4th Quarter Interim Cost Report

Revisions Crosswalk (Form 276-19)
4th Quarter Interim Cost Report
Note: In Changes to the Application column, the quoted words are what are to be entered. Example in issue #1 is “276-19”; do not enter the words that
explain the change and that are outside of the quotations.

Issue
#
1.

Page #

Section

Worksheet S

Row 59

2.

Worksheet S

Row 68

3.

Worksheet D

Row 73

4.

Worksheet D

Row 147

5.

Worksheet D

Row 223

6.

Worksheet D

Row 303

7.

Worksheet M

Line 24

Action to be
performed
Change form
number
Change Date
Change form
number
Change form
number
Change form
number
Change form
number
Add line to read:

Changes to the Application
Changed form number 276-16 to “276-19”.
Changed Form Expiration Date: 12/31/2019
to “12/31/2022”
Changed form name and number HCFA 27616 to “CMS 276-19”.
Changed form name and number HCFA 27616 to “CMS 276-19”.
Changed form name and number HCFA 27616 to “CMS 276-19”.
Changed form number 276-16 to “276-19”.
“Sequestration Adjustment”

Reason for the Change
To reflect the most recent change in the
form number/year.
Pending approval of the PRA package
renewal.
To reflect the most recent change in the
form number/year.
To reflect the most recent change in the
form number/year.
To reflect the most recent change in the
form number/year.
To reflect the most recent change in the
form number/year.
To report the sequestration amount for the
respective year.

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