

8
60
61
62
63
64
65
66
67
68
69
70
71
99
100

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-118

Rev. 1

DRAFT

FORM CMS-1984-14

COST ALLOCATION

Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service (specify)
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care

4390 (Cont.)
PROVIDER CCN:

NURSING
ADMINISTRATION
9

ROUTINE
MEDICAL
SUPPLIES
10

MEDICAL
RECORDS
11

STAFF
TRANSPORTATION
12

VOLUNTEER
SVC COORDINATION
13

PHARMACY

14

PERIOD :
FROM:
TO:
PHYSICIAN
OTHER
ADMINISTRAGENERAL
TIVE SVCS
SERVICE
15
16

WORKSHEET B

PATIENT /
RESIDENTIAL
CARE SVCS
17

TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 1

43-119

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION

Cost Center Descriptions
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable (specify)
99 Negative Cost Center
100 Total

DRAFT
PROVIDER CCN:

NURSING
ADMINISTRATION
9

ROUTINE
MEDICAL
SUPPLIES
10

MEDICAL
RECORDS
11

STAFF
TRANSPORTATION
12

VOLUNTEER
SVC COORDINATION
13

PHARMACY

14

PERIOD :
FROM:
TO:
PHYSICIAN
OTHER
ADMINISTRAGENERAL
TIVE SVCS
SERVICE
15
16

WORKSHEET B

PATIENT/
RESIDENTIAL
CARE SVCS
17

TOTAL
18
60
61
62
63
64
65
66
67
68
69
70
71
99
100

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-120

Rev. 1

FORM CMS-1984-14

DRAFT
COST ALLOCATION - STATISTICAL BASIS

Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service (specify)
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care

4390 (Cont.)
PROVIDER CCN:

CAP REL
BLDG
& FIX
( Square
Feet )
1

CAP REL
MVBLE
EQUIP
( Dollar
Value )
2

EMPLOYEE
BENEFITS
( Gross
Salaries )
3

RECONCILIATION
4A

ADMINISTRATIVE &
GENERAL
( Accum.
Cost )
4

PLANT
OP &
MAINT
( Square
Feet )
5

PERIOD :
FROM:
TO:
LAUNDRY
& LINEN
( In-Facility
Days )
6

WORKSHEET B-1

HOUSEKEEPING

DIETARY

( Square
Feet )
7

( In-Facility
Days )
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 1

43-121

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION - STATISTICAL BASIS

Cost Center Descriptions
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable (specify)
99 Negative Cost Center
100 Cost to be allocated (per Wkst. B)
101 Unit cost multiplier

DRAFT
PROVIDER CCN:

CAP REL
BLDG
& FIX
( Square
Feet )
1

CAP REL
MVBLE
EQUIP
( Dollar
Value )
2

EMPLOYEE
BENEFITS
( Gross
Salaries )
3

RECONCILIATION
4A

ADMINISTRATIVE &
GENERAL
( Accum.
Cost )
4

PLANT
OP &
MAINT
( Square
Feet )
5

PERIOD :
FROM:
TO:
LAUNDRY
& LINEN
( In-Facility
Days )
6

WORKSHEET B-1

HOUSEKEEPING

DIETARY

( Square
Feet )
7

( In-Facility
Days )
8
60
61
62
63
64
65
66
67
68
69
70
71
99
100
101

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-122

Rev. 1

DRAFT

FORM CMS-1984-14

COST ALLOCATION - STATISTICAL BASIS

Cost Center Descriptions
GENERAL SERVICE COST CENTERS
1 Cap Rel Costs-Bldg & Fixt
2 Cap Rel Costs-Mvble Equip
3 Employee Benefits
4 Administrative & General
5 Plant Operation and Maintenance
6 Laundry & Linen Service
7 Housekeeping
8 Dietary
9 Nursing Administration
10 Routine Medical Supplies
11 Medical Records
12 Staff Transportation
13 Volunteer Service Coordination
14 Pharmacy
15 Physician Administrative Services
16 Other General Service (specify)
17 Patient/Residential Care Services
LEVEL OF CARE
50 Continuous Home Care
51 Routine Home Care
52 Inpatient Respite Care
53 General Inpatient Care

NURSING
ADMINISTRATION
( Direct
Nurs. Hrs. )
9

4390 (Cont.)
PROVIDER CCN:

ROUTINE
MEDICAL
SUPPLIES
( Patient
Days )
10

MEDICAL
RECORDS
( Patient
Days )
11

STAFF
TRANSPORTATION
( Mileage )
12

VOLUNTEER
SVC COORDINATION
( Hours of
Service )
13

PHARMACY

( Charges )
14

PERIOD :
FROM:
TO:
PHYSICIAN
OTHER
ADMINISTRAGENERAL
TIVE SVCS
SERVICE
( Patient
( Specify
Days )
Basis )
15
16

WORKSHEET B-1

PATIENT /
RESIDENTIAL
CARE SVCS
( In-Facility
Days )
17

TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 1

43-123

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION - STATISTICAL BASIS

Cost Center Descriptions
NONREIMBURSABLE COST CENTERS
60 Bereavement Program
61 Volunteer Program
62 Fundraising
63 Hospice/Palliative Medicine Fellows
64 Palliative Care Program
65 Other Physician Services
66 Residential Care
67 Advertising
68 Telehealth/Telemonitoring
69 Thrift Store
70 Nursing Facility Room & Board
71 Other Nonreimbursable (specify)
99 Negative Cost Center
100 Cost to be allocated (per Wkst. B)
101 Unit cost multiplier

NURSING
ADMINISTRATION
( Direct
Nurs. Hrs. )
9

DRAFT
PROVIDER CCN:

ROUTINE
MEDICAL
SUPPLIES
( Patient
Days )
10

MEDICAL
RECORDS
( Patient
Days )
11

STAFF
TRANSPORTATION
( Mileage )
12

VOLUNTEER
SVC COORDINATION
( Hours of
Service )
13

PHARMACY

( Charges )
14

PERIOD :
FROM:
TO:
PHYSICIAN
OTHER
ADMINISTRAGENERAL
TIVE SVCS
SERVICE
( Patient
( Specify
Days )
Basis )
15
16

WORKSHEET B-1

PATIENT /
RESIDENTIAL
CARE SVCS
( In-Facility
Days )
17

TOTAL
18
60
61
62
63
64
65
66
67
68
69
70
71
99
100
101

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-124

Rev. 1

DRAFT

FORM CMS-1984-14

CALCULATION OF PER DIEM COST

PROVIDER CCN:

TITLE XVIII
MEDICARE
1

4390 (Cont.)
PERIOD :
FROM:
TO:

TITLE XIX
MEDICAID
2

CONTINUOUS HOME CARE
1 Total cost (Wkst. B, col 18, line 50)
2 Total unduplicated days (Wkst. S-1, col. 4, line 30)
3 Total average cost per diem (line 1 divided by line 2)
4 Unduplicated program days (Wkst. S-1, col. as appropriate, line 30)
5 Program cost (line 3 times line 4)
ROUTINE HOME CARE
6 Total cost (Wkst. B, col. 18, line 51)
7 Total unduplicated days (Wkst. S-1, col. 4, line 31)
8 Total average cost per diem (line 6 divided by line 7)
9 Unduplicated program days (Wkst. S-1, col. as appropriate, line 31)
10 Program cost (line 8 times line 9)
INPATIENT RESPITE CARE
11 Total cost (Wkst. B, col. 18, line 52)
12 Total unduplicated days (Wkst. S-1, col. 4, line 32)
13 Total average cost per diem (line 11 divided by line 12)
14 Unduplicated program days (Wkst. S-1, col. as appropriate, line 32)
15 Program cost (line 13 times line 14)
GENERAL INPATIENT CARE
16 Total cost (Wkst. B, col. 18, line 53)
17 Total unduplicated days (Wkst. S-1, col. 4, line 33)
18 Total average cost per diem (line 16 divided by line 17)
19 Unduplicated program days (Wkst. S-1, col. as appropriate, line 33)
20 Program cost (line 18 times line 19)
TOTAL HOSPICE CARE
21 Total cost (sum of line 1 + line 6 + line 11 + line 16)
22 Total unduplicated days (Wkst. S-1, col. 4, line 34)
23 Average cost per diem (line 21 divided by line 22)

WORKSHEET C

TOTAL
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4330)

Rev. 1

43-125

4390 (Cont.)
BALANCE SHEET

FORM CMS-1984-14
PROVIDER CCN:

DRAFT
PERIOD :
FROM:
TO:

Assets
CURRENT ASSETS
1 Cash on hand and in banks
2 Temporary investments
3 Notes receivable
4 Accounts receivable
5 Other receivables
6
Less: allowances for uncollectible notes and accounts receivable
7 Inventory
8 Prepaid expenses
9 Other current assets
10 TOTAL CURRENT ASSETS (sum of lines 1 through 9)
FIXED ASSETS
11 Land
12 Land improvements
13
Less: Accumulated depreciation
14 Buildings
15
Less Accumulated depreciation
16 Leasehold improvements
17
Less: Accumulated Amortization
18 Fixed equipment
19
Less: Accumulated depreciation
20 Automobiles and trucks
21
Less: Accumulated depreciation
22 Major movable equipment
23
Less: Accumulated depreciation
24 Minor equipment - Depreciable
25
Less: Accumulated depreciation
26 TOTAL FIXED ASSETS (sum of lines 11 through 25)
OTHER ASSETS
27 Investments
28 Deposits on leases
29 Due from owners/officers
30 Other assets
31 TOTAL OTHER ASSETS (sum of lines 27 through 30)
32 TOTAL ASSETS (sum of lines 10, 26, and 31)

AMOUNT

Liabilities and Fund Balances
CURRENT LIABILITIES
33 Accounts payable
34 Salaries, wages & fees payable
35 Payroll taxes payable
36 Notes & loans payable (short term)
37 Deferred income
38 Accelerated payments
39 Other current liabilities
40 TOTAL CURRENT LIABILITIES (sum of lines 33 through 39)
LONG TERM LIABILITIES
41 Mortgage payable
42 Notes payable
43 Unsecured loans
44 Loans from owners:
45 Other long term liabilities
46 TOTAL LONG TERM LIABILITIES (sum of lines 41 through 45)
47 TOTAL LIABILITIES (sum of lines 40 and 46)
CAPITAL ACCOUNT
48 Fund balance
49 TOTAL LIABILITIES AND FUND BALANCE (sum of lines 47 and 48)

AMOUNT

(

WORKSHEET F

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49

) = contra amount

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.1)

43-126

Rev. 1

DRAFT

FORM CMS-1984-14

STATEMENT OF CHANGES
IN FUND BALANCES

PROVIDER CCN:

GENERAL
FUND
1
1
2
3
4

SPECIFIC
PURPOSE FUND
2

4390 (Cont.)
PERIOD :
FROM:
TO:

WORKSHEET F -1

ENDOWMENT
FUND
3

Fund balances at beginning
of period
Net income / (loss)
(from Wkst. F-2, line 41)
Total
(sum of line 1 and line 2)
Additions (credit adjustments)
(specify)

PLANT
FUND
4
1
2
3
4

5

5

6

6

7

7

8

8

9

9

10
11
12

Total additions
(sum of lines 4 - 9)
Subtotal
(line 3 plus line 10)
Deductions (debit adjustments)
(specify)

10
11
12

13

13

14

14

15

15

16

16

17

17

18 Total deductions
(sum of lines 12 - 17)
19 Fund balance at end of period per balance
sheet (line 11 minus line 18)

18
19

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.2)

Rev. 1

43-127

4390 (Cont.)

FORM CMS-1984-14

STATEMENT OF REVENUES
AND OPERATING EXPENSES

PROVIDER CCN:

DRAFT
PERIOD :
FROM:
TO:

WORKSHEET F - 2
PARTS I & II

PART I - REVENUES
TITLE XVIII
MEDICARE
1

TITLE XIX
MEDICAID
2

OTHER
3

TOTAL
4

GROSS PATIENT REVENUE
1 Continuous Home Care
2 Routine Home Care
3 Inpatient Respite Care
4 General Inpatient Care
5 Drug copay / coinsurance
6 Total gross patient revenue
(sum of lines 1 through 5)
7 Less: Contractual allowances and discounts
8 Net patient revenue
(line 6 minus line 7)
OTHER REVENUE
9 Hospice physician services
10 Room and board
11 Palliative consults / Other phys. services
12 Donations / Charitable contributions
13 Rebates / refunds of expenses
14 Income from investments
15 Governmental appropriations
16 Other (specify)
17
18
19
20
21
22
23
24
25
26 Total revenues
(sum of lines 9 through 25)

PART II - OPERATING EXPENSES
27 Operating expenses (per Wkst A, col. 3, line 100)
28 Add (specify)
29
30
31
32
33
34 Total additions (sum of lines 28 through 33)
35 Deduct (specify)
36
37
38
39
40 Total deductions (sum of lines 35 through 39)
41 Total operating expenses
(sum of lines 27 and 34, minus line 40)
42 Net income / (loss) for the period
(line 26 minus line 41)

1
2
3
4
5
6
7
8

9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

1

2
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

FORM CMS-1984-14 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.3)

43-128

Rev. 1