Form CMS-265-11 Independent Renal Dialysis Facility Cost Report

Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24

Form CMS-265-11 Forms.xls

Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 413.178

OMB: 0938-0236

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Overview

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Sheet 1: S

06-13

FORM CMS-265-11






4290 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim







FORM APPROVED

payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).







OMB NO: 0938-0236

INDEPENDENT RENAL DIALYSIS FACILITY



PROVIDER CCN:
PERIOD:
WORKSHEET S

COST REPORT CERTIFICATION





From:








To:


PART I - COST REPORT STATUS










Provider use only
1. [ ] Electronically filed cost report
Date (mm/dd/yyyy): ____________________

Time: ____________________





2. [ ] Manually submitted cost report










3. If this is an amended report enter the number of times the provider resubmitted this cost report. ______








Contractor
4. [ ] Cost Report Status

5. Date Received: _________





use only
(1) As Submitted

6. Contractor No._________







(2) Settled without Audit

7. [ ] First Cost Report for this Provider CCN







(3) Settled with Audit

8. [ ] Last Cost Report for this Provider CCN







(4) Reopened

9. NPR Date: __________







(5) Amended

10. If line 4, column 1 is "4", enter number of times reopened _______










11. Contractor Vendor Code ________

















PART II - GENERAL










1 Name:








1
2 Street:




P.O. Box:


2
3 City:

State:

ZIP Code:


3
4 County:

CBSA:





4
5 Provider CCN:








5
6 Date Certified:








6
7 Contact Person Name :




Phone Number:


7
8 Cost reporting period (mm/dd/yyyy)
From:
To:




8







1 2
9 Type of control (see instructions)







9
10 Is this facility approved as a low-volume facility for this cost reporting period? Enter "Y" for yes or "N" for no.






10





1 2
11 Type of physicians' reimbursement (see instructions)







11
12 Was this facility previously certified as a hospital-based unit? Enter "Y" for yes or "N" for no.







12
13 Did your facility elect 100% PPS effective January 1, 2011? Enter "Y" for yes or "N" for no. (If certified on/after 1/1/2011, see instructions.)







13







1 2
14 If you responded "N" to line 13, enter in column 1 the year of transition for periods prior to January 1 and







14

enter in column 2 the year of transition for periods after December 31. (see instructions)







15 Malpractice premiums







15
16 Malpractice paid losses








16
17 Malpractice self insurance








17
18 Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center? Enter "Y" for yes or "N" for no.








18

If yes, submit a supporting schedule listing cost centers and amounts contained therein.









19 Are you part of a chain organization? Enter "Y" for yes or "N" for no. If yes, complete lines 20 through 22.







19
20 Name:








20
21 Street:




P.O. Box:


21
22 City:

State:

ZIP Code:


22












PART III - CERTIFICATION BY OFFICER OR ADMINISTRATOR










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 PROVIDER






















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 0938-0236. The time required to complete this information collection is estimated 65 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-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4204, 4204.1 AND 4204.2)






















Rev. 2









42-303

Sheet 2: S-1

4290 (Cont.)

FORM CMS-265-11











06-13
INDEPENDENT RENAL DIALYSIS FACILITY



PROVIDER CCN:


PERIOD:


WORKSHEET S-1


STATISTICAL DATA







From:









To:




















RENAL DIALYSIS STATISTICS



















OUTPATIENT TRAINING








PERITONEAL




PERITONEAL






HEMODIALYSIS

DIALYSIS

HEMODIALYSIS

DIALYSIS






1

2

3

4

1 Number of treatments not billed to Medicare and furnished directly





1
2 Number of treatments not billed to Medicare and furnished under arrangements





2
3 Number of patients currently in dialysis program





3
4 Average times per week patient receives dialysis





4
5 Number of days in an average week for patient dialysis treatments





5
6 Average time of patient dialysis treatment including set up time





6
7 Number of machines regularly available for use





7
8 Number of standby machines





8
9 Number of shifts in typical week during regular reporting period





9
10 Hours per shift in typical week during regular reporting period













10

.01 First shift




.01

.02 Second Shift




.02

.03 Third shift




.03
11 Number of treatments provided













11

.01 One (1) time per week




.01

.02 Two (2) times per week




.02

.03 Three (3) times per week




.03

.04 More than three (3) times per week




.04

.05 Total




.05








Type of Dialyzers

Dialyzer Reuse Count

Other Dialyzers









1

2

3

12 Column 1: Type of dialyzers used (see instructions)







12

Column 2: Number of times dialyzers are reused (see instructions)






Column 3: If column 1 is "Other," enter type of dialyzer used





13 Number of back-up sessions furnished to home patients (see instructions)











13

















14 Number of units of Epoetin furnished during cost reporting period











14
15 Number of units of Aranesp furnished during cost reporting period











15




























1

2

15.01 ESA and units furnished to patients during the cost reporting period (see instructions)











15.01

















TRANSPLANT STATISTICS















16 Number of patients awaiting transplants











16
17 Number of patients who received transplants











17

















HOME PROGRAM















18 Number of patients commencing home dialysis training during this period











18
19 Number of patients currently in home program











19








Type of Dialyzers

Dialyzer Reuse Count

Other Dialyzers









1

2

3

20 Column 1: Type of dialyzers used (see instructions)







20

Column 2: Number of times dialyzers were reused (see instructions)






Column 3: If column 1 is "Other," enter type of dialyzer used






















RENAL DIALYSIS FACILITY -- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENTS)















21 Enter the number of hours in your normal work week











21








Staff

Contract

Total









1

2

3

22 Physicians







22
23 Registered Nurses







23
24 Licensed Practical Nurses







24
25 Nurses Aides







25
26 Technicians







26
27 Social Workers







27
28 Dieticians







28
29 Administrative







29
30 Management







30
31 Other (Specify)







31



















































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205)
































42-304














Rev. 2

Sheet 3: S-2

12-11


FORM CMS-265-11
















4290 (Cont.)
INDEPENDENT RENAL DIALYSIS FACILITY



PROVIDER CCN: PERIOD:






WORKSHEET S-2







REIMBURSEMENT QUESTIONNAIRE




From:














To:





























































Y/N DATE V/I
PROVIDER ORGANIZATION AND OPERATION







1



2



3


1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?















1

Enter "Y" for yes or "N" for no in column 1. If yes, enter the date (mm/dd/yyyy) 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.















2

If yes, enter in column 2 the termination date (mm/dd/yyyy); and, 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















3

(e.g., chain home offices, drug or medical supply companies) 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)




































































Y/N A/C/R DATE
FINANCIAL DATA AND REPORTS







1



2



3


4 Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter "Y" for yes or "N" for no.







4

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 (mm/dd/yyyy) 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"















5

for yes or "N" for no in column 1. If yes, submit reconciliation.




















































































BAD DEBTS















Y/N
6 Is the provider seeking reimbursement for bad debts? Enter "Y" for yes or "N" for no. If yes, see instructions.















6
7 If line 6 is yes, did the provider's bad debt collection policy change during the cost reporting period? "Y" for yes or "N" for no. If yes, submit copy.















7
8 If line 6 is yes, were patient deductibles and/or co-payments waived? Enter "Y" for yes or "N" for no. If yes, see instructions.















8



































Y/N DATE
PS&R REPORT DATA












1



2


9 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











9

paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions.)










10 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















10

in col.1. If yes, enter in col. 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)















11 If line 9 or 10 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included on the















11

PS&R report used to file the cost report? Enter "Y" for yes or "N" for no. If yes, see instructions.















12 If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter "Y" for yes















12

or "N" for no. If yes, see instructions.















13 If line 9 or 10 is yes, were adjustments made to PS&R report data for Other? Enter "Y" for yes or "N" for no.















13

If yes, describe the other adjustments:
__________________________________________________________________________













14 Was the cost report prepared only using the provider's records? Enter "Y" for yes or "N" for no.















14

If yes, see instructions.
































































































































































































































































































































































































































































































































































FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205.1)












































Rev. 1




















42-305

Sheet 4: A

4290 (Cont.)


FORM CMS-265-11





12-11
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE




PROVIDER CCN:
PERIOD:
WORKSHEET A
OF EXPENSES






From:








To:








RECLASS.

NET EXPENSES



SALARIES
TOTAL TO EXPENSES RECLASSIFIED ADJUSTMENTS FOR COST


FACILITY HEALTH CARE COSTS PHYSICIAN
( col. 1 through ( from TRIAL BALANCE TO EXPENSES ALLOCATION



COMPENSATION OTHER OTHER col. 3 ) Wkst. A-1 ) ( col 4. +/- col. 5 ) ( from Wkst. A-2 ) ( col. 6+/-col. 7 )



1 2 3 4 5 6 7 8

COST CENTERS








1 0100 Cap Rel Costs-Bldg & Fixt







1
2 0200 Cap Rel Costs-Mvble Equip


#N/A



2
3 0300 Operation & Maintenance of Plant


#N/A



3
4 0400 Housekeeping


#N/A



4
5
Subtotal (sum of lines 1 through 4)*


#N/A



5
6 0600 Machine Cap-Rel or Rental & Maint*


#N/A



6
7 0700 Salaries for Direct Patient Care*


#N/A



7
8 0800 EH&W Benefits for Direct Pt. Care


#N/A



8
9 0900 Supplies*


#N/A



9
10 1000 Laboratory*


#N/A



10
11 1100 Administrative & General


#N/A



11
12 1200 Drugs*


#N/A



12
13 1300 Interest Expense


#N/A



13
14 1400 Laundry and Linen


#N/A



14
15 1500 Medical Records


#N/A



15
16 1600 Phy Rout Prof Svcs-Initial Method


#N/A



16
17 1700 Other (Specify)


#N/A



17
18
Subtotal (sum of line 11 plus lines 13 through 17)* #N/A


#N/A
#N/A
18
19 1900 Phy Rout Prof Svcs-MCP Method


#N/A



19
20 2000 Whole Blood & Packed Red Blood Cells*


#N/A



20
21 2100 Vaccines*


#N/A



21


NONREIMBURSABLE COSTS CENTERS








22 2200 Physicians Private Offices*







22
23 2300 ESAs (prior to January 1, 2011)







23
24 2400 Method II Patients (prior to January 1, 2011)







24
25 2500 Other Nonreimbursable (Specify)*







25
26 2600 Other Nonreimbursable (Specify)*







26
27
Total







27












* Transfer the amounts in column 8 to Worksheet B and B-1, as appropriate.






































































































































































FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4206)






















42-306









Rev. 1

Sheet 5: A-1

06-13
FORM CMS-265-11





4290 (Cont.)
RECLASSIFICATIONS


PROVIDER CCN:
PERIOD:
WORKSHEET A-1






From:






To:














INCREASE DECREASE


CODE COST LINE
COST LINE


EXPLANATION OF ENTRY (1) CENTER NO. AMOUNT (2) CENTER NO. AMOUNT (2)


1 2 3 4 5 6 7
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 must equal sum of col. 7)






100










(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.








(2) Transfer to Worksheet A, col. 5, line as appropriate.
























































































































































































































































FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4207)


















Rev. 2







42-307

Sheet 6: A-2

4290 (Cont.)
FORM CMS-265-11





06-13
ADJUSTMENTS TO EXPENSES

PROVIDER CCN:
PERIOD:
WORKSHEET A-2






From:






To:

















Expense classification on Worksheet A from which






BASIS FOR
amount is to be deducted or to which the amount is






ADJUSTMENT
to be added




DESCRIPTION (1)
(2) AMOUNT COST CENTER LINE NO.



1 2 3 4
1 Investment income on commingled restricted and unrestricted funds (Chapter 2)






1
2 Trade, quantity and time discounts on purchases (Chapter 8)






2
3 Rebates and refunds of expenses (Chapter 8)






3
4 Rental of building or office space to others






4
5 Physician non-routine professional patient care services






5
6 Home office costs (Chapter 21)






6
7 Adjustment resulting from transactions with related organizations (Chapter 10)
From Wkst. A-3




7
8 Vending machines






8
9 Meals served to patients






9
10 Physicians' professional services--MCP Method
A
Physicians' professional services--MCP Method

19 10
11 Services under arrangement






11
12 Provision for doubtful accounts






12
13 Capital Related--Buildings & Fixtures


Capital Related--Buildings & Fixtures

1 13
14 Capital Related--Moveable Equipment


Capital Related--Moveable Equipment

2 14
15 Rebates on Epoetin prior to January 1, 2011


Epoetin

23 15
16 Epoetin
A
Epoetin

23 16
17 Rebates on Aranesp prior to January 1, 2011


Aranesp

23 17
18 Aranesp
A
Aranesp

23 18
19 Rebates on Epoetin on or after January 1, 2011


Epoetin

12 19
20 Rebates on Aranesp on or after January 1, 2011


Aranesp

12 20
20.01 Rebates on ESA drugs on or after January 1, 2012


Drugs

12 20.01
21 Physician malpractice premiums






21
22 Other (specify)






22
23 Other (specify)






23
24 Other (specify)






24
100 Total (transfer to Wkst. A, col. 7, line 27)






100











(1) Description-all chapter references in this column pertain to CMS Pub. 15-1








(2) Basis for adjustment (see instructions)








A. Costs-if cost, including applicable overhead, can be determined








B. Amount Received-if cost cannot be determined





























































































































































































































































































































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4208)


















42-308







Rev. 2

Sheet 7: A-3

12-11






FORM CMS-265-11













4290 (Cont.)
STATEMENT OF COSTS OF SERVICES









PROVIDER CCN:



PERIOD:



WORKSHEET A-3

FROM RELATED ORGANIZATIONS














From:














To:


















































A. Are there any costs included on Worksheet A which resulted from transactions with related organizations as defined in CMS Pub. 15-1, Chapter 10?






















[ ] Yes (If yes, complete Parts B and C)






















[ ] No





































































B. Costs incurred and adjustments required as result of transactions with related organizations:









































AMOUNT
NET

LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COL. 6














AMOUNT

INCLUDED IN
ADJUST-

















ALLOWABLE

WKST. A
MENT (col. 4


LINE NO.


COST CENTER




EXPENSES ITEMS



IN COST

COL. 6
minus col. 5)


1


2




3



4

5
6
1















1
2















2
3















3
4















4
5 TOTALS (sum of lines 1-4)




















5

(Transfer col. 6, lines 1-4 to Wkst. A, col. 7 as appropriate)






















(Transfer col. 6, line 5 to Wkst. A-2, col. 2, line 7)

































































C. Interrelationship to organizations furnishing services, facilities, or supplies:













































The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the provider to furnish the information requested on Part C of this worksheet.














































This information will be used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services, facilities, and supplies furnished






















by organizations related to the facility by common ownership or control, represent reasonable costs as determined under 1861(v)(1)(a) of the Social Security Act. If the provider does






















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.
































































RELATED ORGANIZATION(S)














PERCENTAGE






PERCENTAGE






SYMBOL






OF






OF






(1)


NAME


OWNERSHIP


NAME


OWNERSHIP
TYPE OF BUSINESS


1


2


3


4


5
6
1















1
2





















2
3





















3
4





















4

























(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 the facility





















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





















C. Facility has financial interest in corporation, partnership, or other organization(s)





















D. Director, officer, administrator, or key person of the facility or relative of such person has financial interest in related organization





















E. Individual is director, officer, administrator, or key person of the facility and related organization





















F. Director, officer, administrator, or key person of related organization or relative of such person has financial interest in the facility





















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


















































































































































































































































































































































































































































































































FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4209)














































Rev. 1





















42-309

Sheet 8: A-4

4290 (Cont.)




FORM CMS-265-11











12-11
STATEMENT OF COMPENSATION








PROVIDER CCN:


PERIOD:


WORKSHEET A-4














From:


















To:
























PART I - STATEMENT OF TOTAL COMPENSATION TO OWNERS


















(Include compensation of employees related to owners)






















SOLE












TOTAL




PROPIETORSHIPS
PARTNERS CORPORATION OWNERS COMPENSATION




PERCENTAGE OF




PERCENTAGE




PERCENTAGE OF
INCLUDED IN




CUSTOMARY




OF CUSTOMARY




CUSTOMARY
ALLOWABLE




WORK WEEK

PERCENT SHARE

WORK WEEK

PERCENTAGE OF

WORK WEEK
COSTS FOR




DEVOTED TO

OF OPERATING

DEVOTED TO

PROVIDER'S

DEVOTED TO
THE PERIOD

TITLE FUNCTION (A)
BUSINESS

PROFIT OR (LOSS)

BUSINESS

STOCK OWNED

BUSINESS
(B)

1 2
3

4A

4B

5A

5B
6
1

















1
2

















2
3

















3
4

















4
5

















5
6

















6
7

















7
8

















8
9

















9
10

















10








































PART II - STATEMENT OF TOTAL COMPENSATION TO ADMINISTRATORS, ASSISTANT ADMINISTRATORS AND / OR MEDICAL DIRECTORS OR OTHERS



















PERFORMING THESE DUTIES (OTHER THAN OWNERS) (To be completed by all facilities)




























PERCENTAGE OF




TOTAL COMPENSATION INCLUDED IN












CUSTOMARY WORK WEEK




ALLOWABLE COSTS FOR THE PERIOD


TITLE

DEVOTED TO BUSINESS




(B)


1

2




3

1

















1
2

















2
3

















3
4

















4
5

















5
6

















6
7

















7
8

















8
9

















9
10

















10

















































































(A) Function or job description of each owner. If employee is related to owner, cite relationship.


















(B) Compensation as used in this worksheet has the same definition as 42 CFR 413.102





























































































































































































































































































































































































































































































FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4210)






































42-310

















Rev. 1

Sheet 9: B

06-13


FORM CMS-265-11




4290 (Cont.)
COST ALLOCATION - GENERAL SERVICE COSTS



PROVIDER CCN:
PERIOD:
WORKSHEET B







From:









To:




NET









EXPENSE









FOR CAP REL STEP DOWN MACH CAP SALARIES EH&W BENE




COST ALLOC. OP & MAINT OF REL OR REN FOR DIR FOR DIR




( from Wkst. A, col. 8 ) & HOUSE OF COL. 2 & MAINT PT CARE PT CARE SUPPLIES LABORATORY


1 2 3 4 5 6 7 8
1 COSTS TO BE ALLOCATED

0




1
2 Drugs Included in Composite Rate







2
3 ESAs







3
4 ESRD Related Other Drugs







4
5 Non-ESRD Related Drugs, Supplies & Lab







5
6 Whole Blood and Packed Red Blood Cells







6
7 Vaccines







7

REIMBURSABLE COST CENTERS








8 Maintenance-Hemodialysis
0





8
8.01 Maintenance-Hemo Adult







8.01
8.02 Maintenance-Hemo Pediatric







8.02
9 Maintenance -IPD







9
9.01 Maintenance-IPD Adult







9.01
9.02 Maintenance-IPD Pediatric







9.02
10 Training-Hemodialysis







10
10.01 Training-Hemo Adult







10.01
10.02 Training-Hemo Pediatric







10.02
11 Training-IPD







11
11.01 Training-IPD Adult







11.01
11.02 Training-IPD Pediatric







11.02
12 Training-CAPD







12
12.01 Training-CAPD Adult







12.01
12.02 Training-CAPD Pediatric







12.02
13 Training-CCPD







13
13.01 Training-CCPD Adult







13.01
13.02 Training-CCPD Pediatric







13.02
14 Home Program-Hemodialysis







14
14.01 Home Program-Hemo Adult







14.01
14.02 Home Program-Hemo Pediatric







14.02
15 Home Program-IPD







15
15.01 Home Program-IPD Adult







15.01
15.02 Home Program-IPD Pediatric







15.02
16 Home Program-CAPD







16
16.01 Home Program-CAPD Adult







16.01
16.02 Home Program-CAPD Pediatric







16.02
17 Home Program-CCPD







17
17.01 Home Program-CCPD Adult







17.01
17.02 Home Program-CCPD Pediatric







17.02
18 Subtotal (lines 2-17.02)







18

NONREIMBURSABLE COST CENTERS








19 Physicians' Private Offices 0






19
20 Method II Patients prior to 1/1/2011 0






20
21 Other Nonreimbursable







21
22 Other Nonreimbursable







22
23 Totals (see instructions)

#N/A
#N/A #N/A #N/A #N/A 23
*Transfer the amounts to Wkst. C, col. 2, as appropriate









The total of column 1, line 23 must equal the amount on Wkst. A, col. 8, line 27.









FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)









Rev. 2








42-311
4290 (Cont.)


FORM CMS-265-11




06-13
COST ALLOCATION - GENERAL SERVICE COSTS



PROVIDER CCN:
PERIOD:
WORKSHEET B







From:









To:





A & G




TOTAL



&




EXPENSES


SUBTOTAL OTHER
DRUGS

ESRD ALL


( col. 1 COST
INCLUD. IN SUBTOTAL
RELATED PAT. SVCS.


through col. 8 ) CENTERS DRUGS COMP RATE ( see instructions ) ESA'S DRUGS ( cols. 11A-13 )


8A 9 10 11 11A 12 13 13A
1 COSTS TO BE ALLOCATED







1
2 Drugs Included in Composite Rate







2
3 ESAs







3
4 ESRD Related Other Drugs







4
5 Non-ESRD Related Drugs, Supplies & Lab







5
6 Whole Blood and Packed Red Blood Cells







6
7 Vaccines







7

REIMBURSABLE COST CENTERS








8 Maintenance-Hemodialysis







8
8.01 Maintenance-Hemo Adult







8.01
8.02 Maintenance-Hemo Pediatric







8.02
9 Maintenance -IPD







9
9.01 Maintenance-IPD Adult







9.01
9.02 Maintenance-IPD Pediatric







9.02
10 Training-Hemodialysis







10
10.01 Training-Hemo Adult







10.01
10.02 Training-Hemo Pediatric







10.02
11 Training-IPD







11
11.01 Training-IPD Adult







11.01
11.02 Training-IPD Pediatric







11.02
12 Training-CAPD







12
12.01 Training-CAPD Adult







12.01
12.02 Training-CAPD Pediatric







12.02
13 Training-CCPD







13
13.01 Training-CCPD Adult







13.01
13.02 Training-CCPD Pediatric







13.02
14 Home Program-Hemodialysis







14
14.01 Home Program-Hemo Adult







14.01
14.02 Home Program-Hemo Pediatric







14.02
15 Home Program-IPD







15
15.01 Home Program-IPD Adult







15.01
15.02 Home Program-IPD Pediatric







15.02
16 Home Program-CAPD







16
16.01 Home Program-CAPD Adult







16.01
16.02 Home Program-CAPD Pediatric







16.02
17 Home Program-CCPD







17
17.01 Home Program-CCPD Adult







17.01
17.02 Home Program-CCPD Pediatric







17.02
18 Subtotal (lines 2-17.02)







18

NONREIMBURSABLE COST CENTERS








19 Physicians' Private Offices







19
20 Method II Patients prior to 1/1/2011







20
21 Other Nonreimbursable







21
22 Other Nonreimbursable







22
23 Totals (see instructions)







23
*Transfer the amounts to Wkst. C, col. 2, as appropriate









The total of column 1, line 23 must equal the amount on Wkst. A, col. 8, line 27.









FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)









42-312








Rev. 2

Sheet 10: B-1

06-13


FORM CMS-265-11




4290 (Cont.)
COST ALLOCATION - STATISTICAL BASIS



PROVIDER CCN:
PERIOD:
WORKSHEET B-1







From:









To:





CAP REL STEP DOWN MACH CAP SALARIES EH&W BENE SUPPLIES LABORATORY


NET OP & MAINT OF COL. 2 REL OR RENT FOR DIR FOR DIR




EXPENSES & HOUSE
& MAINT PT CARE PT CARE




FOR ( SQUARE ( # TREAT ( % TIME ) ( HRS OF ( GROSS ( CHARGES ) ( CHARGES )


COST ALLOC. FEET ) (1) MENTS ) (3) (3) SERVICE ) (3) SALARIES ) (3) (3) (3)


1 2 3 4 5 6 7 8
1 COSTS TO BE ALLOCATED







1
2 Drugs Included in Composite Rate







2
3 ESAs







3
4 ESRD Related Other Drugs







4
5 Non-ESRD Related Drugs, Supplies & Lab







5
6 Whole Blood and Packed Red Blood Cells







6
7 Vaccines







7

REIMBURSABLE COST CENTERS








8 Maintenance-Hemodialysis







8
8.01 Maintenance-Hemo Adult







8.01
8.02 Maintenance-Hemo Pediatric







8.02
9 Maintenance -IPD







9
9.01 Maintenance-IPD Adult







9.01
9.02 Maintenance-IPD Pediatric







9.02
10 Training-Hemodialysis







10
10.01 Training-Hemo Adult







10.01
10.02 Training-Hemo Pediatric







10.02
11 Training-IPD







11
11.01 Training-IPD Adult







11.01
11.02 Training-IPD Pediatric







11.02
12 Training-CAPD







12
12.01 Training-CAPD Adult







12.01
12.02 Training-CAPD Pediatric







12.02
13 Training-CCPD







13
13.01 Training-CCPD Adult







13.01
13.02 Training-CCPD Pediatric







13.02
14 Home Program-Hemodialysis







14
14.01 Home Program-Hemo Adult







14.01
14.02 Home Program-Hemo Pediatric







14.02
15 Home Program-IPD







15
15.01 Home Program-IPD Adult







15.01
15.02 Home Program-IPD Pediatric







15.02
16 Home Program-CAPD







16
16.01 Home Program-CAPD Adult







16.01
16.02 Home Program-CAPD Pediatric







16.02
17 Home Program-CCPD







17
17.01 Home Program-CCPD Adult







17.01
17.02 Home Program-CCPD Pediatric







17.02
18 Subtotal (lines 2-16.02)







18

NONREIMBURSABLE COST CENTERS








19 Physicians' Private Offices







19
20 Method II Patients prior to 1/1/2011







20
21 Other Nonreimbursable







21
22 Other Nonreimbursable







22
23 Total (see instructions)







23
24 Total Costs to be Allocated







24
25 Unit Cost Multiplier (Line 24 div. by Line 23)







25
FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)









Rev. 2








42-313
4290 (Cont.)


FORM CMS-265-11




06-13
COST ALLOCATION - STATISTICAL BASIS



PROVIDER CCN:
PERIOD:
WORKSHEET B-1







From:









To:





UNIT COST DRUGS DRUGS
ESA'S ESRD TOTAL



MULTIPLIER
INCLD IN

REL DRUGS EXPENSES





COMP RATE


ALL




( CHARGES ) ( CHARGES )
( CHARGES ) ( CHARGES ) PATIENT


SUBTOTAL COMPUTATION (3) (3) SUBTOTAL (3) (3) SERVICES


8A 9 10 11 11A 12 13 13A
1 COSTS TO BE ALLOCATED







1
2 Drugs Included in Composite Rate







2
3 ESAs







3
4 ESRD Related Other Drugs







4
5 Non-ESRD Related Drugs, Supplies & Lab







5
6 Whole Blood and Packed Red Blood Cells







6
7 Vaccines







7

REIMBURSABLE COST CENTERS








8 Maintenance-Hemodialysis







8
8.01 Maintenance-Hemo Adult







8.01
8.02 Maintenance-Hemo Pediatric







8.02
9 Maintenance -IPD







9
9.01 Maintenance-IPD Adult







9.01
9.02 Maintenance-IPD Pediatric







9.02
10 Training-Hemodialysis







10
10.01 Training-Hemo Adult







10.01
10.02 Training-Hemo Pediatric







10.02
11 Training-IPD







11
11.01 Training-IPD Adult







11.01
11.02 Training-IPD Pediatric







11.02
12 Training-CAPD







12
12.01 Training-CAPD Adult







12.01
12.02 Training-CAPD Pediatric







12.02
13 Training-CCPD







13
13.01 Training-CCPD Adult







13.01
13.02 Training-CCPD Pediatric







13.02
14 Home Program-Hemodialysis







14
14.01 Home Program-Hemo Adult







14.01
14.02 Home Program-Hemo Pediatric







14.02
15 Home Program-IPD







15
15.01 Home Program-IPD Adult







15.01
15.02 Home Program-IPD Pediatric







15.02
16 Home Program-CAPD







16
16.01 Home Program-CAPD Adult







16.01
16.02 Home Program-CAPD Pediatric







16.02
17 Home Program-CCPD







17
17.01 Home Program-CCPD Adult







17.01
17.02 Home Program-CCPD Pediatric







17.02
18 Subtotal (lines 2-16.02)







18

NONREIMBURSABLE COST CENTERS








19 Physicians' Private Offices







19
20 Method II Patients prior to 1/1/2011







20
21 Other Nonreimbursable







21
22 Other Nonreimbursable







22
23 Total (see instructions)







23
24 Total Costs to be Allocated







24
25 Unit Cost Multiplier (Line 24 div. by Line 23)







25
FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)









42-313.1








Rev. 2
06-13


FORM CMS-265-11




4290 (Cont.)






















































































































































































































































This page intentionally left blank.





































































































































































































































































































































































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)




















Rev. 2








42-313.2

Sheet 11: C

4290 (Cont.)


FORM CMS-265-11



06-13
COMPUTATION OF AVERAGE COST PER TREATMENT





PROVIDER CCN: PERIOD: WORKSHEET C
ESRD PPS BUNDLED PAYMENT






From:








To:














TOTAL







NUMBER COSTS AVERAGE COST






OF (Transferred from OF TREATMENT






TREATMENTS Wkst. B, col. 13A) (col. 2 divided by col. 1)






1 2 3



8.01 Maintenance-Hemo Adult



8.01


8.02 Maintenance-Hemo Pediatric



8.02


9.01 Maintenance-IPD Adult



9.01


9.02 Maintenance-IPD Pediatric



9.02


10.01 Training-Hemo Adult



10.01


10.02 Training-Hemo Pediatric



10.02


11.01 Training-IPD Adult



11.01


11.02 Training-IPD Pediatric



11.02


12.01 Training-CAPD Adult



12.01


12.02 Training-CAPD Pediatric



12.02


13.01 Training-CCPD Adult



13.01


13.02 Training-CCPD Pediatric



13.02


14.01 Home Program-Hemodialysis Adult



14.01


14.02 Home Program-Hemodialysis Pediatric



14.02


15.01 Home Program-IPD Adult



15.01


15.02 Home Program-IPD Pediatric



15.02


16.01 Home Program-CAPD Adult
Patient Weeks

16.01












16.02 Home Program-CAPD Pediatric
Patient Weeks

16.02












17.01 Home Program-CCPD Adult
Patient Weeks

17.01












17.02 Home Program-CCPD Pediatric
Patient Weeks

17.02












18 Totals (Column 1 - Sum of Lines 8.01 through 15.02)


18




(Column 2 - Sum of Lines 8.01 through 17.02)






19 Total provider treatments



19



(informational only)





























































































































































FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4212)


















42-314







Rev. 2

Sheet 12: D

06-13




FORM CMS-265-11








4290 (Cont.)
COMPUTATION OF AVERAGE COST PER TREATMENT









PROVIDER CCN:
PERIOD:
WORKSHEET D
BASIC COMPOSITE COST











From:















To:





















TOTAL MEDICARE





NUMBER NUMBER NUMBER










TOTAL
AVERAGE OF OF OF
AVERAGE AVERAGE AVERAGE TOTAL TOTAL TOTAL



NUMBER COSTS COST OF TREAT- TREAT- TREAT- TOTAL PAYMENT PAYMENT PAYMENT PAYMENT PAYMENT PAYMENT



OF ( transfer from TREAT- MENTS MENTS MENTS EXPENSES RATE RATE RATE DUE DUE DUE TOTAL


TREAT- Wkst. B, MENT ( see ( see ( see ( see ( see ( see ( see ( col. 4 x ( col. 4.01 x ( col. 4.02 x PAYMENT


MENTS col. 11A ) ( col 2 / col. 1 ) instructions ) instructions ) instructions ) instructions ) instructions ) instructions ) instructions ) col. 6 ) col. 6.01 ) col. 6.02 ) DUE


1 2 3 4 4.01 4.02 5 6 6.01 6.02 7 7.01 7.02 8
1 Maintenance-Hemodialysis
(line 8.01 and











1



line 8.02)





























2 Maintenance-IPD
(line 9.01 and











2



line 9.02)















0 0











3 Training-Hemodialysis
(line 10.01 and











3



line 10.02)
















0











4 Training-IPD
(line 11.01 and











4



line 11.02)















0 0











5 Training-CAPD
(line 12.01 and











5



line 12.02)















0 0











6 Training-CCPD
(line 13.01 and











6



line 13.02)
















0











7 Home Program-Hemodialysis
(line 14.01 and











7



line 14.02)
















0











8 Home Program-IPD













8



line 15.02)















0 0











9 Home Program-CAPD Patient (line 16.01 and











9


Weeks line 16.02)















0 0











10 Home Program-CCPD Patient (line 17.01 and











10


Weeks line 17.02)















0 0











11 Total





0



0
0 11

(see instructions)





0



0
0








































































































































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4213)
































Rev. 2














42-315

Sheet 13: E

4290 (Cont.)
FORM CMS-265-11




06-13
CALCULATION OF BAD DEBT REIMBURSEMENT

PROVIDER CCN:
PERIOD:
WORKSHEET E,





From:
PARTS I & II





To:











PART I - CALCULATION OF REIMBURSABLE BAD DEBTS TITLE XVIII - PART B







1 Total Expenses Related to Care of Medicare Beneficiaries (from Wkst. D, col. 5, line 11)





1













Column 1 Column 2
2 Total payment due net of Part B deductibles (from Wkst. D, col. 7, line 11) (see instructions)





2
2.01 Total payment due net of Part B deductibles (from Wkst. D. col. 7.01, line 11) (see instr.)





2.01
2.02 Total payment due net of Part B deductibles (from Wkst. D. col. 7.02, line 11) (see instr.)





2.02
2.03 Total payment due net of Part B deductibles (see instructions)





2.03
3 Outlier payments





3
4






4
5 Program payments (80% of line 2.03, column 2)





5
6 Amount of cost to be recovered from Medicare patients (line 1 minus line 5)





6
7 Deductibles and coinsurance billed to Medicare Part B patients (see instructions)





7
7.01 Deductibles and coinsurance billed to Medicare Part B patients (see instructions)





7.01
7.02 Deductibles and coinsurance billed to Medicare Part B patients (see instructions)





7.02
7.03 Total deductibles and coinsurance billed to Medicare Part B patients for comparison (see instructions)





7.03
8 Bad debts for deductibles and coinsurance net of bad debt recoveries for services rendered prior to 1/1/2011





8
9 Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for





9

services rendered on or after 1/1/2011 but before 1/1/2012






10 Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for





10

services rendered on or after 1/1/2012 but before 1/1/2013






11 Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for





11

services rendered on or after 1/1/2013 but before 1/1/2014






12 100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries for





12

services rendered on or after 1/1/2014






13 Total bad debts (sum of line 8 through line 12)





13
14 Net deductibles and coinsurance billed to Medicare Part B patients (line 7.03 minus line 13, col. 2)





14
15 Unrecovered from Medicare Part B patients (line 6 minus line 14) (If line 14 exceeds line 6, do not complete line 16)





15
16 Reimbursable bad debts (see instructions)





16
17 Reimbursable bad debts for dual eligible beneficiaries (see instructions--informational only)





17
18 Tentative adjustment





18
19 Sequestration adjustment amount





19
20 Balance due provider/program (line 16 minus lines 18 and 19) (Indicate overpayment in parentheses) (see instructions)





20


















PART II - CALCULATION OF FACILITY SPECIFIC COMPOSITE COST PERCENTAGE







1 Total allowable expenses (from Wkst. C, col. 2, line 18)



1

2 Total composite costs (from Wkst. D, col. 2, line 11)



2

3 Facility specific composite cost percentage (line 2 divided by line 1)



3





























































































































































































































































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4214)
















42-316






Rev. 2

Sheet 14: E1

06-13
FORM CMS-265-11



4290 (Cont.)
ANALYSIS OF PAYMENTS TO PROVIDERS

PROVIDER CCN: PERIOD:
WORKSHEET E-1
FOR SERVICES RENDERED


From:





To:










PART I - TO BE COMPLETED BY CONTRACTOR











Part B





mm/dd/yyyy Amount

Description


1

1 List separately each tentative settlement
Program .01

1.01

payment after desk review. Also show
to .02

1.02

date of each payment.
Provider .03

1.03

If none, write "NONE," or enter a zero. (1)
Provider .50

1.50



to .51

1.51



Program .52

1.52

SUBTOTAL (sum of lines 1.01 - 1.49 minus sum of lines 1.50 - 1.98)

.99

1.99

(Transfer to Wkst E, Part I, line 18)

2 Determine net settlement amount (balance
Program to provider .01

2.01

due) based on the cost report. (1)
Provider to program .50

2.50
3 Name of Contractor

Contractor Number
3
















(1) On line 2.50, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment






even though total repayment is not accomplished until a later date.






























PART II - TO BE COMPLETED BY PROVIDER






4 Low volume payment amount (see instructions)




4
























































































































































































































































































































































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4215)














Rev 2





42-317

Sheet 15: F

4290 (Cont.)
FORM CMS-265-11




06-13
BALANCE SHEET


PROVIDER CCN:
PERIOD: WORKSHEET F






From:







To:











ASSETS (omit cents)







CURRENT ASSETS
Amount




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 and accounts receivable

6



7 Inventory

7



8 Prepaid expenses

8



9 Other current assets

9



10 Due from other funds

10



11 TOTAL CURRENT ASSETS (Sum of lines 1 through 10)

11




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 (Sum of lines 12 through 26)

27




OTHER ASSETS






28 Investments

28



29 Deposits on leases

29



30 Due from owners/officers

30



31 Other assets

31



32 TOTAL OTHER ASSETS (Sum of lines 28 through 31)

32



33 TOTAL ASSETS (Sum of lines 11, 27, and 32)

33













LIABILITIES AND FUND BALANCES (omit cents)







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 (Sum of lines 34 through 41)

42




LONG TERM LIABILITIES






43 Mortgage payable

43



44 Notes payable

44



45 Unsecured loans

45



46 Other long term liabilities

46



47


47



48 TOTAL LONG TERM LIABILITIES (Sum of lines 43 through 47)

48



49 TOTAL LIABILITIES (Sum of lines 42 and 48)

49




CAPITAL ACCOUNTS






50 FUND BALANCES

50



51 TOTAL LIABILITIES AND FUND BALANCES (Sum of lines 49 and 50)

51













( ) = contra amount



















































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)
















Rev. 2






42-318

Sheet 16: F-1

06-13
FORM CMS-265-11


4290 (Cont.)
STATEMENT OF REVENUES AND EXPENSES

PROVIDER CCN: PERIOD: WORKSHEET F-1




From:





To:











Amount Amount

1 Total patient revenues


1
2 Less: Allowances and discounts on patients' accounts


2
3 Net patient revenues (Line 1 minus line 2)


3
4 Operating expenses (From Worksheet A, column 6, line 27)


4
5 Additions to operating expenses (Specify)


5
6



6
7



7
8



8
9



9
10



10
11 Subtractions from operating expenses (Specify)


11
12



12
13



13
14



14
15



15
16



16
17 Less total operating expenses (net of lines 4 through 16)


17
18 Net income from services to patients (Line 3 minus line 17)


18

Other income:




19 Contributions, donations, bequests, etc.


19
20 Income from investments


20
21 Purchase discounts


21
22 Rebates and refunds of expenses


22
23 Sale of medical and nursing supplies to other than patients


23
24 Sale of durable medical equipment to other than patients


24
25 Sale of drugs to other than patients


25
26 Sale of medical records and abstracts


26
27 Other revenues (Specify)


27
28



28
29



29
30



30
31



31
32 Total Other Income (Sum of lines 19 through 31)


32
33 Net Income or Loss for the period (Line 18 plus line 32)


33
































































































































































































































FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)












Rev. 2




42-319
File Typeapplication/vnd.ms-excel
File TitleWORKSHEETS
AuthorNadia Massuda
Last Modified ByWILLIAM PARHAM
File Modified2014-06-27
File Created2004-09-09

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