CMS-287-05 Home Office Cost Report

08-05

FORM CMS-287-05

3990 (Cont.)
FORM APPROVED
OMB NO. 0938-0202

This report is required by law (42 USC 1395g: 42 CFR 413.20(b)).
Failure to report can result in all interim payments made since
the beginning of the cost report period being deemed overpayments
(42 USC 1395g).

HOME OFFICE COST
STATEMENT

Designated Intermediary Use Only
Desk Reviewed
Audited

Date Received:

SCHEDULE
A
page 1 of 3

Intermediary No.

GENERAL INFORMATION, CERTIFICATION AND LISTING OF CHAIN COMPONENTS
Part I - General Information
l. Home Office Name:
2. No. Assigned by Designated Intermediary:
2.01 No. Assigned by CMS:
3. Home Office Address:
4. Chain Operations
Started On:
6. Cost Statement Period:
From:
To:
7. Was Audited Financial Data used on
Schedule B?
[ ] Yes

5. Contact Person
Name:
Title:
Phone:
8. Type of Chain Organization (check applicable item)
a) voluntary non-profit
Church affiliated
Community
Private
Charitable
Other (specify)

b) proprietary/investor-owned
Individual
Partnership
Corporation
Other (specify)

[ ] No

c) governmental
Federal
State
County
City
District
Other(specify)

9. Key Officers of Home Office (attach listing if necessary)
President
Vice President(s)
Secretary
Treasurer
Controller
Others(specify)
Part II--Certification of Officer of Home Office
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 PROCURED 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 statement of allowable
Home Office costs (and equity capital if applicable), the allocation thereof to the chain components, and the other supporting
schedules for the period beginning _______, 20__, and ending ____________, 20__. To the best of my knowledge and belief,
they are true and correct statements from the books and records of the Home Office in accordance with applicable instructions,
except as noted (attach a statement with exception if necessary).
(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 0938-0202. The time required to complete this information collection is estimated 466 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, Baltimore, Maryland 21244-1850.

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3906-3906.2)

Rev. 1

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3990 (Cont.)
PART III-- LISTING OF CHAIN HEALTHCARE FACILITY COMPONENTS
(Attach additional pages if necessary) (Please indicate all Medicare numbers excluding
Sub-Providers, Provider-Based Skilled Nursing Facilities and Home Health Agencies)
Periods Ending During
Component Name
Home Office Fiscal Year
Health Care Facilities
Medicare No.
From:
To:
1
2
3
4

FORM CMS-287-05
Home Office:

Date Acquired
During the Home
Office Fiscal Year
5

Date Sold/Closed
During the Home
Office Fiscal Year
6

08-05
Period
From:_____________
To:_________________
Medicaid
Type of
Participation
Reimbursement
Yes/No
N, P, T, O
7
8

SCHEDULE
A
page 2 of 3
Medicare
Intermediaries
9

Medicaid
Intermediaries
10

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.

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3906.3)

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FORM CMS-287-05

PART IV-- LISTING OF OTHER

Home Office:

3990 (Cont.)

Period

CHAIN COMPONENTS (Attach

SCHEDULE

From:________________

A

additional pages if necessary)

page 3 of 3
To:__________________
Periods Ending During

Component Name

During the Home Office Fiscal Year

Home Office Fiscal Year

Other Components
1

Date

Date

From

To

Acquired

Sold or Closed

2

3

4

5

1

1

2

2

3

3

4

4

5

5

6

6

7

7

8

8

9

9

PART V--LISTING OF REGIONS/DIVISIONS
Location
Name
1

Costs Included

Separate Cost

in this Cost Statement

Statement Filed

Designated
Region/Division

City

State

Amount

Yes

No

2

3

4

5

6

Intermediary
7

1

1

2

2

3

3

4

4

DISCLOSURE OF THE HOME OFFICE COST STATEMENT
The home office cost statement is not an integral part of the providers' cost report; therefore,it is not affected by 20 CFR 422.435(c)
which requires disclosure of providers' cost reports. Any request received under the Freedom of Information Act (FOIA) regarding
a home office cost statement will be subjected to a case by case determination of whether to withhold the information in whole or in part.
In most cases, since the home office cost statements contain information the disclosure of which may result in a competitive disadvantage
for many provider chains, the exemption from disclosure provided in 5 USC, Sec. 552(b)(4) will apply.

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 3906.4-3906.5)

Rev. 1

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3990 (Cont.)

FORM CMS-287-05

TRIAL BALANCE OF EXPENSES

Home Office:

08-05
Period

RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS
Expenses per
Cost Center Description
(omit cents)

Reclassified

B

To:______________________

page 1 of 3

Net Allowable

Direct

Functional

Pooled

Expenses

Allocations

Allocations

Allocations

(col. 1minus/

Adjustments

(col.3 minus/plus

To Chain

To Chain

(col.5 minus

plus col.2)

(from Sch.C)

col.4)

Components

Components

cols. 6,7)

3

4

5

6

7

8

Reclassifications

Trial Balance

Books

(from Sch.B-1)
2

From:____________________

Medicare

Home Office

1

SCHEDULE

1. Old Cap. Rel. Costs--Bldg and Fixtures

1

1.01 Int. Exp.-Old Capital Bldg and Fixtures

1.01

2. Old Cap. Rel. Costs--Movable Equip.

2

2.01 Int. Exp.-Old Capital Movable Equip.

2.01

3. Sub-Total (Lines 1 and 2)

3

4 New Cap. Rel. Costs--Bldg and Fixtures

4

4.01 Int. Exp.-New Capital Bldg and Fixtures

4.01

5 New Cap. Rel. Costs--Movable Equip.

5

5.01 Int. Exp.-New Capital Movable Equip.

5.01

6 Sub-Total (Lines 4 and 5)

6

Other Capital Related Costs
---------------------------------7 Insurance Premiums

7

8 Taxes & Licenses (Other than Income)

8

9 Other (Specify)

9

10 Sub-Total (sum of lines 7-9)

10

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)

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Rev. 1

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FORM CMS-287-05

TRIAL BALANCE OF EXPENSES
RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS

Home Office:

Cost Center Description
(omit cents)

Expenses per
Home Office
Books

Reclassifications
(from Sch.B-1)

1

2

3990 (Cont.)
Period
From:____________________
To:______________________
Direct
Functional
Allocations
Allocations
To Chain
To Chain

SCHEDULE
B
page 2 of 3
Pooled
Allocations
(col.5 minus

Reclassified
Trial Balance
(col. 1minus/

Medicare
Adjustments

Net Allowable
Expenses
(col.3 minus/plus

plus col.2)

(from Sch.C)

col.4)

Components

Components

cols. 6,7)

3

4

5

6

7

8

Non-Capital Related Cost
11 Salaries of Officers

11

12 Salaries and Wages of Others

12

13 Payroll Taxes

13

14 Employee Benefits - Payroll Related

14

15 Employee Benefits - Non-Payroll Related

15

16 Profit Sharing/Pension Plans

16

17 Legal Fees

17

18 Auditing and Accounting Fees

18

19 Utilities

19

20 Communications

20

21 Travel and Entertainment

21

22 Transportation

22

23 Cleaning, Office and Adm. Supplies

23

24 Minor Equipment Expensed

24

25 Repairs and Maintenance

25

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)

Rev. 1

39-107

3990 (Cont.)

FORM CMS-287-05

TRIAL BALANCE OF EXPENSES

Home Office:

08-05
Period

RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS
Expenses per
Cost Center Description
(omit cents)

Reclassified

B

To:______________________

page 3 of 3

Net Allowable

Direct

Functional

Pooled

Expenses

Allocations

Allocations

Allocations

(col. 1minus/

Adjustments

(col.3 minus/plus

To Chain

To Chain

(col.5 minus

plus col.2)

(from Sch.C)

col.4)

Components

Components

cols. 6,7)

3

4

5

6

7

8

Reclassifications

Trial Balance

Books

(from Sch.B-1)
2

From:____________________

Medicare

Home Office

1

SCHEDULE

Non Capital Related Cost (Cont.)
26 Dues and Subscriptions

26

27 Contributions

27

28 Insurance Premiums - Non-Cap. Rel.

28

29 Taxes and Licenses - Non-Cap. Rel.

29

30 Interest Expense

30

31 Interest Income

31

32 Other (Specify)

32

33 Other (Specify)

33

34 Other (Specify)

34

35 Other (Specify)

35

36 Sub-Total (sum of lines 11-35)

36

100 Total Exp. (sum of lines 3, 6, 10, 36)

100

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)

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FORM CMS-287-05

3990 (Cont.)

Home Office:

Period:

RECLASSIFICATION OF HOME OFFICE EXPENSES

SCHEDULE

From:_______________

B-1

To: ________________
Code
Explanation of Reclassification Entry

Increase

Decrease

(1)

Cost Center

Line No.

Amount(2)

Cost Center

Line 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.

Total Reclassifications (Sum of col.4 must
100 equal sum of col.7)
(1) A letter (A,B, etc) must be entered on each line to identify each reclassification entry.
(2) Transfer to Schedule B, column 2, line as appropriate.

100

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3909)

Rev. 1

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3990 (Cont.)

FORM CMS-287-05

ANALYSIS OF CHANGES DURING COST STATEMENT
PERIOD IN CAPITAL ASSET BALANCES OF CHAIN
HOME OFFICE WHERE THE CHAIN INCLUDES HOSPITALS
SUBJECT TO THE PROSPECTIVE PAYMENT SYSTEM

Home Office:

08-05

PERIOD:
FROM: __________
TO:
__________

SCHEDULE B-2
PARTS I & II

PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES
Acquisitions

Disposals

Beginning
Description

Fully

and

Ending

Depreciated

Balances

Purchases

Donation

Total

Retirements

Balance

Assets

1

2

3

4

5

6

7

1.

Land

1.

2.

Land Improvements

2.

3.

Buildings and Fixtures

3.

4.

Building Improvements

4.

5.
6.
7.
8.

Fixed Equipment
Movable Equipment
SUBTOTAL
Reconciling Items

5.
6.
7.
8.

9.

TOTAL (Line 7 minus line 8)

9.

PART II - ANALYSIS OF CHANGES IN NEW CAPITAL ASSET BALANCES
Acquisitions

Disposals

Beginning
Description

Fully

and

Ending

Depreciated

Balances

Purchases

Donation

Total

Retirements

Balance

Assets

1

2

3

4

5

6

7

1.
2.

Land
Land Improvements

1.
2.

3.
4.

Buildings and Fixtures
Building Improvements

3.
4.

5.
6.
7.
8.
9.

Fixed Equipment
Movable Equipment
SUBTOTAL
Reconciling Items
TOTAL (Line 7 minus line 8)

5.
6.
7.
8.
9.

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3910)

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FORM CMS-287-05

RECONCILIATION OF CAPITAL COSTS CENTERS

Home Office:

3990 (Cont.)
PERIOD:
FROM:
TO:

SCHEDULE B-2
Part III

PART III
COMPUTATION OF RATIOS

Description
*
1
2
3
4
5

Gross Assets
1

Capitalized
Leases
2

Gross Assets
for Ratio
(Col. 1 - Col. 2)
3

ALLOCATION OF OTHER CAPITAL
Ratio
(See Instructions)
4

Insurance
5

Taxes
6

Other CapitalRelated Costs
7

Total (1)
(Sum of
Columns 5-7)
8

Old Cap. Rel Costs-Bldgs and Fixtures
Old Cap. Rel. Costs-Movable Equipment
New Cap. Rel Costs-Bldgs and Fixtures
New Cap. Rel. Costs-Movable Equipment
Total (Sum of Lines 1-4)

1
2
3
4
5

SUMMARY OF OLD AND NEW CAPITAL

Description
*
1
2
3
4
5

Insurance

Taxes

Other CapitalRelated Costs

Total (2)
(Sum of

Depreciation

Lease

Interest

(From Col. 5)

(From Col. 6)

(From Col. 7)

Columns 9-14)

9

10

11

12

13

14

15

Old Cap. Rel Costs-Bldgs and Fixtures
Old Cap. Rel. Costs-Movable Equipment
New Cap. Rel Costs-Bldgs and Fixtures
New Cap. Rel. Costs-Movable Equipment
Total (Sum of Lines 1-4)

1
2
3
4
5

* All lines numbers except line 5 are to be consistent with Schedule B line numbers for capital cost centers
(1) The sum of the amounts on lines 1 thru 4 must equal the amount on Schedule B, column 2, lines 7-9, net of other capital-related costs directly allocated to components of the chain.
(2) The amounts on lines 1 thru 4 must equal the corresponding amounts on Schedule B, Column 3, lines 1,2,4,5 and 7-9.

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3910)

Rev. 1

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3990 (Cont.)

FORM CMS-287-05

08-05

MEDICARE ADJUSTMENTS TO HOME OFFICE EXPENSES

SCHEDULE C

Home

Period

Office:

From:

To:
Cost Center to be
Adjusted (on

*

Schedule B, col. 3)

Description

Line
Amount

No.

Cost Center

1

2

3

1. Federal/State income tax, franchise tax and related

1.

interest and penalties on late payments
(CMS Pub. 15-1, secs.2122.2 and 2133)
2. Donations (See CMS Pub. 15-1, Chapter 6)

2.

3. Stockholders servicing costs (stock transfers and

3.

registrations) (CMS Pub 15-1, se. 2134.9)
4. Acquisition expenses (CMS Pub. 15-1, sec. 2134.11)

4.

5. Disposal expenses re: non-patient care assets

5.

or subsidiaries (CMS Pub. 15-1, sec. 2102.3)
6. Bad Debts (CMS Pub. 15-1, sec. 308)

6.

7. Life insurance premiums where home office is

7.

direct/indirect beneficiary (CMS Pub 15-1, sec. 2102.3)
8. Annual stockholder meeting expenses

8.

(CMS Pub. 15-1, sec. 2134.9)
9. Nonhealth care projects (CMS Pub. 15-1, sec. 2102.3)
10. Noncompetition agreement expenses

9.
10.

(CMS Pub. 15-1, sec 2105.1/1218.7)
11. Fund-raising expenses (CMS Pub. 15-1, sec. 2136.2)

11.

12. Rebates/refunds on expenses (CMS

12.

Pub. 15-1, sec. 804)
13. Other (Specify)

13.

14. Cost of ownership of assets leased from related

14.

organization in lieu of rent (CMS Pub. 15-1, sec. 700)
15. Related organizations (from Schedule D, Part B

15.

col. 5, line 15 (CMS Pub. 15-1, sec. 700)
16. Value of services of nonpaid

16.

workers (CMS Pub. 15-1, sec. 700)
17. Interest on Loans between home office and

17.

components of the chain (CMS Pub. 15-1,
sec. 2150.2c) where no exception applies
18. Costs of corporate acquisitions of

18.

capital stocks and acquisition and
development department cost
(CMS Pub. 15-1, sec. 2150.2B)
19. Interest on Loans from owners

19.

(CMS Pub.15-1, sec. 218.2)
20. Abandoned construction in progress

20.

cost (CMS Pub. 15-1, sec. 2155)
21 Other (specify)

21

22 Other (specify)

22

23 Other (specify)

23

24 Other (specify)

24

25 Other (specify)

25

26 Other (specify)

26

27 Other (specify)

27

28 Total (sum of lines 1-27)

28

* A. Costs--if cost, including applicable overhead, can be determined.
B. Amount Received--if cost cannot be determined.

FORM CMS-287-05(8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 3911

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FORM CMS-287-05

3990 (Cont.)

STATEMENT OF COSTS OF SERVICES

SCHEDULE D

FROM RELATED ORGANIZATIONS

page 1 of 2
Period

Home
Office:

From:

Part A.

To:

Are there any costs included on Schedule B which resulted
from transactions with related organizations as defined in
42 CFR 413.17?
_________________Yes

___________________

No

If "YES," complete Parts B and C following.
Part B.
Costs incurred and adjustment required as a result of
transactions with related organizations:
Account and Amount

Amount

Net Adjustment

(on Schedule B, column 3)

Allowable

(col. 3 minus

Line

Expense Account

Amount

in Cost

col.4) *

1

2

3

4

5

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

7.

7.

8.

8.

9.

9.

10.

10.

11.

11.

12.

12.

13.

13.

14.

14.

100

Total (sum of lines 1-99)

100

* transfer to column 1 of Schedule C, applicable lines

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3912)

Rev. 1

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3990 (Cont.)

FORM CMS-287-05

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS

Home Office:

08-05
Period:
From: ______________________________

SCHEDULE
D
page 2 of 2

To: ________________________________

Part C.

Inter-relationship of chain Home Office to related organization:

Name of Related Organization

Type of Business

1

2

Related Through
Ownership or Control
3

Explanation of Relationship
4

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

7

7

8.

8.

9

9.

10.

10.

11

11

12

12

13

13

14

14

15

15

16

16

100

100

FORM CMS-287-05(8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3912)

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FORM CMS-287-05

DIRECT ALLOCATION OF HOME OFFICE CAPITAL

Home Office:

3990 (Cont.)

Period

COSTS TO CHAIN COMPONENTS

From:____________________

SCHEDULE

To:______________________
Old Capital
Chain Components

E Page 1

New Capital

Building

Other Capital

Building

Medicare

and

Movable

and

Movable

Other

Total

No.

Fixtures

Equipment

Fixtures

Equipment

Insurance

Taxes

Capital

(cols. 1 thru 7)

1

2

3

4

5

6

7

8

Health Care Facilities:
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

Total (sum of lines 1-17)

18

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3913)

Rev. 1

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3990 (Cont.)

FORM CMS-287-05

DIRECT ALLOCATION OF HOME OFFICE CAPITAL

Home Office:

08-05

Period

COSTS TO CHAIN COMPONENTS

From:____________________

SCHEDULE

To:______________________
Old Capital
Chain Components

E Page 2

New Capital

Building

Other Capital

Building

Medicare

and

Movable

and

Movable

Other

Total

No.

Fixtures

Equipment

Fixtures

Equipment

Insurance

Taxes

Capital

(cols. 1 thru 7)

1

2

3

4

5

6

7

8

Other Components:
------------------------19

19

20

20

21

21

22

22

23

23

24

24

25

25

26

26

27

Other Managed Facilities

27

28

Total (sum of lines 19-27)

28

Regional Offices:
------------------------29

29

30

30

31

31

32

32

33

Total (sum of lines 29-32)

33

34

Grand Total (sum of lines 18, 28 and 33)

34

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3913)

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FORM CMS-287-05

DIRECT ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED

Home Office:

3990 (Cont.)

Period

EXPENSES TO CHAIN COMPONENTS

From:______________________________

SCHEDULE

To:________________________________

E-1

Specify:
Chain Components
Medicare

Total

No.

(cols. 1 thru 9)
1

2

3

4

5

6

7

8

9

10

Health Care Facilities:
--------------------------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

Total (sum of lines 1-17)

18

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3914)

Rev. 1

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3990 (Cont.)

FORM CMS-287-05

DIRECT ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED

Home Office:

08-05

Period

EXPENSES TO CHAIN COMPONENTS

From:______________________________

SCHEDULE

To:________________________________

E-1

Specify:
Chain Components
Medicare

Total

No.

(cols. 1 thru 9)
1

2

3

4

5

6

7

8

9

10

Other Components:
--------------------------19

19

20

20

21

21

22

22

23

23

24

24

25

25

26

26

27

Other Managed Facilities

27

28

Total (sum of lines 19-27)

28

Regional Offices:
--------------------29

29

30

30

31

31

32

32

33

Total (sum of lines 29-32)

33

34

Grand Total (sum of lines 18, 28 and 33)

34

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3914)

39-118

Rev. 1

08-05

FORM CMS-287-05

FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL

Home Office:

3990 (Cont.)
Period

COSTS TO CHAIN COMPONENTS---STATISTICS

From:

SCHEDULE F

To:

Part II

Old Capital

New Capital

Base:
Chain Components
Building

Building

and

Movable

Interest

and

Movable

Interest

Health Care Facilities:

Fixtures

Equipment

Expense

Fixtures

Equipment

Expense

-------------------------------------------------------------------

1

2

2.01

3

4

4.01

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

Total (sum of lines 1-17)

18

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3915)

Rev. 1

39-121

3990 (Cont.)

FORM CMS-287-05

FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL

Home Office:

08-05
Period

COSTS TO CHAIN COMPONENTS---STATISTICS

From:

SCHEDULE F

To:

Part II

Old Capital

New Capital

Base:
Chain Components

Building

Building

and

Movable

Interest

and

Movable

Interest

Other Components:

Fixtures

Equipment

Expense

Fixtures

Equipment

Expense

-------------------------------------------------------------------

1

2

2.01

3

4

4.01

19

19

20

20

21

21

22

22

23

23

24

24

25

25

26

26

27

Other Managed Facilities

27

28

Total (sum of lines 19-27)

28

Regional Offices:
------------------------------------------------------------------29

29

30

30

31

31

32

32

33

Total (sum of lines 28-31)

33

34

Total statistics (sum of lines 18, 28 and 33) (A)

34

35

Cost to be Allocated (B)

35

36

Unit Cost Multiplier (B/A)

36

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3915)

39-122

Rev. 1

08-05

FORM CMS-287-05

FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED

Home Office:

3990 (Cont.)

Period

EXPENSES TO CHAIN COMPONENTS

From:______________________________

SCHEDULE

To:________________________________

F-1 Part I

Specify:
Chain Components

Medicare

Total

No.
Health Care Facilities:

(cols. 1 thru 9)
1

2

3

4

5

6

7

8

9

10

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

Total (sum of lines 1-17)

18

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)

Rev. 1

31-123

3990 (Cont.)

FORM CMS-287-05

FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED

Home Office:

08-05

Period

EXPENSES TO CHAIN COMPONENTS

From:______________________________

SCHEDULE

To:________________________________

F-1 Part I

Specify:
Chain Components

Medicare

Total

No.

(cols. 1 thru 9)
1

2

3

4

5

6

7

8

9

10

Other Components:
--------------------------19

19

20

20

21

21

22

22

23

23

24

24

25

25

26

26

27

Other Managed Facilities

27

28

Total (sum of lines 18-27)

28

Regional Offices:
--------------------29

29

30

30

31

31

32

32

33

Total (sum of lines 29-32)

33

34

Grand Total (sum of lines 18, 28 and 33)

34

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)

39-124

Rev. 1

08-05

FORM CMS-287-05

FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED

Home Office:

3990 (Cont.)

Period

EXPENSES TO CHAIN COMPONENTS -STATISTICS

From:______________________________

SCHEDULE

To:________________________________

F-1 Part II

Base:
Chain Components
Total
(cols. 1 thru 9)
1

2

3

4

5

6

7

8

9

10

Health Care Facilities:
--------------------------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

Total (sum of lines 1-17)

18

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)

Rev. 1

39-125

3990 (Cont.)

FORM CMS-287-05

FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED

Home Office:

08-05

Period

EXPENSES TO CHAIN COMPONENTS -STATISTICS

From:______________________________

SCHEDULE

To:________________________________

F-1 Part II

Base:
Chain Components
Total
(cols. 1 thru 9)
1

2

3

4

5

6

7

8

9

10

Other Components:
--------------------------19

19

20

20

21

21

22

22

23

23

24

24

25

25

26

26

27

Other Managed Facilities

27

28

Total (sum of lines 19-27)

28

Regional Offices:
--------------------29

29

30

30

31

31

32

32

33

Total (sum of lines 29-32)

33

34

Grand Total (sum of lines 18, 28 and 33)

34

FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)

39-126

Rev. 1

3990 (Cont.)

FORM CMS-287-05

08-05

STATEMENT OF REVENUE AND EXPENSES

Home Office:

SCHEDULE
I
Period
From:

To:

l. Total operating revenue

$

2. Less: Operating expenses
(Schedule B, column 1, line 37)

$

3. Operating profit (loss)

$

4. Other income:
a.
b.
c.
d.
e.
f.
g.
h.

contributions, donations
income from investments
interest income
purchase discounts
rebates and refunds of expenses
parking lot receipts
rental income
other (specify)

$
$
$
$
$
$
$
$
$
$
$
$
$

5. Total other income
(sum of item 4 above)
6. Other expenses (specify)

$
$
$
$
$
$

7. Total other expenses
(sum of item 6 above)

$

8. Net income (loss) for the period (line 3 plus line 5 minus line 7)

$

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECTION 3918)

39-130

Rev. 1

08-05

FORM CMS-287-05
BALANCE SHEET

Home Office:

3990 (Cont.)
Period:
From:
To:

Assets
(Omit Cents)
Current Assets

SCHEDULE J
page 1 of 5
Balance
Sheet
Per Books
1

1 Cash - On Hand & In Bank

1

2 Current Investments

2

3 Notes Receivable

3

4 Accounts Receivable

4

5 Other Receivables (Specify)

5

6 Less:Allowance for Uncollectable Notes and Account Receivable

6

7 Inventory

7

8 Prepaid Expenses

8

9 Other Current Assets (Specify)

9

10 Total Current Assets (Sum of lines 1-9)

10

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)

Rev. 1

39-131

3990 (Cont.)

FORM CMS-287-05

BALANCE SHEET

08-05
SCHEDULE J
page 2 of 5

Assets
(Omit Cents)
Fixed Assets

Balance
Sheet
Per Books
1

11 Land

11

12 Land Improvements

12

13 Less: Accumulated Depreciation

13

14 Building

14

15 Less: Accumulated Depreciation

15

16 Leasehold Improvement

16

17 Less: Accumulated Depreciation

17

18 Fixed Equipment

18

19 Less: Accumulated Depreciation

19

20 Motor Vehicles

20

21 Less: Accumulated Depreciation

21

22 Major Movable Equipment

22

23 Less: Accumulated Depreciation

23

24 Minor Equipment - Depreciable

24

25 Less: Accumulated Depreciation

25

26 Minor Equipment - Non-Depreciable

26

27 Other Fixed Assets (Specify)

27

28 Other Fixed Assets (Specify)

28

29 Total Fixed Assets (Sum of lines 11-28)

29

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)

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Rev. 1

08-05

FORM CMS-287-05
BALANCE SHEET

3990 (Cont.)
SCHEDULE J
page 3 of 5
Balance

Assets

Sheet

(Omit Cents)

Per Books

Other Assets

1

30 Investments

30

31 Deposits on Leases

31

32 Due from Owners/Officers

32

33 Due from Related Organizations

33

34 Special Funds

34

35 Goodwill

35

36 Construction in Progress

36

37 Other (Specify)

37

38 Total Other Assets (Sum of lines 30-37)

38

39 Total Assets (Sum of lines 10, 29, and 38)

39

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)

Rev. 1

39-133

3990 (Cont.)

FORM CMS 287-92

BALANCE SHEET

08-05
SCHEDULE J
page 4 of 5
Balance

Liabilities and Capital

Sheet

(Omit Cents)

Per Books

Liabilities

1

Current Liabilities:
40 Accounts Payable

40

41 Notes and Loans Payable - Short Term

41

42 Current Portion of Long-Term Debt

42

43 Salaries, Wages and Fees Payable

43

44 Payroll Taxes Payable

44

45 Other Accrued Expenses Payable

45

46 Deferred Income

46

47 Notes and Loans Payable to Related Organization

47

48 Other (Specify)

48

49 Total Current Liabilities (Sum of lines 40-48)

49

Long Term Liabilities:
50 Mortgage Payable (Long-term Portion)

50

51 Notes Payable - (Long-term Portion)

51

52 Unsecured Loans - (Long-term Portion)

52

53 Loans from Owners

53

54 Other (Specify)

54

55 Total Long-term Liabilities (Sum of lines 50-54)

55

56 Total Liabilities (Sum of lines 49 and 55)

56

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)

39-134

Rev. 1

08-05

FORM CMS-287-05
BALANCE SHEET

Home Office:

3990 (Cont.)
Period:
From: ______________
To: ________________

Liabilities and Capital
(Omit Cents)
Capital

SCHEDULE J
page 5 of 5
Balance
Sheet
Per Books
1

57 Preferred Stock

57

58 Common Stock

58

59 Additional Paid-In Capital

59

60 Retained Earnings - Unrestricted

60

61 Other (Specify)

61

62 Total Capital (Sum of lines 57-61)

62

63 Total Liabilities and Total Capital (Sum of lines 56 and 62)

63

64 Equity in Assets Leased from Related Organizations (Attach supporting Schedules)

64

65 Equity in Related Organizations (attach Supporting Schedules)

65

66 Total Equity Capital (Lines 62 plus/minus 64 and 65)

66

FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)

Rev. 1

39-135