CMS-216-94 Data and Certification Statement

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Overview

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Sheet 1: ws-S^

06-15				Form CMS-216-94			3390(Cont.)
This report is required by law (42 USC 1395g) and 42CFR 413.20 and 413.24.						FORM APPROVED
Failure to report can result in all payments made during the reporting period						OMB NO. 0938-0102
being deemed overpayments (42 USC 1395g).						Expires: 09/30/2020
ORGAN PROCUREMENT ORGANIZATION				Provider CCN:	PERIOD:	WORKSHEET
HISTOCOMPATIBILITY LABORATORY GENERAL				_______________	FROM:_______	S
DATA AND CERTIFICATION STATEMENT					TO:__________
Contractor Use Only:
		[ ] Audited	Date Received ________________		[ ] Initial	[ ] Re-opened
		[ ] Desk Reviewed	Contractor No. ______________		[ ] Final
PART I - GENERAL
Check			[ ] Electronic filed cost report			Date:
applicable box			[ ] Manually submitted cost report			Time:
1	Name:			Provider CCN:			1
1.01	Street:				P.O. Box:		1.01
1.02	City:		State:		Zip Code:		1.02
2	Name:			Provider CCN:			2
2.01	Street:				P.O. Box:		2.01
2.02	City:		State:		Zip Code:		2.02
3	Reporting Period: From To						3
		Type of Control		Type of Provider
		(see instructions)		(see instructions)	Participation Date
	1	2		3	4
4							4
PART II-CERTIFICATION BY OFFICER OR ADMINISTRATOR OF FACILITY
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. FUTHERMORE, IF SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED
OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATION ACTION, FINES AND/OR IMPRISONMENT MAY RESULT
CERTIFICATION BY OFFICER, ADMINISTRATOR OR DIRECTOR OF ORGANIZATION/LABORATORY
I HEREBY CERTIFY that I have read the above cerification 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 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 OPO/LAB in accordance with applicable instructions, except as noted.
I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that the services
identified in this cost report were provided in compliance with such laws and regulations.
			(Signed)	______________________________________________
				Officer, Administrator or Director
				______________________________________________
				Title
				______________________________________________
				Date
PART III - SETTLEMENT SUMMARY
					TITLE XVIII
					Organ Acquisition	Tissue Typing
					1	2
1	OPO/LAB						1
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 0938-0102. The time required to complete
this information collection is estimated to average 45 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 comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form please write to: Centers for Medicare and Medicaid Services, 7500 Security
Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved
under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions
or concerns regarding where to submit your documents, please contact 1-800-MEDICARE.
FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2,
SECTIONS 3302, 3302.1 and 3302.2)
Rev. 6							33-303

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Sheet 2: ws-S1^

3390 (Cont.)				Form CMS 216-94				06-15
ORGAN PROCUREMENT ORGANIZATION/				Provider CCN:	PERIOD:
HISTOCOMPATIBILITY LABORATORY				___________________	FROM_______________		WORKSHEET S-1
IDENTIFICATION DATA					TO________________
PART I-OPO STATISTICS
					1	2	3
					Local	Imported	Total (Columns 1 & 2)
1	Total number of kidneys retrieved (viable and nonviable)							1
2	Total number of kidneys included in line 1 that were nonviable.							2
3	Net number of kidneys for which payment should							3
	have been received (line 1 minus line 2).
					USA	Foreign Country	Total
4	Total number of kidneys included in line 3, column 3 that							4
	were exported out of local retrieval areas
					Military	VA	Total
5	Total number of kidneys sent to military or VA							5
	hospitals that were included in line 3,column 3.			Number
6	Amount received for kidneys listed in line 5.			Amount Received				6
						Number of Kidneys	Amount Received
7	Was payment received for kidneys furnished to foreign countries and included							7
	on line 4,column 2. Enter "Y" for yes or "N" for no. If yes, enter the total number
	of kidneys and amount received in columns 2 and 3, respectively.
	Total number of organs/tissue other than kidneys retrieved and administratively processed. In the amount received column enter
	the total amount of payment received for each type of organ.
	Organ				Total	Nonviable	Amount Received
8	Cornea							8
8.01	Liver							8.01
8.02	Pancreas							8.02
8.03	Pancreas Islet							8.03
8.04	Heart							8.04
8.05	Heart Valves							8.05
8.06	Heart/Lung							8.06
8.07	Bone							8.07
8.08	Skin							8.08
8.09	Lung							8.09
8.10	Other							8.10
9	Total							9
PART II-LAB STATISTICS
1	Total number of tests performed- all laboratory.							1
2	Total number of tests performed-tissue typing laboratory.							2
3	Total number of pre-transplant tests performed for kidney transplantation that are included in line 2.							3
	Tissue typing pre-transplant tests performed for kidney transplant:
		Test Name					Number of Tests
4								4
4.01								4.01
4.02								4.02
4.03								4.03
4.04								4.04
4.05								4.05
4.06								4.06
4.07								4.07
4.08								4.08
4.09								4.09
4.10								4.10
5	Total Tests							5
PART III-Full Time Equivalent Employees (FTEs)
Number of full-time equivalent employees
	Administrative			OPO		Histo-Lab
	1		2	3	4	5	6
1	Medical Director			Medical Director		Lab Director		1
1.01	Exec. Director			Procurement Coordinator		Technicians		1.01
1.02	Clerical			Preservation Technicians		Tissue Typing Tech.		1.02
1.03	Other			Other		Other		1.03
2	Total FTEs							2
FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2 SECTIONS 3303, 3303.1, 3303.2 and 3303.3)
33-304								Rev. 6

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Sheet 3: ws-A^

06-15			Form CMS-216-94							3390 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL			Provider CCN:		REPORTING PERIOD			WORKSHEET A
BALANCE OF EXPENSES			_________________		FROM:_______________________
					TO:____________________
						RECLASS.	RECLASSIFIED	ADJUSTMENTS	NET COST
						TO EXPENSES	TRIAL BALANCE	TO COST	FOR COST
		COST CENTERS (OMIT CENTS)			TOTAL	(FROM	(COL.3	(FROM	ALLOCATION
			SALARIES	OTHER	(Cols. 1 & 2)	WKST.A-4)	+/- COL.4)	(WKST. A-5)	(COL.5+/-COL.6)
			1	2	3	4	5	6	7
		GENERAL SERVICE COST CENTERS
1	0100	Capital Costs--Buildings and Fixtures								1
2	0200	Capital Costs--Movable Equipment								2
3	0300	Employee Benefits								3
4	0400	Administrative and General-Cols. 1-3-From W/S-A-1								4
5	0500	Operation and Maintenance of Plant								5
6	0600	Housekeeping								6
7	0700	Medical Supplies								7
8	0800	Other Overhead (Specify)								8
		ORGAN ACQUISITION OVERHEAD
9	0900	Procurement Coordinators								9
10	1000	Professional Education								10
11	1100	Public Education								11
12	1200	Other Acquisition (Specify)								12
		REIMBURSABLE COST CENTERS
13	1300	Kidney Acquisition(From W/S A-2 Cols. 1-3,line 23)								13
14	1400	Tissue Typing Laboratory (Cols. 1-3,From W/S-A-3, Line 11)								14
		NON-REIMBURSABLE COST CENTERS
15	1500	Liver Acquisitions (W/S-A-2, Col. 1-3, Line 23)								15
16	1600	Heart Acquisitions (W/S-A-2, Col.1-3, Line 23)								16
17	1700	Pancreas Acquisitions (W/S-A-2, Col.1-3, Line 23)								17
18	1800	Lung Acquisitions (W/S-A-2, Col. 1-3, line 23)								18
19	1900	Other Acquisitions (W/S-A-2, Col. 1-3, line 23)								19
20	2000	Other Acquisitions (W/S-A-2, Col. 1-3)								20
21	2100	Research								21
22	2200	Blood Bank								22
23	2300	Laboratory-Non-Tissue Typing								23
24	2400	Dialysis Units								24
25	2500	Other Non-Reimbursable (Specify)								25
26		Total Expenses (sum of lines 1-25), Transfer Column 7 to W/S-B								26
		line 1, or W/S-C, as per instructions
FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3304)
Rev. 6										33-305

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Sheet 4: ws-A-1^

3390 (Cont.)		Form CMS-216-94			06-15
ADMINISTRATIVE AND GENERAL EXPENSES		Provider CCN:	REPORTING	WORKSHEET A-1
			PERIOD:
			FROM___________
			TO______________
	COST CENTER	SALARIES	OTHER	TOTAL
		1	2	3
1	Medical Director				1
2	Executive Director				2
3	Home Office/Central Administration				3
4	Data Processing				4
5	Accounting-Legal-Audit				5
6	Rent and Lease Expense				6
7	Office Supplies				7
8	Telephone				8
9	Travel-Meetings and Seminars				9
10	Insurance				10
11	Employee Professional Education				11
12	Public Relations				12
13	Interest Expense				13
14	Taxes				14
15	Office Salaries				15
16	Other Administrative and General:				16
17					17
18					18
19					19
20	Total Administrative and General				20
	sum of lines 1-19
	Transfer line 20 columns 1-3 to
	Worksheet A, line 4, columns 1-3
FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,
SECTION 3305)
33-306					Rev. 6

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Sheet 5: ws-A-2

06-15		Form CMS-216-94			3390 (Cont.)
ORGAN ACQUISITION COST		Provider CCN:	REPORTING	WORKSHEET A-2
			PERIOD:
			FROM___________
			TO______________
Check One:
[ ] Kidney [ ] Liver [ ] Heart [ ] Pancreas [ ] Lung [ ] Other ___________
	COST CENTER	SALARIES	OTHER	TOTAL
		1	2	3
	Organ Acquisition Costs
	Amounts Paid To Excision Hospitals
1	Operating Room				1
2	Anesthesiology				2
3	Respiratory Therapy				3
4	Intensive Care Unit				4
5	Medical Supplies				5
6	Pharmacy				6
7	Electroencephalography				7
8	Hospital Laboratory				8
9	Other Excision Hospital Cost (specify)				9
10	Subtotal-Excision Hospital Cost (sum of lines 1-9)				10
	Other Acquisitions Costs
11	Computer Registry				11
12	Donor Evaluation				12
13	Surgeon Fee				13
14	Organ Preservation				14
15	Donor Tissue Typing				15
16	Recipient Crossmatch				16
17	Imported Organ Cost				17
18	Transportation of Organs				18
19	Tissue Typing Lab-Under Agreement				19
20	Anesthesiologist Professional Fees				20
21	Other Acquisition Costs (specify)				21
22	Subtotal-Other Acquisition Cost (sum of lines 11-21)				22
23	Total-Organ Acquisition Cost				23
	(sum of lines 10 and 22)
	Transfer line 23 columns 1 and 2 to W/S A.
	(see instructions)
FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,
SECTION 3306)
Rev. 6					33-307

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Sheet 6: ws-A-3

3390 (Cont.)		Form CMS-216-94			06-15
TISSUE TYPING LABORATORY COSTS		Provider CCN:	REPORTING	WORKSHEET A-3
			PERIOD:
			FROM___________
			TO______________
	COST CENTER	SALARIES	OTHER	TOTAL
		1	2	3
1	Laboratory Director				1
2	Tissue Typing Technologist				2
3	Sera Procurement				3
4	Equipment Maintenance				4
5	Other Tissue Typing Cost (Specify)				5
6					6
7					7
8					8
9					9
10					10
11	Total -Tissue Typing Cost				11
	(sum of lines 1-10)
	Transfer line 11 columns 1-3 to
	Worksheet A, Line 14, columns 1-3
FORM CMS 216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2,
SECTION 3307)
33-308					Rev. 6

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Sheet 7: ws-A-4

06-15			Form CMS-216-94						3390 (Cont.)
RECLASSIFICATIONS		Provider CCN:			REPORTING PERIOD:		WORKSHEET A-4
		_______________________			FROM:___________________
					TO:____________________
		CODE	INCREASE			DECREASE
			COST	LINE		COST	LINE
	EXPLANATION OF RECLASSIFICATION 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
36	TOTAL RECLASSIFICATIONS (Sum of Column 4								36
	must equal sum of Column 7)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer to Worksheet A, Column 4, line as appropriate.
FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3308)
Rev. 6									33-309

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Sheet 8: ws-A-5

3390 (Cont.)				Form CMS-216-94					06-15
ADJUSTMENTS TO EXPENSES		Provider CCN:			REPORTING PERIOD:		WORKSHEET A-5
		___________________			FROM:_____________
					TO:____________
		Basis for			Expense Classification on Worksheet A
		Adjust-			from which amount is to be deducted
	Description (1)	ment			or to which the amount is to be added
		(2)		Amount	Cost Center			Ln No.
		1		2	3			4
1	Purchase Discounts								1
2	Rebates and Refunds								2
3	Home Office Costs								3
4	Adjustments resulting from transactions	From							4
	with related organizations (Chapter 10)	Supp. W/S
		A-5-1
5	Income received from the procurement								5
	of organs other than kidneys. (3)
6	Vending Machines								6
7	Rental or Lease Income								7
8	Organs Sold for Research								8
9	Public Relations-Not related to								9
	Organ Procurement
10	Income received from Professional								10
	Education
11	Sale of Supplies								11
12	Interest Income applied to interest exp.								12
13	Capital Costs -Buildings & Fixtures								13
14	Capital Costs -Movable Equipment								14
15									15
16									16
17	Total -Transfer to W/S. A, Column 6,								17
	Line as Appropriate
	(1) Description-all line 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
	(3) Only the income from organs such as Cornea, Skin, Heart Valves, Bone, and Pancreas Islet may be offset.
	All solid organs such as Kidneys, Hearts, Livers, Lung, and Pancreas must go through cost finding on W/S B
	FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
	PUB 15-2, SECTION 3309)
33-310									Rev. 6

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Sheet 9: ws-A-6^

06-15			Form CMS-216-94					3390 (Cont.)
CAPITAL EXPENDITURES AND		Provider CCN:		REPORTING PERIOD			WORKSHEET
DEPRECIATION RECONCILIATION				FROM:__________________			A-6
				TO:_____________________
Part I - Analysis of Changes in		Beginning	Acquisitions				Ending
Capital Asset Balances During Cost		Balance	Purchase	Donations	Total	Disposals	Balance
Reporting Period		1	2	3	4	5	6
1	Land							1
2	Land Improvements							2
3	Building and Fixtures							3
4	Fixed Equipment							4
5	Movable Equipment							5
6	Auto,Truck, Van							6
7	Other (Specify)							7
8	Total							8
Part II - Analysis of Changes				Beginning			Ending
In Accumulated Depreciation				Balance	Additions	Deletions	Balance
Description				1	2	3	4
1	Land							1
2	Land Improvements							2
3	Buildings and Fixtures							3
4	Building Improvements							4
5	Fixed Equipment							5
6	Movable Equipment							6
7	Auto,Truck, Van							7
8	Other (Specify)							8
9	Total							9
Part III - Depreciation Reported In Cost Statement
1	Straight Line							1
2	Declining Balance							2
3	Sum of Years Digits							3
4	Depreciation reported on W/S -A column 7. (Total- Sum of 1, 2 and 3)							4
						1	2
5	Is depreciation funded? Enter "Y" for yes or "N" for no in column 1. If yes,							5
	enter in column 2 the balance in fund at the end of the period.
6	Was there a gain or loss on the sale of assets during the cost reporting							6
	period? (See CMS Pub-15-1, Section 132)
FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2
SECTION 3310)
Rev.6								33-311

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Sheet 10: ws-B^

3390 (Cont.)					Form CMS-216-94								06-15
COST ALLOCATION-GENERAL SERVICE COSTS					Provider CCN:			REPORTING PERIOD			WORKSHEET B
								FROM____________________
								TO_______________________
		NET	CAPITAL-
		COST	BUILDING,
		FOR	OPERATION	CAPITAL	EMPLOYEE	MEDICAL			ORGAN	SUBTOTAL	ADMIN.	TOTAL
		ALLOCATION	OF PLANT	COSTS	BENEFITS	SUPPLIES	OTHER		ACQUISITION	(COLS.1-8)	&	EXPENSES
		(FROM	AND	MOVABLE					COSTS		GENERAL
COST CENTER		WKST. A,	HOUSE	EQUIPMENT
		COL.7)	KEEPING
		1	2	3	4	5	6	7	8	9	10	11
1	COSTS TO BE ALLOCATED		( )	( )	( )	( )	( )				( )		1
2	Organ Acquisitions								( )	-0-			2
	REIMBURSABLE
	COST CENTERS
3	Kidney Acquisitions (1)												3
4	Tissue Typing Laboratory(2)												4
	NONREIMBURSABLE
	COST CENTERS
5	Liver Acquisitions												5
6	Heart Acquisitions												6
7	Pancreas Acquisitions												7
8	Lung Acquisitions												8
9	Other Acquisitions												9
10	Research												10
11	Blood Bank												11
12	Laboratory-Non-Tissue Typing												12
13	Dialysis Units												13
14
15													14
16	Totals Expenses		-0-	-0-	-0-	-0-	-0-		-0-		-0-		16
(1) Transfer amount on line 3, column 11 to Worksheet C, line 4, Part I
(2) Transfer amount on line 4, column 11 to Worksheet C, line 4, Part II
FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3311)
33-312													Rev. 6

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Sheet 11: ws-B-1^

06-15					Form CMS-216-94								3390 (Cont.)
COST ALLOCATION-STATISTICAL BASIS					Provider CCN:			REPORTING PERIOD:			WORKSHEET B-1
					___________________			FROM________________
								TO_______________
			CAPITAL
			BUILDING
	COST CENTERS		OPERATION	CAPITAL					ORGAN			ADMINISTRATION
			OF PLANT	COSTS	EMPLOYEE	MEDICAL	OTHER		ACQUISITION			&
			AND	MOVABLE	BENEFITS	SUPPLIES			COSTS		RECONCILIATION	GENERAL
			HOUSE-	EQUIPMENT					(NUMBER
			KEEPING	(DOLLAR	(ADJUSTED	(COSTED			OF			(ACCUMULATED
			(SQ. FEET)	VALUE)	SALARIES)	REQUISITIONS)			ORGANS)			COSTS)
			2	3	4	5	6	7	8	9	10A	10
1	COSTS TO BE ALLOCATED												1
2	Organ Acquisition Costs												2
	REIMBURSABLE COST CENTERS
3	Kidney Acquisitions												3
4	Tissue Typing Laboratory												4
	NONREIMBURSABLE COST CENTERS
5	Liver Acquisitions												5
6	Heart Acquisitions												6
7	Pancreas Acquisitions												7
8	Lung Acquisitions												8
9	Other Organ Acquisitions												9
10	Research												10
11	Blood Bank												11
12	Laboratory-Non-Tissue Typing												12
13	Dialysis Units												13
14													14
15
16	Total (lines 2-15)												16
17	COSTS TO BE ALLOCATED PER W/S B												17
18	UNIT COST MULTIPLIER (line 17/line 16)												18
FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 3311)
Rev. 6													33-313

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Sheet 12: ws-C^

06-15		Form CMS-216-94			3390 (Cont.)
COMPUTATION OF MEDICARE COST		Provider CCN:	REPORTING PERIOD	WORKSHEET C
			FROM_____________
			TO________________
	Part I - KIDNEY ACQUISITION
1	Total Number of Viable Kidneys Procured (W/S S-1, Part 1, line 3, col. 3)				1
2	Total Number of Medicare Kidneys (see instructions)				2
3	Ratio of Medicare Kidneys to Total Kidneys (line 2 / line 1)				3
4	Total Cost Applicable to Kidney Acquisition (see instructions)				4
5	Total Medicare Kidney Acquisition Costs (line 3 x line 4) (1)				5
(1) Transfer amount on line 5 to Worksheet D, Column 1, Line 1
	Part II - TISSUE TYPING LABORATORY
1	Gross Charges - Tissue Typing Laboratory-All Tests				1
2	Gross Charges - Tissue Typing Laboratory-Kidney Transplant Related Tests Only (2)				2
3	Ratio of Kidney Transplant Charges to Total Charges (line 2 / line 1)				3
4	Total Cost Applicable to Tissue Typing Lab. (see instructions)				4
5	Reimbursable Kidney Transplant Related Costs (line 3 x line 4) (3)				5
(2) If the cost report is a partial year under the program, show only the kidney related revenue earned since
the participation date.
(3) Transfer amount on line 5 to Worksheet D, Column 2, Line 1.
Form CMS-216-94 (06-2015) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, Section 3312)
33-314					Rev. 6

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Sheet 13: ws-D

06-15		Form CMS-216-94			3390 (Cont.)
CALCULATION OF REIMBURSEMENT		Provider CCN:	REPORTING PERIOD	WORKSHEET D
SETTLEMENT			FROM_____________
			TO________________
			1	2
			Kidney Acquisition	Tissue Typing Lab
1	Medicare Reimbursable Cost-Kidney Acquisition-				1
	W/S-C, Part I, line 5
	Tissue Typing-Laboratory W/S-C, Part II, line 5
2	Total Revenue Received for Lab Services Furnished to				2
	Foreign Countries, Military and VA Hospitals
3	Total Reimbursable Cost to OPO/HL (line 1 - line 2)				3
4	Total Payments Received and Receivable from OPOs				4
	and Transplant Hospitals for Kidneys Furnished or
	Laboratory Services Provided for Kidney Transplantation
	(From Your Records)
5	Subtotal (line 3 - line 4)				5
6	Sequestration Adjustment (see instructions)				6
7	Interim Payments				7
8	Net Balance Due to/from the OPO/LAB (Medicare Program)				8
	(line 5 - (line 6 + line 7)
Form CMS-216-94 (06-2015) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, Section 3313)
Rev. 6					33-315

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Sheet 14: ws-E

3390 (Cont.)		Form CMS 216-94				06-15
		Provider CCN:		PERIOD:
BALANCE SHEET				FROM _____________________		WORKSHEET
				TO ________________________		E
				Liabilities and Fund
	Assets	General		Balance		General
	(Omit cents)	Fund		(Omit Cents)		Fund
		1				1
	CURRENT ASSETS			CURRENT LIABILITIES
1	Cash		34	Accounts payable
2	Temporary investments		35	Salaries, wages & fees payable
3	Notes receivable		36	Payroll taxes payable
4	Accounts receivable		37	Notes & loans payable (Short term)
5	Other receivables		38	Advanced blood deposits
6	Less: allowances for uncollectible	( )	39
	notes and accounts receivable		40	Due to other funds
7	Inventory		41
8	Prepaid expenses		42	TOTAL CURRENT LIABILITIES
9	Other current assets			(sum of lines 34 - 41)
10	Due from other funds			LONG TERM LIABILITIES
11	TOTAL CURRENT ASSETS		43	Mortgage payable
	(sum of lines 1 - 10)		44	Notes payable
	FIXED ASSETS		45	Unsecured loans
12	Land		46
13	Land improvements
14	Less: Accumulated depreciation	( )	47
15	Buildings		48
16	Less: Accumulated depreciation	( )	49	TOTAL LONG TERM LIABILITIES
17	Leasehold improvements			(sum of lines 43 - 48)
18	Less: Accumulated depreciation	( )	50	TOTAL LIABILITIES
19	Fixed equipment			(sum of lines 42 and 49)
20	Less: Accumulated depreciation	( )		CAPITAL ACCOUNTS
21	Automobiles and trucks		51	General fund balance
22	Less: Accumulated depreciation	( )	52	Specific purpose fund balance
23	Major movable equipment		53	Donor created - endowment fund
24	Less: Accumulated depreciation	( )		balance - restricted
25	Minor equipment nondepreciable		54	Donor created - endowment fund
26	Other fixed assets			balance - unrestricted
27	TOTAL FIXED ASSETS		55	Governing board created - endowment
	(Sum of lines 12 - 26)			fund balance
	OTHER ASSETS		56	Plant fund balance - invested in plant
28	Investments		57	Plant fund balance - reserve for
29	Deposits on leases			plant improvement, replacement and
30	Due from owners/officers			expansion
31			58	TOTAL FUND BALANCE
32	TOTAL OTHER ASSETS			(sum of lines 51 thru 57)
	(sum of lines 28 - 31)		59	TOTAL LIABILITIES AND
33	TOTAL ASSETS			FUND BALANCE
	(sum of lines 11, 27 and 32)			(sum of lines 50 and 58)
	( ) = contra amount
FORM CMS -216-94 ( 06-2015 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-2, SECTION 3314 )
33-316						Rev. 6

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Sheet 15: ws-E-1

06-15		Form CMS-216-94			3390 (Cont.)
STATEMENT OF OPERATING EXPENSES		Provider CCN:	REPORTING PERIOD	WORKSHEET E-1
AND REVENUES			FROM_____________
			TO________________
PART I		OPO	BLOOD BANK/LAB	TOTAL
REVENUES
1	Whole Blood and Components				1
2	Processing Fees				2
3	Other Blood Products and Services				3
4	Tissue Typing Services				4
5	Other Laboratory Services				5
6	Other Patient Service Fees:				6
7					7
8					8
9					9
10	Kidney Procurement Revenue				10
11	Other Organ Procurement Revenue				11
12	Total Revenue for Services Provided				12
PART II
EXPENSES
1	Operating Expenses (W/S A, column 3, line 26)				1
2	Add (Specify)				2
3					3
4					4
5					5
6	Total Additions				6
7	Deduct (Specify)				7
8			( )		8
9			( )		9
10			( )		10
11	Total Deductions			( )	11
12	Total Operating Expenses (sum of lines 1 and 6 minus 11)				12
	Transfer to Worksheet E-2 Line 4
Form CMS 216-94 (06-2015) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2
Section 3315)
Rev. 6					33-317

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Sheet 16: ws-E-2

3390 (Cont.)		Form CMS-216-94			06-15
STATEMENT OF REVENUES		Provider CCN:	REPORTING PERIOD	WORKSHEET E-2
AND EXPENSES			FROM_____________
			TO________________
1	Total Revenues for Services Provided (W/S E-1, Part I, Line 12)				1
2	Less: Allowances for Discounts on Services			( )	2
3	Net Revenue for Services Provided				3
4	Less: Total Operating Expenses (W/S E-1, Part II Line 12)			( )	4
5	Net Income From Services				5
6	Other Income:				6
7	Contributions				7
8	Income From Investments				8
9	Purchase Discounts				9
10	Rebates and Refunds of Expenses				10
11	Parking Lot Receipts				11
12	Vending Machine Receipts				12
13	Rental or Lease Income				13
14	Income From Sales of Supplies				14
15	Federal Research Grants (Specify)				15
16	Federal Research Grants (Specify)				16
17	Federal Research Grants (Specify)				17
18	Other Research Grants (Specify)				18
19	Other Research Grants (Specify)				19
20	Other (Specify)				20
21	Other (Specify)				21
22	Other (Specify)				22
23	Other (Specify)				23
24	Total Other Income (sum of lines 6-23)				24
25	Total (line 5 plus line 24)				25
26	Other Expenses(Specify)				26
27	Other Expenses(Specify)				27
28	Total Other Expenses (sum of lines 26 & 27)			( )	28
29	Net Income (or Loss) for the Period (line 25 minus line 28)				29
Form CMS 216-94 (06-2015) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2
Section 3316)
33-318					Rev. 6

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Sheet 17: sup ws-A-5-1

06-15

Form CMS-216-94

3390 (Cont.)

STATEMENT OF COSTS OF SERVICES

Provider CCN:

REPORTING PERIOD:

SUPPLEMENTAL

FROM RELATED ORGANIZATIONS

FROM__________________

WORKSHEET

AND HOME OFFICE COSTS

TO_________________

A-5-1

A.

Are there any costs included on Worksheet A which resulted from transactions with related organizations as

defined in the Provider Reimbursement Manual, Part 1, Chapter 10?

[ ] Yes

[ ] No (If "Yes", complete Parts II and III )

B.

Costs incurred and adjustments required as a result of transactions with related organizations or claimed home office costs

AMOUNT OF

NET

LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COLUMN 6

ALLOWABLE

ADJUSTMENT

COST

(COL.4 MINUS

LINE NO.

COST CENTER

EXPENSES ITEMS

AMOUNT

COL. 5)

1

2

3

4

5

6

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1-4) Transfer col.6, line 1-4 to Wkst. A,col.6 as appropriate)

5

(Transfer col.6, line 5 to Wkst. A-5, col.2, line 4, Adjustment to Expenses)

C.

Interrelationship of facility 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 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 section 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) and/or Home Office

(S) AND/ OR HOME OFFICE

Percentage

Percentage

SYMBOL

of

of

Type of

(1)

Name

Ownership

Name

Ownership

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-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, Section 3317)

Rev. 6

33-319