CMS-1984-14 Hospice Facility Cost Report

FORM CMS-1984-14

02-21

4390 (Cont.)

THIS REPORT IS REQUIRED BY LAW (42 USC 1395g; 42 CFR.200(B)). COMPLETION OF THIS
REPORT IS VIEWED AS A CONDITION OF YOUR PROVIDER AGREEMENT.
HOSPICE COST AND DATA REPORT

PROVIDER CCN:
____________________

FORM APPROVED
OMB NO. 0938-0758
APPROVAL EXPIRES 04/30/20XX
PERIOD:
WORKSHEET S
FROM _______________ PARTS I & II
TO _______________

PART I - COST REPORT STATUS
ECR DATE
2

1
Provider
use only

Contractor
use only:

ECR TIME
3

1
2
3
4
5

Electronically prepared cost report
Manually prepared cost report
Number of times cost report has been amended
Medicare utilization
Cost report status
[ 1 ] As Submitted
[ 2 ] Reserved
[ 3 ] Reserved
[ 4 ] Reserved
[ 5 ] Amended
6 Date received
7 Contractor number
8 First cost report for this provider CCN
9 Last cost report for this provider CCN
10 Reserved
11 Contractor vendor code
12 Reserved

1
2
3
4
5

6
7
8
9
10
11
12

PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL
AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS
REPORT WERE PROVIDED OR PROCURED 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 CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)
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.

SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR
1
1

2
3
4

CHECKBOX
2

ELECTRONIC
SIGNATURE STATEMENT
1

I have read and agree with the above certification statement.
I certify that I intend my electronic signature on this
certification be the legally binding equivalent of my original
signature.
Signatory Printed Name
Signatory Title
Signature date

2
3
4

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-0758. The time required to complete this information collection is estimated to be 188 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: CMS, 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-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4306)

Rev. 4

43-101

FORM CMS-1984-14

4390 (Cont.)

02-21

HOSPICE IDENTIFICATION DATA

PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

WORKSHEET S-1
PART I

PART I - IDENTIFICATION DATA
1 Name

1
1

2 Street address
3 City
4 County

2
P.O. Box:
State:

1

3
2
3
4

ZIP Code:

2

5 CCN
6 Date hospice began operation

5
6
TITLE XVIII - MEDICARE

TITLE XIX - MEDICAID

FROM

TO

7 Certification date

7
8

8 Cost reporting period
1

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

2

3
9
10

PREMIUMS

PAID LOSSES

SELF-INSURANCE

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

11
12

1
Y/N

Home Office/Chain Organization Information
13 Are HO/CO costs (as defined in CMS Pub. 15-1, §2150ff) claimed? Enter "Y" for yes or "N" for no in col. 1
If yes, enter the home office number in col. 2. (see instructions)

2
HO NUMBER
13

14 HO/CO name

14
1

15 HO/CO street address
16 HO/CO city

2
HO/CO P.O. Box:
HO/CO State:

3
15
16

HO/CO ZIP Code:

17
18

17 HO/CO contractor name
18 HO/CO contractor number
1
Other Information
19 Type of control (see instructions)
20 Number of CBSAs where Medicare covered services were provided during the cost reporting period
21 List each CBSA code where Medicare covered hospices services were provided during the cost reporting period (line 21 contains the first code)

2
19
20
21

FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4307 - 4307.1)

43-102

Rev. 4

08-14

FORM CMS-1984-14

HOSPICE IDENTIFICATION DATA

4390 (Cont.)
PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

WORKSHEET S-1
PART II

PART II - STATISTICAL DATA
TITLE XVIII - MEDICARE
1
30
31
32
33
34

UNDUPLICATED
TITLE XIX - MEDICAID
2

DAYS
OTHER
3

TOTAL
4
30
31
32
33
34

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

PART III - CONTRACTED STATISTICAL DATA
TITLE XVIII - MEDICARE
1

UNDUPLICATED
TITLE XIX - MEDICAID
2

40 Inpatient Respite Care
41 General Inpatient Care

DAYS
OTHER
3

TOTAL
4
40
41

FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4307.2 - 4307.3)

Rev. 1

43-103

4390 (Cont.)

FORM CMS-1984-14

HOSPICE REIMBURSEMENT QUESTIONNAIRE

08-14
PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

WORKSHEET S-2

PROVIDER ORGANIZATION AND OPERATION
Y/N
1

DATE
2

V/I
3

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

1
2

3

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

A/C/R
2

DATE
3
4

5

FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4308)

43-104

Rev. 1

FORM CMS-1984-14

02-21

4390 (Cont.)

HOSPICE REIMBURSEMENT QUESTIONNAIRE

PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

WORKSHEET S-2

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

DATE
2
6
7
8
9
10
11

COST REPORT PREPARER CONTACT INFORMATION
1
12 First name
13 Employer
14 Telephone number

3

2
Last name
Email address

Title

12
13
14

FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4308)

Rev. 4

43-105

4390 (Cont.)

FORM CMS-1984-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

02-21
PROVIDER CCN:
____________________

SALARIES
1

OTHER
2

TOTAL
( SUM OF COL. 1
PLUS COL. 2 )
3

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

RECLASSIFICATIONS
4

PERIOD:
FROM _______________
TO _______________

SUBTOTAL
5

ADJUSTMENTS
6

WORKSHEET A

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

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

FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4310)

43-106

Rev. 4

DRAFT

FORM CMS-1984-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

4390 (Cont.)
PROVIDER CCN:
____________________

SALARIES
1

OTHER
2

TOTAL
( SUM OF COL. 1
PLUS COL. 2 )
3

DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40
Imaging Services**
4000
41
Labs and Diagnostics**
4100
42
Medical Supplies - Non-routine**
4200
4250
42.50
Drugs Charged to Patients**
4300
43
Outpatient Services**
4400
44
Palliative Radiation Therapy**
45
Palliative Chemotherapy**
4500
46
Other Patient Care Services (specify)**
NONREIMBURSABLE COST CENTERS
6000
60
Bereavement Program*
6100
61
Volunteer Program*
6200
62
Fundraising*
6300
63
Hospice/Palliative Medicine Fellows*
64
Palliative Care Program*
6400
65
Other Physician Services*
6500
66
Residential Care *
6600
67
Advertising*
6700
68
Telehealth/Telemonitoring*
6800
69
Thrift Store*
6900
7000
70
Nursing Facility Room & Board*
71
Other Nonreimbursable (specify)*
72 7200
Medicide
100
Total

RECLASSIFICATIONS
4

PERIOD:
FROM _______________
TO _______________

SUBTOTAL
5

ADJUSTMENTS
6

WORKSHEET A

TOTAL
( COL. 5 ± COL. 6 )
7
40
41
42
42.50
43
44
45
46
60
61
62
63
64
65
66
67
68
69
70
71
72
100

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

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

Rev. x

43-107

4390 (Cont.)

FORM CMS-1984-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
CONTINUOUS HOME CARE

DRAFT
PROVIDER CCN:
____________________

SALARIES
1

OTHER
2

TOTAL
( SUM OF COL. 1
PLUS COL. 2 )
3

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

RECLASSIFICATIONS
4

PERIOD:
FROM _______________
TO _______________

SUBTOTAL
5

ADJUSTMENTS
6

WORKSHEET A-1

TOTAL
( COL. 5 ± COL. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
42.50
43
44
45
46
100

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

FORM CMS-1984-14 (04-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

43-108

Rev. x

02-21

FORM CMS-1984-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
ROUTINE HOME CARE

4390 (Cont.)
PROVIDER CCN:
____________________

SALARIES
1

OTHER
2

TOTAL
( SUM OF COL. 1
PLUS COL. 2 )
3

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

RECLASSIFICATIONS
4

PERIOD:
FROM _______________
TO _______________

SUBTOTAL
5

ADJUSTMENTS
6

WORKSHEET A-2

TOTAL
( COL. 5 ± COL. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
42.50
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. B, col. 0, line 51.

FORM CMS-1984-14 (04-2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

Rev. 4

43-109

4390 (Cont.)

FORM CMS-1984-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
INPATIENT RESPITE CARE

02-21
PROVIDER CCN:
____________________

SALARIES
1

OTHER
2

TOTAL
( SUM OF COL. 1
PLUS COL. 2 )
3

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

RECLASSIFICATIONS
4

PERIOD:
FROM _______________
TO _______________

SUBTOTAL
5

ADJUSTMENTS
6

WORKSHEET A-3

TOTAL
( COL. 5 ± COL. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
42.50
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. B, col. 0, line 52.

FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

43-110

Rev. 4

02-21

FORM CMS-1984-14

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
GENERAL INPATIENT CARE

4390 (Cont.)
PROVIDER CCN:
____________________

SALARIES
1

OTHER
2

TOTAL
( SUM OF COL. 1
PLUS COL. 2 )
3

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

RECLASSIFICATIONS
4

PERIOD:
FROM _______________
TO _______________

SUBTOTAL
5

ADJUSTMENTS
6

WORKSHEET A-4

TOTAL
( COL. 5 ± COL. 6 )
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
42.50
43
44
45
46
100

* Transfer the amount in column 7 to Wkst. B, col. 0, line 53.

FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

Rev. 4

43-111

4390 (Cont.)

FORM CMS-1984-14

RECLASSIFICATIONS

02-21
PROVIDER CCN:
____________________

EXPLANATION OF
OF RECLASSIFICATION(S)

CODE(1)
1

COST CENTER
2

INCREASES
WKST A
AMOUNT
LINE NO.
SALARY
OTHER
3
4
4.01

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

COST CENTER
5

PERIOD:
FROM _______________
TO _______________

WORKSHEET A-6

DECREASES
WKST A
AMOUNT
LINE NO.
SALARY
OTHER
6
7
7.01

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

(1)
A letter (A, B, etc.) must be entered on each line to identify each reclassification entry
Transfer the amounts in columns 4, 4.01, 7, and 7.01 to Wkst. A, col. 4, lines as appropriate.

FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4316)

43-112

Rev. 4

07-15

FORM CMS-1984-14

ADJUSTMENTS TO EXPENSES

4390 (Cont.)

PROVIDER CCN:
____________________

DESCRIPTION

BASIS
FOR
ADJUSTMENT(2)
1

(1)

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

AMOUNT
2

PERIOD:
FROM _______________
TO _______________

WORKSHEET A-8

EXPENSE CLASSIFICATION
ON WKST. A TO / FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
WKST A.
LINE NO.
COST CENTER
3
4

LOC
WKST INDICATOR
5
1
2

Wkst.
A-8-1
B
B

3
Dietary

8

4

Administrative and General

4

5
6

A

7

7 Patient personal purchases
8 Depreciation - buildings and fixtures

Buildings & Fixtures

1

8

9 Depreciation - movable equipment

Movable Equipment

2

9

Nursing Facility Room & Board

70

10

10 Revenue - State-redirected room and board
11 Other adjustments (specify)

B

(3)

11

12

12

13

13

14

14

15

15

50 TOTAL (sum of lines 1 through 49)
(transfer to Wkst. A, col. 6, line 100)

50

(1)
(2)

(3)

Description - all chapter references in this column pertain to CMS Pub. 15-1
Basis for adjustment (see instructions)
A. Costs - if cost, including applicable overhead, can be determined
B. Amount Received - if cost cannot be determined
Additional adjustments may be made on lines 11 thru 49 and subscripts thereof

FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4318)

Rev. 2

43-113

4390 (Cont.)

FORM CMS-1984-14

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

PROVIDER CCN:
____________________

07-15
PERIOD:
FROM _______________
TO _______________

WORKSHEET A-8-1

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR
CLAIMED HOME OFFICE COSTS
NET
AMOUNT
ADJUSTMENTS
WKST. A
AMOUNT
ALLOWABLE
(COL. 4 MINUS
LINE
INCLUDED
COST CENTER
EXPENSE ITEMS
IN WKST. A
COL. 5) *
NUMBER
IN COST
2
3
5
6
1
4
1
2
3
4
5
6
7
8
9
10 TOTALS (sum of lines 1 through 9)
(transfer col. 6, line 10 to Wkst. A-8, col. 2, line 3)

LOC WS
INDICATOR
7
1
2
3
4
5
6
7
8
9
10

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

PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND / OR HOME OFFICE
THE SECRETARY, BY VIRTUE OF THE AUTHORITY GRANTED UNDER SECTION 1814(B)(1) OF THE SOCIAL SECURITY ACT, REQUIRES THAT YOU
FURNISH THE INFORMATION REQUESTED UNDER PART II OF THIS WORKSHEET.
This information is used by the Centers for Medicare and Medicare Services and its contractors in determining that the costs applicable to services, facilities, and supplies
furnished by organizations related to you by common ownership or control represent reasonable costs as determined under section 1861 of the Social Security Act. If you
do not provide all or any part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under
title XVIII.

SYMBOL(1)
1

NAME
2

PERCENTAGE
OF
OWNERSHIP
3

RELATED ORGANIZATION(S) AND/OR HOME OFFICE
PERCENTAGE
TYPE OF
OF
NAME
BUSINESS
OWNERSHIP
4
5
6

1
2
3
4
5
6
7
8
9
10

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

Use the followings symbols to indicate interrelationship to related organizations:
A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.
B. Corporation, partnership or other organization has financial interest in provider.
C. Provider has financial interest in corporation, partnership, or other organization.
D. Director, officer, administrator or key person of provider or organization.
E. Individual is director, officer, administrator or key person of provider and related organization.
F. Director, officer, administrator or key person of related organization or relative of such person has financial interest in provider.
G. Other (financial or non-financial) specify ______________________________________________________________

FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4319)

43-114

Rev. 2

DRAFT

FORM CMS-1984-14

COST ALLOCATION

4390 (Cont.)
PROVIDER CCN:
____________________

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

NET
EXPENSES
FOR ALLOC.
0

CAP REL
BLDG
& FIX
1

CAP REL
MVBLE
EQUIP
2

EMPLOYEE
SUBTOTAL
BENEFITS
(SUM COLS 0
DEPARTMENT THROUGH 3)
3
3A

ADMINISTRATIVE &
GENERAL
4

PLANT
OP &
MAINT
5

PERIOD:
FROM _______________
TO _______________

WORKSHEET B

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

6

7

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

FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. x

43-115

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION

DRAFT
PROVIDER CCN:
____________________

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

NET
EXPENSES
FOR ALLOC.
0

CAP REL
BLDG
& FIX
1

CAP REL
MVBLE
EQUIP
2

EMPLOYEE
SUBTOTAL
BENEFITS
(SUM COLS 0
DEPARTMENT THROUGH 3)
3
3A

ADMINISTRATIVE &
GENERAL
4

PLANT
OP &
MAINT
5

PERIOD:
FROM _______________
TO _______________

WORKSHEET B

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

6

7

8
60
61
62
63
64
65
66
67
68
69
70
71
72
100
101

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

43-116

Rev. x

DRAFT

FORM CMS-1984-14

COST ALLOCATION

4390 (Cont.)
PROVIDER CCN:
____________________

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

NURSING
ADMINISTRATION
9

ROUTINE
MEDICAL
SUPPLIES
10

MEDICAL
RECORDS
11

STAFF
TRANSPORTATION
12

VOLUNTEER
SVC COORDINATION
13

PHARMACY

14

PERIOD:
FROM _______________
TO _______________

PHYSICIAN
ADMINISTRATIVE SVCS
15

OTHER
GENERAL
SERVICE
16

WORKSHEET B

PATIENT /
RESIDENTIAL
CARE SVCS
17

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

FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. X

43-117

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION

DRAFT
PROVIDER CCN:
____________________

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

NURSING
ADMINISTRATION
9

ROUTINE
MEDICAL
SUPPLIES
10

MEDICAL
RECORDS
11

STAFF
TRANSPORTATION
12

VOLUNTEER
SVC COORDINATION
13

PHARMACY

14

PERIOD:
FROM _______________
TO _______________

PHYSICIAN
ADMINISTRATIVE SVCS
15

OTHER
GENERAL
SERVICE
16

WORKSHEET B

PATIENT /
RESIDENTIAL
CARE SVCS
17

TOTAL
18
60
61
62
63
64
65
66
67
68
69
70
71
72
100
101

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

43-118

Rev. x

DRAFT

FORM CMS-1984-14

COST ALLOCATION - STATISTICAL BASIS

4390 (Cont.)
PROVIDER CCN:
____________________

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

CAP REL
BLDG
& FIX
SQUARE
FEET
1

CAP REL
MVBLE
EQUIP
DOLLAR
VALUE
2

EMPLOYEE
BENEFITS
DEPARTMENT
GROSS
SALARIES
3

RECONCILIATION
4A

ADMINISTRATIVE &
GENERAL
ACCUM.
COST
4

PLANT
OP &
MAINT
SQUARE
FEET
5

PERIOD:
FROM _______________
TO _______________

WORKSHEET B-1

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

IN-FACILITY DAYS
6

SQUARE
FEET
7

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

FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. X

43-119

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION - STATISTICAL BASIS

DRAFT
PROVIDER CCN:
____________________

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

CAP REL
BLDG
& FIX
SQUARE
FEET
1

CAP REL
MVBLE
EQUIP
DOLLAR
VALUE
2

EMPLOYEE
BENEFITS
DEPARTMENT
GROSS
SALARIES
3

RECONCILIATION
4A

ADMINISTRATIVE &
GENERAL
ACCUM.
COST
4

PLANT
OP &
MAINT
SQUARE
FEET
5

PERIOD:
FROM _______________
TO _______________

WORKSHEET B-1

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

IN-FACIL
ITY DAYS
6

SQUARE
FEET
7

IN-FACIL
ITY DAYS
8
60
61
62
63
64
65
66
67
68
69
70
71
72
100
101
102

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

43-120

Rev. X

DRAFT

FORM CMS-1984-14

COST ALLOCATION - STATISTICAL BASIS

4390 (Cont.)
PROVIDER CCN:
____________________

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

NURSING
ADMINISTRATION
DIRECT
NURS. HRS.
9

ROUTINE
MEDICAL
SUPPLIES
PATIENT
DAYS
10

MEDICAL
RECORDS
PATIENT
DAYS
11

STAFF
TRANSPORTATION
MILEAGE
12

VOLUNTEER
SVC COORDINATION
HOURS OF
SERVICE
13

PHARMACY

CHARGES
14

PERIOD:
FROM _______________
TO _______________

PHYSICIAN
ADMINISTRATIVE SVCS
PATIENT
DAYS
15

OTHER
GENERAL
SERVICE
SPECIFY
BASIS
16

WORKSHEET B-1

PATIENT /
RESIDENTIAL
CARE SVCS
IN-FACIL
ITY DAYS
17

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

FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. X

43-121

4390 (Cont.)

FORM CMS-1984-14

COST ALLOCATION - STATISTICAL BASIS

DRAFT
PROVIDER CCN:
____________________

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

NURSING
ADMINISTRATION
DIRECT
NURS. HRS.
9

ROUTINE
MEDICAL
SUPPLIES
PATIENT
DAYS
10

MEDICAL
RECORDS
PATIENT
DAYS
11

STAFF
TRANSPORTATION
MILEAGE
12

VOLUNTEER
SVC COORDINATION
HOURS OF
SERVICE
13

PHARMACY

CHARGES
14

PERIOD:
FROM _______________
TO _______________

PHYSICIAN
ADMINISTRATIVE SVCS
PATIENT
DAYS
15

OTHER
GENERAL
SERVICE
SPECIFY
BASIS
16

WORKSHEET B-1

PATIENT /
RESIDENTIAL
CARE SVCS
IN-FACIL
ITY DAYS
17

TOTAL
18
60
61
62
63
64
65
66
67
68
69
70
71
72
100
101
102

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

43-122

Rev. X

08-14
CALCULATION OF PER DIEM COST

FORM CMS-1984-14

4390 (Cont.)

PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

TITLE XVIII
MEDICARE
1

TITLE XIX
MEDICAID
2

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

WORKSHEET C

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

FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4330)

Rev. 1

43-123

4390 (Cont.)

FORM CMS-1984-14

BALANCE SHEET

PROVIDER CCN:
____________________

08-14
PERIOD:
FROM _______________
TO _______________

WORKSHEET F

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

AMOUNT

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

AMOUNT

(

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

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

) = contra amount

FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.1)

43-124

Rev. 1

02-21
STATEMENT OF CHANGES
IN FUND BALANCES

FORM CMS-1984-14
PROVIDER CCN:
____________________

GENERAL
FUND
1

4390 (Cont.)
PERIOD:
FROM _______________
TO _______________

SPECIFIC
PURPOSE FUND
2

ENDOWMENT
FUND
3

WORKSHEET F-1

PLANT
FUND
4

1 Fund balances at beginning
of period
2 Net income / (loss)
(from Wkst. F-2, line 42)
3 Total
(sum of line 1 and line 2)
4 Additions (credit adjustments)
(specify)
5

1

6

6

7

7

8

8

9

9

2
3
4
5

10 Total additions
(sum of lines 4 through 9)
11 Subtotal
(line 3 plus line 10)
12 Deductions (debit adjustments)
(specify)
13

10

14

14

15

15

16

16

17

17

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

18

11
12
13

19

FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.2)

Rev. 4

43-125

4390 (Cont.)
STATEMENT OF REVENUES
AND OPERATING EXPENSES

FORM CMS-1984-14

02-21

PROVIDER CCN:
____________________

PERIOD:
FROM _______________
TO _______________

WORKSHEET F-2

PART I - REVENUES
TITLE XVIII
MEDICARE
1
GROSS
1
2
3
4
5
6
7
8
OTHER
9
10
11
12
13
14
15
16
16.50
17
18
19
20
21
22
23
24
25
26

TITLE XIX
MEDICAID
2

PATIENT REVENUE
Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Drug copay / coinsurance
Total gross patient revenue (sum of lines 1 through 5)
Less: Contractual allowances and discounts
Net patient revenue (line 6 minus line 7)
REVENUE
Hospice physician services
Room and board
Palliative consults / Other phys. services
Donations / Charitable contributions
Rebates / refunds of expenses
Income from investments
Governmental appropriations
Other (specify)
COVID-19 PHE Funding

OTHER
3

TOTAL
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
16.50
17
18
19
20
21
22
23
24
25
26

`

Total revenues (sum of lines 8 through 25)

PART II - OPERATING EXPENSES
1
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

2

3

Operating expenses (per Wkst A, col. 3, line 100)
Add (specify)

Total additions (sum of lines 28 through 33)
Deduct (specify)

Total deductions (sum of lines 35 through 39)
Total operating expenses (sum of lines 27 and 34, minus line 40)
Net income / (loss) for the period (line 26 minus line 41)

4
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.3)

43-126

Rev. 4