{"text_format":"2","workbook":"xls","n_sheets":51,"sheets":["S","S-2","S-3","S-3, Pt IV","S-4","S-5","S-6","A","A-1","A-2","A-3","A-4","A-5","A-6","A-7","A83-1","A83-2","B,B-1","C^","D^","D-1","F","F-1","F-2","J-1 & J-2","J-1, PT3","J-3","J-4","K","K-1","K-2","K-3","K-4I","K-4II","K-5I","K-5II","K-5III","K-6","CM-1 & CM-2^","CM-1, PT3^","CM-3^","CM-4^","RHC","RH-1, PT3","FQHC","FQ-1, PT3","RF-1","RF-2","RF-3^","RF-4^","RF-5"],"not_rendered":{"charts":0,"images":0,"macros":0,"external_links":1,"defined_names":61,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"run_cost":"one","rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900","formulas":"cached_only"}

{"sheet":"S","index":0,"n_rows":70,"n_cols":10,"rows_kept":70,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["06-01",null,null,null,"FORM CMS 1728-94",{"$nulls":4},"3290 (Cont.)"]
["This report is required by law (42 USC 1395g; 42 CFR 413.20(b)).  Failure to report can result"]
["in all interim payments made since the beginning of the cost reporting period  being deemed",{"$nulls":6},"         FORM APPROVED"]
["as overpayments (42 USC 1395g).",{"$nulls":6},"         OMB NO. 0938-0022"]
["HOME HEALTH AGENCY COST REPORT",null,null,null,"   PROVIDER NO.:",null,"   PERIOD:"]
["CERTIFICATION AND SETTLEMENT SUMMARY",{"$nulls":5},"From:  ___________",null,"WORKSHEET S"]
[{"$nulls":4},"    _______________",null,"To: ___________"]
[null,"      Intermediary Use Only:"]
[]
[null,"[ ]  Audited","Date Received",null,"____________","[  ]","Initial",null,"[  ]  Re-opened"]
[null,"[ ]  Desk Reviewed","Intermediary No.",null,"____________","[  ]","Final"]
[]
["PART I - CERTIFICATION"]
[]
["Check ",null,"[  ]","Electronically filed cost report",null,null,"Date: ___________"]
["applicable box",null,"[  ]","Manually submitted cost report",null,null,"Time: ___________"]
["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."]
[]
[null,null,null,"CERTIFICATION BY OFFICER OR DIRECTOR OF THE AGENCY"]
[]
[null,"I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying"]
[null,"Home Health Agency Cost Report and the Balance Sheet and Statement of Revenue and Expenses"]
[null,"prepared by _________________________________________(Provider name(s) and number(s)) for the cost"]
[null,"report beginning _____________________and ending __________________________, and that to the"]
[null,"best of my knowledge and belief, it is a true, correct and complete report prepared from the"]
[null,"books and records of the provider in accordance with applicable instructions, except as noted. "]
[null,"I further certify that I am familiar with the laws and regulations regarding the provision of "]
[null,"health care services, and that the services identified in this cost report were provided in"]
[null,"compliance with such laws and regulations."]
[]
[null,null,"(Signed)","__________________________________________"]
[null,null,null,"  Officer or Director"]
[null,null,null,"__________________________________________"]
[null,null,null,"  Title"]
[null,null,null,"__________________________________________"]
[null,null,null,"  Date"]
[]
[]
[]
["PART II - SETTLEMENT SUMMARY"]
[]
[{"$nulls":5},"     TITLE XVIII"]
[{"$nulls":4},"PART A",null,null,"PART B",null," "]
[{"$nulls":4},"1",null,null,"2",null," "]
[]
["1","HOME HEALTH AGENCY",{"$nulls":7},"1"]
[]
["2","HOME HEALTH-BASED CORF",{"$nulls":7},"2"]
[]
["3","HOME HEALTH-BASED CMHC",{"$nulls":7},"3"]
[3.5,"HOME HEALTH-BASED RHC/FQHC",{"$nulls":7},3.5]
[null,"(specify)"]
[]
[4,"TOTAL",{"$nulls":7},4]
[]
["\"According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid"]
["OMB control number.  The valid OMB control number for this information collection is 0938-0022.  The time required to complete this"]
["information collection is estimated to average 176 hours per response, including the time to review instructions, search existing data resources,"]
["gather the data needed, and complete and review the information collection.  If you have any comments concerning the accuracy of the time"]
["estimate(s) or suggestions for improving this form, please write to:  CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail"]
["Stop C4-26-05, Baltimore, Maryland  21244-1850.\""]
[]
[]
["FORM CMS-1728-94-S (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS. 3203-3203.2)"]
[]
["Rev. 10",{"$nulls":8},"32-303"]

{"sheet":"S-2","index":1,"n_rows":70,"n_cols":29,"rows_kept":70,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":13},"FORM CMS 1728-94",{"$nulls":13},"06-01"]
["HOME HEALTH AGENCY COMPLEX",{"$nulls":11},"PROVIDER NO.:",{"$nulls":4},"PERIOD:"]
["IDENTIFICATION DATA",{"$nulls":16},"From:  ___________",{"$nulls":5},"  WORKSHEET S-2"]
[{"$nulls":12},"________________",{"$nulls":4},"To: ___________"]
[]
["Home Health Agency Complex Address:"]
[1,null,"Street:",{"$nulls":13},"P.O. Box:",{"$nulls":11},"1"]
[1.01,null,"City:",{"$nulls":7},"State:",{"$nulls":5},"Zip Code:",{"$nulls":11},"1.01"]
[]
["Home Health Agency Component Identification"]
[]
[null,"Component",{"$nulls":6},"Component Name",{"$nulls":8},"Provider No.",{"$nulls":5},"Date Certified"]
[{"$nulls":4},"0",{"$nulls":7},"1",{"$nulls":6},2,{"$nulls":5},"3"]
["2",null,"Home Health Agency",{"$nulls":25},"2"]
["3",null,"HHA-based CORF",{"$nulls":25},"3"]
[3.5,null,"HHA-based Hopsice",{"$nulls":25},3.5]
["4",null,"HHA-based CMHC",{"$nulls":25},"4"]
["5",null,"HHA- based RHC",{"$nulls":25},"5"]
["6",null,"HHA-based FQHC",{"$nulls":25},"6"]
[]
["7","Cost Reporting Period (mm/dd/yyyy)",{"$nulls":13},"From: ______________",{"$nulls":7},"To: ______________",{"$nulls":4},"7"]
[]
["8","Type of control (see instructions)",{"$nulls":26},"8"]
[]
[9,"If this a low or no Medicare utilization cost report,",{"$nulls":26},9]
[null,"enter \"L\" for Low or \"N\" for No Medicare Utilization."]
[]
["Depreciation: Enter the amount of depreciation reported in this HHA for the methods indicated."]
[10,"Straight Line",{"$nulls":26},10]
[11,"Declining Balance",{"$nulls":26},11]
[12,"Sum of the Years' Digits",{"$nulls":26},12]
[13,"Sum of lines 10, 11 and 12",{"$nulls":26},13]
[]
[14,"Were there any disposals of capital assets during this cost reporting period?",{"$nulls":26},14]
[15,"Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period?",{"$nulls":26},15]
[16,"Was accelerated depreciation claimed on assets acquired on or after August l, l970 (See PRM 15-1,",{"$nulls":26},16]
[null,"Chapter l)?"]
[17,"If depreciation is funded, enter the balance at end of period.",{"$nulls":26},17]
[18,"Did the provider cease to participate in the Medicare program at the end of",{"$nulls":26},18]
[null,"the period to which this cost report applies (See PRM 15-1, Chapter 1)?"]
[19,"Was there substantial decrease in health insurance proportion of allowable",{"$nulls":26},19]
[null,"costs from prior cost reporting periods (See PRM 15-1, Chapter 1)?"]
[20,"Does the provider qualify as a small HHA (defined in 42 CFR 413.24(d))?",{"$nulls":26},20]
[21,"Does the home health agency qualify as a nominal charge provider (defined in 42 CFR 409.3)?",{"$nulls":26},21]
[22,"Does the home health agency contract with outside suppliers for physical therapy services?",{"$nulls":26},22]
[22.01,"Does the home health agency contract with outside suppliers for occupational therapy services?",{"$nulls":26},22.01]
[22.02,"Does the home health agency contract with outside suppliers for speech therapy services?",{"$nulls":26},22.02]
[]
["If this facility contains a non-public provider that qualifies for an exemption from the application of the"]
["lower of costs or charges, enter \"Y\" for each component and type of service that qualifies for the exemption."]
[null,"               ",{"$nulls":21},"Part A",null,null,"Part B"]
[{"$nulls":23},"1",null,null,"2"]
[23,"Home Health Agency",{"$nulls":26},23]
[24,"CORF",{"$nulls":26},24]
[25,"CMHC",{"$nulls":26},25]
[26,"If the home health agency componentized (or fragmented) its administrative and general service",{"$nulls":26},26]
[null,"costs, indicate whether option one or option two is being utilized.  (See PRM-II, Section 3214)"]
[null,"(Enter \"1\" for option one and \"2\" for option two)"]
[]
["27","List amounts of malpractice premiums and paid losses:",{"$nulls":26},"27"]
[27.01,"Premiums",{"$nulls":26},27.01]
[27.02,"Paid Losses",{"$nulls":26},27.02]
[27.03,"Self Insurance",{"$nulls":26},27.03]
["28","Are malpractice premiums and/or paid losses reported in other than the Administrative and General",{"$nulls":26},"28"]
[null,"cost center? If yes, submit a supporting schedule listing cost centers and amounts contained therein."]
[]
["FORM CMS 1728-94-S-2  (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,"]
["SECTION 3204)"]
[]
["32-304",{"$nulls":27},"Rev. 10"]

{"sheet":"S-3","index":2,"n_rows":68,"n_cols":11,"rows_kept":68,"cut":false,"hidden":false,"merged":[[7,8,7,9],[7,6,7,7],[7,4,7,5]],"flags":["formulas_cached_only"]}
["06-01",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":4},"3290 (Cont.)"]
["HOME HEALTH AGENCY",{"$nulls":4},"  PROVIDER NO.:",null,"  PERIOD:",null,"WORKSHEET S-3"]
["STATISTICAL DATA",{"$nulls":6},"From:  ___________",null,"PARTS I - III"]
[{"$nulls":5},"  ______________",null,"To: ___________"]
[]
["PART I - STATISTICAL DATA",{"$nulls":5},"COUNTY","Cook"]
[]
[{"$nulls":4},"Title XVIII",null,"Other",null,"Total"]
[null,"     DESCRIPTION",null,null,"Visits","Patients","Visits","Patients","Visits","Patients"]
[{"$nulls":4},"1","2","3","4","5","6"]
[" 1"," Skilled Nursing",{"$nulls":8}," 1"]
[" 2"," Physical Therapy",{"$nulls":8}," 2"]
[" 3"," Occupational Therapy",{"$nulls":8}," 3"]
[" 4"," Speech Pathology",{"$nulls":8}," 4"]
[" 5"," Medical Social Service",{"$nulls":8}," 5"]
[" 6"," Home Health Aide",{"$nulls":8}," 6"]
[" 7"," All Other Services",{"$nulls":8}," 7"]
[" 8"," Total Visits",{"$nulls":8}," 8"]
[" 9"," Home Health Aide Hours",{"$nulls":8}," 9"]
["10"," Unduplicated Census Count -",{"$nulls":8},"10"]
[null," Full Cost Reporting Period"]
[10.01," Unduplicated Census Count -",{"$nulls":8},10.01]
[null," Pre 10/1/2000"]
[10.02," Unduplicated Census Count -",{"$nulls":8},10.02]
[null," Post 9/30/2000"]
[]
["PART II - EMPLOYMENT DATA"]
["(FULL TIME EQUIVALENT)"]
[]
[null,"Number of hours in"]
[null,"your normal work week __________",{"$nulls":5},"Staff","Contract","Total"]
[{"$nulls":7},"1",2,"3"]
[11,"Administrator and Assistant Administrator(s)",{"$nulls":8},11]
[12,"Director and Assistant Director(s)",{"$nulls":8},12]
[13,"Other Administrative Personnel",{"$nulls":8},13]
[14,"Direct Nursing Service",{"$nulls":8},14]
[15,"Nursing Supervisor",{"$nulls":8},15]
[16,"Physical Therapy Service",{"$nulls":8},16]
[17,"Physical Therapy Supervisor",{"$nulls":8},17]
[18,"Occupational Therapy Service",{"$nulls":8},18]
[19,"Occupational Therapy Supervisor",{"$nulls":8},19]
[20,"Speech Pathology Service",{"$nulls":8},20]
[21,"Speech Pathology Supervisor",{"$nulls":8},21]
[22,"Medical Social Service",{"$nulls":8},22]
[23,"Medical Social Supervisor",{"$nulls":8},23]
[24,"Home Health Aide",{"$nulls":8},24]
[25,"Home Health Aide Supervisor",{"$nulls":8},25]
[26,{"$nulls":9},26]
[27,{"$nulls":9},27]
[]
["PART III - METROPOLITAN STATISTICAL AREA (MSA) CODE DATA"]
[null,"Enter the total number of MSAs in which Medicare covered services were provided during the"]
[28,"cost reporting period.",{"$nulls":8},28]
[null,"List all MSA codes in which Medicare covered home health services were provided during the",{"$nulls":7},"MSA Codes"]
[29,"cost reporting period (line 29 contains the first code):",{"$nulls":8},29]
[{"$nulls":10},29.01]
[{"$nulls":10},29.02]
[{"$nulls":10},29.03]
[{"$nulls":10},29.04]
[{"$nulls":10},29.05]
[{"$nulls":10},29.06]
[{"$nulls":10},29.07]
[{"$nulls":10},29.08]
[{"$nulls":10},29.09]
["FORM CMS-1728-94 (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,"]
["SEC. 3205) "]
[]
["Rev. 10",{"$nulls":9},"32-305"]

{"sheet":"S-3, Pt IV","index":3,"n_rows":49,"n_cols":11,"rows_kept":49,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":4},"06-01"]
["HOME HEALTH AGENCY",{"$nulls":4},"  PROVIDER NO.:",null,"  PERIOD:",null,"WORKSHEET S-3"]
["STATISTICAL DATA",{"$nulls":6},"From:  ______________",null,"PART IV"]
[{"$nulls":5},"  ______________",null,"To: ______________"]
[]
["PART IV - PPS ACTIVITY DATA - Applicable for Services Rendered on or After October 1, 2000",{"$nulls":6},"Cook"]
[]
[null,null,null,"Full Episodes","Full Episodes","LUPA Episodes","PEP Only","SCIC within a","SCIC Only","Totals"]
[null,"     DESCRIPTION",null,"without Outliers","with Outliers",null,"Episodes","PEP","Episodes"]
[null,null,null,1,2,3,4,5,6,7]
[30,"Skilled Nursing Visits",{"$nulls":8},30]
[31,"Skilled Nursing Visit Charges",{"$nulls":8},31]
[32,"Physical Therapy Visits",{"$nulls":8},32]
[33,"Physical Therapy Visit Charges",{"$nulls":8},33]
[34,"Occupational Therapy Visits",{"$nulls":8},34]
[35,"Occupational Therapy Visit Charges",{"$nulls":8},35]
[36,"Speech Pathology Visits",{"$nulls":8},36]
[37,"Speech Pathology Visit Charges",{"$nulls":8},37]
[38,"Medical Social Service Visits",{"$nulls":8},38]
[39,"Medical Social Service Visit Charges",{"$nulls":8},39]
[40,"Home Health Aide Visits",{"$nulls":8},40]
[41,"Home Health Aide Visit Charges",{"$nulls":8},41]
[42,"Total Visits (Sum of lines 30,32,34,36,38,40)",{"$nulls":8},42]
[43,"Other Charges",{"$nulls":8},43]
[44,"Total Charges (Sum of lines 31,33,35,37,39,41,43)",{"$nulls":8},44]
[45,"Total Number of Episodes",{"$nulls":8},45]
[46,"Total Number of Outlier Episodes",{"$nulls":8},46]
[47,"Total Non-Routine Medical Supply Charges",{"$nulls":8},47]
{"$rows_empty":18}
["FORM CMS-1728-94 (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3205) "]
[]
["32-305.1",{"$nulls":9},"Rev. 10"]

{"sheet":"S-4","index":4,"n_rows":82,"n_cols":18,"rows_kept":82,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["06-01",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":8},"3290 (Cont.)"]
["HHA-BASED RURAL HEALTH CLINIC/",{"$nulls":7},"PROVIDER NO.:",null,null,null,"PERIOD:",null,null,"WORKSHEET S-4"]
["FEDERALLY QUALIFIED HEALTH CENTER",{"$nulls":7},"_____________",null,null,null,"FROM: __________"]
["PROVIDER STATISTICAL DATA",{"$nulls":7},"COMPONENT NO.:",null,null,null,"TO: ___________"]
[{"$nulls":8},"_____________"]
["Check ",null,null,"  [  ]  RHC"]
["Applicable Box",null,null,"  [  ]  FQHC"]
[]
["Clinic Address and Identification:"]
[1,"Street:",{"$nulls":15},1]
[1.01,"City:",{"$nulls":6},"State:",null,null,null,"Zip Code:",null,"County:",null,null,1.01]
[2,"Designation (for FQHCs only) - Enter \"R\" for rural or \"U\" for urban",{"$nulls":15},2]
[]
["Source of Federal Funds:",{"$nulls":12},"Grant Award",null,"Date"]
[{"$nulls":13},1,null,2]
[3,"Community Health Center (Section 330(d), PHS Act)",{"$nulls":15},3]
[4,"Migrant Health Center (Section 329(d), PHS Act)",{"$nulls":15},4]
[5,"Health Services for the Homeless (Section 340(d), PHS Act)",{"$nulls":15},5]
[6,"Appalachian Regional Commission",{"$nulls":15},6]
[7,"Look-Alikes",{"$nulls":15},7]
[8,"Other (specify)",{"$nulls":15},8]
[]
["Physician Information:",{"$nulls":12},"Physician",null,"Billing"]
[{"$nulls":13},"Name",null,"Number"]
[9,"Physician(s) furnishing services at the clinic or under agreement (see instructions)",{"$nulls":15},9]
[]
[{"$nulls":13},"Physician",null,"Hours of"]
[{"$nulls":13},"Name",null,"Supervision"]
[10,"Supervisory physician(s) and hours of supervision during period (see instructions)",{"$nulls":15},10]
[]
[11,"Does the facility operate as other than an RHC or FQHC?  If yes, indicate number of other operations in column 2 and ",{"$nulls":15},11]
[null,"list the other type(s) of operation(s) and hours on subscripts of line 12."]
[]
[null,"Enter the clinic hours on line 12 and list the other type(s) of operation(s) and hours on subscripts of line 12. (1)"]
[null,null,null,"Sunday",null,"Monday",null,"Tuesday",null,"Wednesday",null,"Thursday",null,"Friday",null,"Saturday"]
[null,null,null,"from","to","from","to","from","to","from","to","from","to","from","to","from","to"]
[null,0,null,1,2,3,4,5,6,7,8,9,10,11,12,13,14]
[12,"Clinic",{"$nulls":15},12]
[12.01,"Specify:",{"$nulls":15},12.01]
[12.02,"Specify:",{"$nulls":15},12.02]
[12.03,"Specify:",{"$nulls":15},12.03]
[]
[null,"(1) List hours of operation based on a 24 hour clock.  For example, 8:30am is 0830, 5:30pm is 1730 and 12 midnight is 2400. "]
[]
[13,"Has the facility been approved for an exception to the productivity standard?",{"$nulls":15},13]
[14,"Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)?  If yes, enter in column 2 the",{"$nulls":15},14]
[null,"number of providers included in this report.  List all provider names and numbers below."]
[15,"Provider name: ______________________________",{"$nulls":7},"Provider number: _______________",{"$nulls":7},15]
[15.01,"Provider name: ______________________________",{"$nulls":7},"Provider number: _______________",{"$nulls":7},15.01]
[15.02,"Provider name: ______________________________",{"$nulls":7},"Provider number: _______________",{"$nulls":7},15.02]
[15.03,"Provider name: ______________________________",{"$nulls":7},"Provider number: _______________",{"$nulls":7},15.03]
[16,"Are you claiming allowable and/or non-allowable GME costs as a result of \"substantial payment\" for interns",{"$nulls":15},16]
[null,"and residents?  If yes, enter the number of Medicare visits in column 2  performed by interns and residents"]
[null,"and complete Worksheet RF-1, lines 20 and 27 as applicable."]
{"$rows_empty":25}
["FORM CMS-1728-94-S4  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3233)"]
[]
["Rev. 10",{"$nulls":16},"32-305.2"]

{"sheet":"S-5","index":5,"n_rows":63,"n_cols":12,"rows_kept":63,"cut":false,"hidden":false,"merged":[[8,7,8,8]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":5},"FORM CMS-1728-94",{"$nulls":4},"06-01"]
[{"$nulls":6},"PROVIDER NO.:",null,"PERIOD:"]
["HOSPICE IDENTIFICATION DATA ",{"$nulls":5},"_____________",null,"FROM: _____________",null,"WORKSHEET S-5"]
[{"$nulls":6},"HOSPICE NO.:",null,"TO: ________________"]
[{"$nulls":6},"_____________"]
[]
[]
["PART I"]
[{"$nulls":7},"Title XVIII",null,null,"Total"]
[{"$nulls":8},"Unduplicated",null,"Unduplicated"]
[{"$nulls":8},"Skilled","Other"," Days"]
[{"$nulls":7},"Unduplicated","Nursing","Unduplicated","(sum of"]
[null,null,null,"Enrollment Days",null,null,null,"Days","Facility Days","Days","cols. 1 & 3)"]
[{"$nulls":7},1,2,3,4]
[1,"Continuous Home Care",{"$nulls":9},1]
[2,"Routine Home Care",{"$nulls":9},2]
[3,"Inpatient Respite Care ",{"$nulls":9},3]
[4,"General Inpatient Care",{"$nulls":9},4]
[5,"Total Hospice Days",{"$nulls":9},5]
[]
["PART II"]
[{"$nulls":8},"Title XVIII"]
[{"$nulls":8},"Skilled",null,"Total"]
[{"$nulls":8},"Nursing",null,"(sum of"]
[null,null,"Census Data",{"$nulls":4},"Title XVIII","Facility","Other","cols. 1 & 3)"]
[{"$nulls":7},1,2,3,4]
[6,"Number of Patients Receiving",{"$nulls":9},6]
[null,"Hospice Care"]
[7,"Total Number of Unduplicated",{"$nulls":9},7]
[null,"Continuous Care Hours"]
[null,"Billable to Medicare"]
[8,"Average Length of Stay (line 5 divided by line 6)",{"$nulls":9},8]
[9,"Unduplicated Census Count",{"$nulls":9},9]
[]
[]
["NOTE:   Parts I & II, column 1 also includes the days reported in column 2."]
{"$rows_empty":24}
["FORM CMS-1728-94-S-5 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,"]
["SECTIONS 3239 - 3239.2)"]
["32-306",{"$nulls":10},"Rev. 10"]

{"sheet":"S-6","index":6,"n_rows":55,"n_cols":56,"rows_kept":55,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":30},"FORM CMS 1728-94",{"$nulls":23},"3290 (Cont.)"]
["HHA-BASED CORF STATISTICAL DATA",{"$nulls":16},"PROVIDER NO.: _______________",{"$nulls":15},"PERIOD:",{"$nulls":15},"SUPPLEMENTAL"]
[{"$nulls":17},"CORF NO.: _______________",{"$nulls":15}," ","From:  ___________",{"$nulls":5}," ",{"$nulls":8},"WORKSHEET S-6"]
[{"$nulls":21}," ",{"$nulls":11}," ","To: ___________",{"$nulls":5}," "]
[null,null,"CORF TREATMENTS",{"$nulls":28},"Title XVIII",{"$nulls":7},"Other",{"$nulls":7},"Total"]
[{"$nulls":31},"Treatments",null,null,null,"Patients",null,null,null,"Treatments",null,null,null,"Patients",null,null,null,"Treatments",null,null,null,"Patients"]
[{"$nulls":31},1,null,null,null,2,null,null,null,3,null,null,null,4,null,null,null,5,null,null,null,6]
[1,"Skilled Nursing Care",{"$nulls":53},1]
[2,"Physical Therapy",{"$nulls":53},2]
[3,"Occupational Therapy",{"$nulls":53},3]
[4,"Speech Pathology",{"$nulls":53},4]
[5,"Medical Social Services",{"$nulls":53},5]
[6,"Respiratory Therapy",{"$nulls":53},6]
[7,"Psychological Services",{"$nulls":53},7]
[8,"All Other Service",{"$nulls":53},8]
[9,"Total Treatments (Sum of lines 1-8)",{"$nulls":53},9]
[null,"CORF - NUMBER OF EMPLOYEES ( FULL TIME EQUIVALENT )"]
[{"$nulls":6},"Enter the number of hours "]
[{"$nulls":6},"in your normal workweek  __________",{"$nulls":27},"Staff",{"$nulls":7},"Contract",{"$nulls":7},"Total"]
[{"$nulls":34},"  1",{"$nulls":8},"2",{"$nulls":6},"  3"]
[10,"Administrators and Assistant Administrators",{"$nulls":53},10]
[11,"Directors and Assistant Directors",{"$nulls":53},11]
[12,"Other Administrative Personnel",{"$nulls":53},12]
[13,"Direct Nursing Service",{"$nulls":53},13]
[14,"Nursing Supervisor",{"$nulls":53},14]
[15,"Physical Therapy Service",{"$nulls":53},15]
[16,"Physical Therapy Supervisor",{"$nulls":53},16]
[17,"Occupational Therapy Service",{"$nulls":53},17]
[18,"Occupational Therapy Supervisor",{"$nulls":53},18]
[19,"Speech Pathology Service",{"$nulls":53},19]
[20,"Speech Pathology Supervisor",{"$nulls":53},20]
[21,"Medical Social Service",{"$nulls":53},21]
[22,"Medical Social Supervisor",{"$nulls":53},22]
[23,"Respiratory Therapy Service",{"$nulls":53},23]
[24,"Respiratory Therapy Supervisor",{"$nulls":53},24]
[25,"Psychological Service",{"$nulls":53},25]
[26,"Psychological Service Supervisor",{"$nulls":53},26]
[27,{"$nulls":54},27]
[28,{"$nulls":54},28]
{"$rows_empty":13}
["FORM CMS 1728-94-S-6 (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3220)"]
[]
["Rev. 7",{"$nulls":54},"32-307"]

{"sheet":"A","index":7,"n_rows":45,"n_cols":16,"rows_kept":45,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"08-99"]
[{"$nulls":10},"   PROVIDER NO.:",null,"     PERIOD:"]
[null,null,"   RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES",{"$nulls":7},"    _______________",null,"From:  ___________",null,"  WORKSHEET A"]
[{"$nulls":10}," ",null,"To: ___________"]
[{"$nulls":8},"CONTRACTED",null,null,null,"RECLASSI-",null,"EXPENSES"]
[{"$nulls":6},"EMPLOYEE","  TRANSPOR-","PURCHASED",null,null,"RECLASSI-","FIED TRIAL",null,"FOR COST"]
[{"$nulls":5},"SALARIES","BENEFITS"," TATION (See","SERVICES","OTHER",null,"FICATION","BALANCE","ADJUST-","ALLOCATION"]
[{"$nulls":5},"(Fr Wks A-1)","(Fr Wks A-2)","Instructions)","(Fr Wks A-3)","COSTS","TOTAL","(Fr Wks A-4)","(Cols 6 + 7)","MENTS","(Col 8 + 9)"]
[{"$nulls":5},"1","2","3","4","5","6","7","8","9","10"]
[null,null,"   GENERAL SERVICE COST CENTER"]
[" 1","0100"," Capital Related - Bldg. & Fix.",{"$nulls":12}," 1"]
[" 2","0200"," Capital Related - Movable Equip",{"$nulls":12}," 2"]
[" 3","0300"," Plant Operation & Maintenance",{"$nulls":12}," 3"]
[" 4","0400"," Transportation (See Instructions)",{"$nulls":12}," 4"]
[" 5","0500"," Administrative and General",{"$nulls":12}," 5"]
[null,null,"   HHA REIMBURSABLE SERVICES"]
[" 6","0600"," Skilled Nursing Care",{"$nulls":12}," 6"]
[" 7","0700"," Physical Therapy",{"$nulls":12}," 7"]
[" 8","0800"," Occupational Therapy",{"$nulls":12}," 8"]
[" 9","0900"," Speech Pathology",{"$nulls":12}," 9"]
["10","1000"," Medical Social Services",{"$nulls":12},"10"]
["11","1100"," Home Health Aide",{"$nulls":12},"11"]
["12","1200"," Supplies (See Instructions)",{"$nulls":12},"12"]
["13","1300","Drugs",{"$nulls":12},"13"]
["14","1400"," DME",{"$nulls":12},"14"]
[null,null,"   HHA NONREIMBURSABLE SERVICES"]
["15","1500"," Home Dialysis Aide Services",{"$nulls":12},"15"]
["16","1600"," Respiratory Therapy",{"$nulls":12},"16"]
["17","1700"," Private Duty Nursing",{"$nulls":12},"17"]
["18","1800"," Clinic",{"$nulls":12},"18"]
["19","1900"," Health Promotion Activities",{"$nulls":12},"19"]
["20","2000"," Day Care Program",{"$nulls":12},"20"]
["21","2100"," Home Delivered Meals Program",{"$nulls":12},"21"]
["22","2200","Homemaker",{"$nulls":12},"22"]
["23",null,"Other",{"$nulls":12},"23"]
[null,null,"   SPECIAL PURPOSE COST CENTERS"]
["24","2400","CORF",{"$nulls":12},"24"]
["25","2500","Hospice",{"$nulls":12},"25"]
["26","2600","CMHC",{"$nulls":12},"26"]
["27","2700","RHC",{"$nulls":12},"27"]
["28","2800","FQHC",{"$nulls":12},"28"]
["29",null," Total",{"$nulls":12},"29"]
["FORM CMS-1728-94 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3206)"]
[]
["32-308",{"$nulls":14},"Rev. 7"]

{"sheet":"A-1","index":8,"n_rows":45,"n_cols":14,"rows_kept":45,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":6},"FORM CMS 1728-94",{"$nulls":5},"3290 (Cont.)"]
["COMPENSATION ANALYSIS",{"$nulls":7},"   PROVIDER NO.:",null,"     PERIOD:"]
["SALARIES AND WAGES",{"$nulls":7},"    _______________",null,"From:  ___________",null," WORKSHEET A-1"]
[{"$nulls":8}," ",null,"To: ___________"]
[{"$nulls":4},"ADMINIS-",{"$nulls":6},"ALL","TOTAL"]
[{"$nulls":4},"TRATORS","DIRECTORS","CONSULTANTS","SUPERVISORS","NURSES","THERAPISTS","AIDES","OTHER","(1)"]
[{"$nulls":4},"1","2","3","4","5","6","7","8","9"]
[null,"   GENERAL SERVICE COST CENTER"]
[" 1"," Capital Related - Bldg. and Fixtures",{"$nulls":11}," 1"]
[" 2"," Capital Related - Movable Equipment",{"$nulls":11}," 2"]
[" 3"," Plant Operation & Maintenance",{"$nulls":11}," 3"]
[" 4"," Transportation (See Instructions)",{"$nulls":11}," 4"]
[" 5"," Administrative and General",{"$nulls":11}," 5"]
[null,"   HHA REIMBURSABLE SERVICES"]
[" 6"," Skilled Nursing Care",{"$nulls":11}," 6"]
[" 7"," Physical Therapy",{"$nulls":11}," 7"]
[" 8"," Occupational Therapy",{"$nulls":11}," 8"]
[" 9"," Speech Pathology",{"$nulls":11}," 9"]
["10"," Medical Social Services",{"$nulls":11},"10"]
["11"," Home Health Aide",{"$nulls":11},"11"]
["12"," Supplies ",{"$nulls":11},"12"]
["13","Drugs",{"$nulls":11},"13"]
["14","DME",{"$nulls":11},"14"]
[null,"   HHA NONREIMBURSABLE SERVICES"]
["15"," Home Dialysis Aide Services",{"$nulls":11},"15"]
["16"," Respiratory Therapy",{"$nulls":11},"16"]
["17"," Private Duty Nursing",{"$nulls":11},"17"]
["18"," Clinic",{"$nulls":11},"18"]
["19"," Health Promotion Activities",{"$nulls":11},"19"]
["20"," Day Care Program",{"$nulls":11},"20"]
["21"," Home Delivered Meals Program",{"$nulls":11},"21"]
["22","Homemaker Service",{"$nulls":11},"22"]
["23","Other",{"$nulls":11},"23"]
[null,"   SPECIAL PURPOSE COST CENTERS"]
["24","CORF",{"$nulls":11},"24"]
["25","Hospice",{"$nulls":11},"25"]
["26","CMHC",{"$nulls":11},"26"]
["27","RHC",{"$nulls":11},"27"]
["28","FQHC",{"$nulls":11},"28"]
["29"," Total",{"$nulls":11},"29"]
[null,null," (1) Transfer the amounts in column 9 to Wkst. A, column 1"]
[]
["FORM CMS-1728-94-A-1  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3207)"]
[]
["Rev. 7",{"$nulls":12},"32-309"]

{"sheet":"A-2","index":9,"n_rows":45,"n_cols":14,"rows_kept":45,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":6},"FORM CMS 1728-94",{"$nulls":5},"08-99"]
["COMPENSATION ANALYSIS",{"$nulls":7},"   PROVIDER NO.:",null,"     PERIOD:"]
["EMPLOYEE BENEFITS (PAYROLL RELATED)",{"$nulls":7},"    _______________",null,"From:  ___________",null," WORKSHEET A-2"]
[{"$nulls":10},"To: ___________"]
[{"$nulls":4},"ADMINIS-",{"$nulls":6},"ALL","TOTAL"]
[{"$nulls":4},"TRATORS","DIRECTORS","CONSULTANTS","SUPERVISORS","NURSES","THERAPISTS","AIDES","OTHER","(1)"]
[{"$nulls":4},"1","2","3","4","5","6","7","8","9"]
[null,"   GENERAL SERVICE COST CENTER"]
[" 1"," Capital Related - Bldg. and Fixtures",{"$nulls":11}," 1"]
[" 2"," Capital Related - Movable Equipment",{"$nulls":11}," 2"]
[" 3"," Plant Operation & Maintenance",{"$nulls":11}," 3"]
[" 4"," Transportation (See Instructions)",{"$nulls":11}," 4"]
[" 5"," Administrative and General",{"$nulls":11}," 5"]
[null,"   HHA REIMBURSABLE SERVICES"]
[" 6"," Skilled Nursing Care",{"$nulls":11}," 6"]
[" 7"," Physical Therapy",{"$nulls":11}," 7"]
[" 8"," Occupational Therapy",{"$nulls":11}," 8"]
[" 9"," Speech Pathology",{"$nulls":11}," 9"]
["10"," Medical Social Services",{"$nulls":11},"10"]
["11"," Home Health Aide",{"$nulls":11},"11"]
["12"," Supplies ",{"$nulls":11},"12"]
["13","Drugs",{"$nulls":11},"13"]
["14"," DME",{"$nulls":11},"14"]
[null,"   HHA NONREIMBURSABLE SRVS"]
["15"," Home Dialysis Aide Services",{"$nulls":11},"15"]
["16"," Respiratory Therapy",{"$nulls":11},"16"]
["17"," Private Duty Nursing",{"$nulls":11},"17"]
["18"," Clinic",{"$nulls":11},"18"]
["19"," Health Promotion Activities",{"$nulls":11},"19"]
["20"," Day Care Program",{"$nulls":11},"20"]
["21"," Home Delivered Meals Program",{"$nulls":11},"21"]
["22","Homemaker Services",{"$nulls":11},"22"]
["23","Other",{"$nulls":11},"23"]
[null,"   SPECIAL PURPOSE COST CENTERS"]
["24","CORF",{"$nulls":11},"24"]
["25","Hospice",{"$nulls":11},"25"]
["26","CMHC",{"$nulls":11},"26"]
["27","RHC",{"$nulls":11},"27"]
["28","FQHC",{"$nulls":11},"28"]
["29","Total",{"$nulls":11},"29"]
[null,null," (1) Transfer the amounts in column 9 to Wkst. A, column 2"]
[]
["FORM CMS-1728-94-A-2  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3208)"]
[]
["32-310",{"$nulls":12},"Rev. 7"]

{"sheet":"A-3","index":10,"n_rows":45,"n_cols":14,"rows_kept":45,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":6},"FORM CMS 1728-94",{"$nulls":5},"3290 (Cont.)"]
["COMPENSATION ANALYSIS",{"$nulls":7},"   PROVIDER NO.:",null,"     PERIOD:"]
["CONTRACTED SERVICES/PURCHASED SERVICES",{"$nulls":7},"    _______________",null,"From:  ___________",null," WORKSHEET A-3"]
[{"$nulls":10},"To: ___________"]
[{"$nulls":4},"ADMINIS-",{"$nulls":6},"ALL","TOTAL"]
[{"$nulls":4},"TRATORS","DIRECTORS","CONSULTANTS","SUPERVISORS","NURSES","THERAPISTS","AIDES","OTHER","(1)"]
[{"$nulls":4},"1","2","3","4","5","6","7","8","9"]
[null,"   GENERAL SERVICE COST CENTER"]
[" 1"," Capital Related - Bldg. and Fixtures",{"$nulls":11}," 1"]
[" 2"," Capital Related - Movable Equipment",{"$nulls":11}," 2"]
[" 3"," Plant Operation & Maintenance",{"$nulls":11}," 3"]
[" 4"," Transportation (See Instructions)",{"$nulls":11}," 4"]
[" 5"," Administrative and General",{"$nulls":11}," 5"]
[null,"   HHA REIMBURSABLE SERVICES"]
[" 6"," Skilled Nursing Care",{"$nulls":11}," 6"]
[" 7"," Physical Therapy",{"$nulls":11}," 7"]
[" 8"," Occupational Therapy",{"$nulls":11}," 8"]
[" 9"," Speech Pathology",{"$nulls":11}," 9"]
["10"," Medical Social Services",{"$nulls":11},"10"]
["11"," Home Health Aide",{"$nulls":11},"11"]
["12"," Supplies ",{"$nulls":11},"12"]
["13","Drugs",{"$nulls":11},"13"]
["14"," DME",{"$nulls":11},"14"]
[null,"   HHA NONREIMBURSABLE SERVICES"]
["15"," Home Dialysis Aide Services",{"$nulls":11},"15"]
["16"," Respiratory Therapy",{"$nulls":11},"16"]
["17"," Private Duty Nursing",{"$nulls":11},"17"]
["18"," Clinic",{"$nulls":11},"18"]
["19"," Health Promotion Activities",{"$nulls":11},"19"]
["20"," Day Care Program",{"$nulls":11},"20"]
["21"," Home Delivered Meals Program",{"$nulls":11},"21"]
["22","Homemaker Services",{"$nulls":11},"22"]
["23","Other",{"$nulls":11},"23"]
[null,"   SPECIAL PURPOSE COST CENTERS"]
["24","CORF",{"$nulls":11},"24"]
["25","Hospice",{"$nulls":11},"25"]
["26","CMHC",{"$nulls":11},"26"]
["27","RHC",{"$nulls":11},"27"]
["28","FQHC",{"$nulls":11},"28"]
["29"," Total",{"$nulls":11},"29"]
[" (1) Transfer the amounts in column 9 to Wkst. A, column 4"]
[]
["FORM CMS-1728-94  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3209)"]
[]
["Rev. 7",{"$nulls":12},"32-311"]

{"sheet":"A-4","index":11,"n_rows":42,"n_cols":15,"rows_kept":42,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":5},"08-99"]
[{"$nulls":9},"  PROVIDER NO.",null,"   PERIOD:",null,"WORKSHEET A-4"]
[null,null,null,"   RECLASSIFICATIONS",{"$nulls":5},"    _______________",null,"From:  ___________"]
[{"$nulls":9}," ",null,"To: ___________"]
[{"$nulls":7},"CODE","                                INCREASE",null,null,"                           DECREASE"]
[null,"  EXPLANATION OF RECLASSIFICATION ENTRY",{"$nulls":5},"(1)","COST CENTER","LINE NO.","AMOUNT(2)","COST CENTER","LINE NO.","AMOUNT(2)"]
[{"$nulls":7},"1","2","3","4","5","6","7"]
[" 1",{"$nulls":13},"  1"]
[" 2",{"$nulls":13},"  2"]
[" 3",{"$nulls":13},"  3"]
[" 4",{"$nulls":13},"  4"]
[" 5",{"$nulls":13},"  5"]
[" 6",{"$nulls":13},"  6"]
[" 7",{"$nulls":13},"  7"]
[" 8",{"$nulls":13},"  8"]
[" 9",{"$nulls":13},"  9"]
["10",{"$nulls":13}," 10"]
["11",{"$nulls":13}," 11"]
["12",{"$nulls":13}," 12"]
["13",{"$nulls":13}," 13"]
["14",{"$nulls":13}," 14"]
["15",{"$nulls":13}," 15"]
["16",{"$nulls":13}," 16"]
["17",{"$nulls":13}," 17"]
["18",{"$nulls":13}," 18"]
["19",{"$nulls":13}," 19"]
["20",{"$nulls":13}," 20"]
["21",{"$nulls":13}," 21"]
["22",{"$nulls":13}," 22"]
["23",{"$nulls":13}," 23"]
["24",{"$nulls":13}," 24"]
["25",{"$nulls":13}," 25"]
["26",{"$nulls":13}," 26"]
["27",{"$nulls":13}," 27"]
["28",{"$nulls":13}," 28"]
["29",{"$nulls":13}," 29"]
["30"," TOTAL RECLASSIFICATIONS (Sum of col. 4 must equal sum of col. 7)",{"$nulls":12}," 30"]
["(1)  A letter (A, B, etc.) must be entered on each line to identify each reclassification entry."]
["(2)  Transfer to Worksheet A, column 7, line as appropriate."]
["FORM CMS-1728-94-A-4 (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3210)"]
[]
["32-312",{"$nulls":13},"Rev. 7"]

{"sheet":"A-5","index":12,"n_rows":70,"n_cols":9,"rows_kept":70,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":4},"FORM CMS 1728-94",null,null,"3290 (Cont.)"]
[{"$nulls":4},"   PROVIDER NO.:",null," PERIOD:"]
[null,"   ADJUSTMENTS TO EXPENSES",null,null,"  _______________",null,"From: __________","  WORKSHEET A-5"]
[{"$nulls":6},"To: __________"]
[{"$nulls":4}," ",null," Expense Classification on Worksheet A"]
[{"$nulls":4}," ",null," To/From Which The Amount is to be Adjusted"]
[null,"     Description (1)",null,null,"(2)"]
[{"$nulls":4},"BASIS/CODE","Amount","Cost Center","Line No."]
[{"$nulls":4},"1","2","3","4"]
[" 1","Excess funds generated from operations,",null,null,"B",-3985,"A&G Shared Costs",5.01," 1"]
[null,"other than net income"]
[" 2","Trade, quantity, time and other discounts",null,null,"B",null,null,null," 2"]
[null,"on purchases (Chap. 8)"]
[" 3"," Rebates and refunds of expenses (Chap. 8)",null,null,"B",null,null,null," 3"]
[" 4"," Home office costs (Chap. 21)",null,null,"A",15250,"A&G Reimb. Costs",5.02," 4"]
[" 5","Adjustments resulting from transaction",null,null,"From Wks",{"$error":"#REF!"},"Home Health Aide","11"," 5"]
[null,"with related organization (Chap. 10)",null,null,"A-6"]
[" 6"," Sale of medical records and abstracts",null,null,"B",null,null,null," 6"]
[" 7","Income from imposition of interest,",null,null,"B",null,null,null," 7"]
[null,"finance or penalty charges (Chap. 21)"]
[" 8","Sale of medical and surgical supplies to",null,null,"A",null,null,null," 8"]
[null,"other than patients"]
[" 9"," Sale of Drugs to other than patients",null,null,"A",null,null,null," 9"]
["10","Physical therapy adjustment (Chap. 14)",null,null,"From Supp",null,null,null,"10"]
[{"$nulls":4},"Wks A-8-3",null,"Physical Therapy","7"]
["10.1","Occupational therapy adjustment (Chap. 14)",null,null,"From Supp",null,null,null,"10.1"]
[{"$nulls":4},"Wks A-8-3",null,"Occupational Therapy",8]
["10.2","Speech pathology adjustment (Chap. 14)",null,null,"From Supp",null,null,null,"10.2"]
[{"$nulls":4},"Wks A-8-3",null,"Speech Pathology",9]
["11","Interest expense on Medicare overpayments and",null,null,"A",null,null,null,"11"]
[null,"borrowings to repay Medicare overpayments"]
["12","Lobbying Activities",null,null,"A",-2050,"A&G Nonreimb. Costs",5.03,"12"]
[]
["13",{"$nulls":7},"13"]
[]
["14",{"$nulls":7},"14"]
[]
["15",{"$nulls":7},"15"]
[]
["16",{"$nulls":7},"16"]
[]
["17",{"$nulls":7},"17"]
[]
["18",{"$nulls":7},"18"]
[]
["19",{"$nulls":7},"19"]
[]
["20",{"$nulls":7},"20"]
[]
["21"," TOTAL (Sum of lines 1-20)",null,null,null,{"$error":"#REF!"},null,null,"21"]
[]
[null,"(1) Description - All line references in this column pertain to the Provider"]
[null,"    Reimbursement Manual, Part I."]
[]
[null,"(2) Basis for adjustment (See Instructions)"]
[]
[null,"    A.  Costs - if cost, including applicable overhead, can be determined"]
[null,"    B.  Amount Received - If cost cannot be determined"]
{"$rows_empty":9}
["FORM CMS-1728-94-A-5  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3211)"]
[]
["Rev. 7",{"$nulls":7},"32-313"]

{"sheet":"A-6","index":13,"n_rows":70,"n_cols":11,"rows_kept":70,"cut":false,"hidden":false,"merged":[[15,1,15,2]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":5},"FORM CMS 1728-94",null,null,null,"08-99"]
["This report is required by law (42 USC 1395g; 42 CFR 413.20(b)).  Failure to report can result"]
["in all interim payments made since the beginning of the cost reporting period being deemed"]
["as overpayments (42 USC 1395g)."]
[null,"  STATEMENT OF COSTS OF ",{"$nulls":4}," PROVIDER NO.:",null,"  PERIOD:",null," WORKSHEET A-6"]
[null,"      SERVICES FROM",{"$nulls":6},"From:  ___________"]
[null,"  RELATED ORGANIZATIONS",{"$nulls":4}," ____________",null,"To: ___________"]
["A.  Are there any costs included on Worksheet A which resulted from transactions"]
["    with related organizations as defined in CMS Pub. 15-I, chapter 10?"]
[]
[null,null," [   ]  Yes  [   ] No    (If \"Yes,\" complete Parts B and C)"]
["B.  Costs incurred and adjustment required as result of transactions with related organizations"]
[null,null,null,"   LOCATION AND AMOUNT INCLUDED ON WKST A, COL. 8",{"$nulls":5},"AMOUNT","NET"]
[{"$nulls":9},"ALLOWABLE","ADJUSTMENT"]
[null,"LINE  NO.",null,"COST CENTER",null,"EXPENSE ITEMS",null,null,"AMOUNT","IN COST","(col 4 -5)"]
[null,1,null,2,null,3,null,null,"4","5","6"]
[" 1"]
[" 2",{"$nulls":9},0]
[" 3",{"$nulls":9},0]
[" 4"," TOTALS (Sum of lines 1-3)(Transfer col. 6, lines 1-3 to Wkst A, Col. 9,"]
[null," lines as appropriate)(Transfer col. 6, line 4 to Wkst A-5, col. 2, line 5)"]
["C.  Interrelationship of provider to related organization(s):"]
[]
["The Secretary, by virtue of authority granted under section 1814(b)(1) of the Health Insurance for the Aged"]
["and Disabled Act, requires the provider to furnish the information requested on Part C of this worksheet."]
[]
["The information will be used by the CMS and its intermediaries in determining that the costs applicable to services,"]
["facilities and supplies furnished by organizations related to the provider by common ownership or control,"]
["represent reasonable costs as determined under section 1861 of the Health Insurance for the Aged and Disabled Act."]
["If the provider does not provide all or any part of the requested information, the cost report will be considered"]
["incomplete and not acceptable for purposes of claiming reimbursement under title XVIII."]
[]
[]
[{"$nulls":8},"Percent","Percent"]
[{"$nulls":8},"Owned","Ownership"]
["SYMBOL",{"$nulls":7},"by","of","Type of"]
[null," (1)","Name",null,null,"Address",null,null,"Provider","Provider","Business"]
[null,"1",2,null,null,3,null,null,4,"5","6"]
[" 1"]
[" 2"]
[" 3"]
[" 4"]
[" 5"]
[]
[null,"(1)  Use the following symbols to indicate the interrelationship of the provider to related organizations:"]
[]
[null,null,"A.  Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider."]
[null,null,"B.  Corporation, partnership or other organization has financial interest in provider."]
[null,null,"C.  Provider has financial interest in corporation, partnership or other organization."]
[null,null,"D.  Director, officer, administrator or key person of provider or relative of such person has financial interest in"]
[null,null,"     related organization."]
[null,null,"E.  Individual is director, officer, administrator or key person of provider and related organization."]
[null,null,"F.  Director, officer, administrator or key person of  related organization or relative of such person has financial"]
[null,null,"     interest in provider."]
[null,null,"G.  Other (financial or nonfinancial) specify."]
{"$rows_empty":11}
["FORM CMS-1728-94-A-6  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3212)"]
[]
[]
["32-314",{"$nulls":9},"Rev. 7"]

{"sheet":"A-7","index":14,"n_rows":43,"n_cols":14,"rows_kept":43,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":6},"FORM CMS 1728-94",{"$nulls":5},"3290 (Cont.)"]
[{"$nulls":7},"   PROVIDER NO.:",null,"     PERIOD:"]
["ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCE",{"$nulls":8},"From:  ___________",null,"   WORKSHEET A-7"]
[{"$nulls":7},"    _______________",null,"To: ___________"]
[{"$nulls":11},"Disposals"]
[null,null,null,"Description",null,null,null,"Beginning",null,"    Acquisitions",null,"and","Ending"]
[{"$nulls":7},"Balances","Purchases","Donations","Total","Retirements","Balance"]
[{"$nulls":7},"1","2","3","4","5","6"]
["1"," Land",{"$nulls":11},"1"]
["2"," Land Improvements",{"$nulls":11},"2"]
["3"," Buildings and Fixtures",{"$nulls":11},"3"]
["4"," Building Improvements",{"$nulls":11},"4"]
["5"," Fixed Equipment",{"$nulls":11},"5"]
["6"," Movable Equipment",{"$nulls":11},"6"]
["7"," TOTAL",{"$nulls":11},"7"]
{"$rows_empty":25}
["FORM CMS-1728-94-A-7 (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3213)"]
[]
["Rev. 7",{"$nulls":12},"32-315"]

{"sheet":"A83-1","index":15,"n_rows":60,"n_cols":13,"rows_kept":60,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":5},"FORM CMS 1728-94",{"$nulls":5},"08-99"]
["REASONABLE COST DETERMINATION FOR THERAPY",{"$nulls":6},"  PROVIDER NO.:",null,"  PERIOD:",null,"WORKSHEET A-8-3"]
["SERVICES FURNISHED BY OUTSIDE SUPPLIERS",{"$nulls":8},"From:  ___________",null,"PARTS I - III        "]
[{"$nulls":7},"  ________________",null,"To: ___________"]
["Check applicable box:",null,null,"[   ]  Physical Therapy services rendered before 4/10/98  [   ]  Occupational Therapy  [   ]  Speech Pathology"]
[null,null,null,"[   ]  Physical Therapy services rendered on or after 4/10/98"]
[]
[null,"PART I - GENERAL INFORMATION"]
[" 1"," Total number of weeks worked (During which outside suppliers (excluding aides) worked)",{"$nulls":10}," 1"]
[" 2"," Line 1 multiplied by 15 hours per week",{"$nulls":10}," 2"]
[" 3"," Number of unduplicated HHA visits - supervisors or therapists (See Instructions)",{"$nulls":10}," 3"]
[" 4"," Number of unduplicated HHA visits - therapy assistants (Include only visits made by therapy assistants and on which",{"$nulls":10}," 4"]
[null," supervisor and/or therapist was not present during the visit) (See Instructions)"]
[" 5"," Standard travel expense rate",{"$nulls":10}," 5"]
[" 6"," Optional travel expense rate per mile",{"$nulls":10}," 6"]
[{"$nulls":8},"Supervisors","Therapists","Assistants","Aides"]
[{"$nulls":8},"1","2","3","4"]
[" 7"," Total hours worked",{"$nulls":10}," 7"]
[" 8"," AHSEA (See Instructions)",{"$nulls":10}," 8"]
[" 9"," Standard Travel Allowance (Cols 1 and 2, one-half of col 2, line 8; col 3, one-half of col 3, line 8)",{"$nulls":10}," 9"]
["10"," Number of travel hours (HHA only)",{"$nulls":10},"10"]
["11"," Number of miles driven (HHA only)",{"$nulls":10},"11"]
[]
[null,"PART II - SALARY EQUIVALENCY COMPUTATIONS"]
["12"," Supervisors (Col 1, line 7 times col 1, line 8)",{"$nulls":10},"12"]
["13"," Therapists (Col 2, line 7 times col 2, line 8)",{"$nulls":10},"13"]
["14"," Assistants (Col 3, line 7 times col 3, line 8)",{"$nulls":10},"14"]
["15"," Subtotal Allowance Amount (Sum of lines 12-14)",{"$nulls":10},"15"]
["16"," Aides (Col 4, line 7 times col 4, line 8)",{"$nulls":10},"16"]
["17"," Total Allowance Amount (Sum of lines 15 and 16)",{"$nulls":10},"17"]
[" If the sum of cols 1-3, line 7, is greater than line 2, make no entries on lines 18 and 19"]
[" and enter on line 20 the amount from line 17.  Otherwise, complete lines 18-20."]
["18"," Weighted average rate excluding aides (Line 15 divided by the sum of cols 1-3, line 7)",{"$nulls":10},"18"]
["19"," Weighted allowance excluding aides (Line 2 times line 18)",{"$nulls":10},"19"]
["20"," Total Salary Equivalency (Line 17 or sum of lines 16 plus 19)",{"$nulls":10},"20"]
[]
[null,"PART III - TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - HHA SERVICES"]
[null,"Standard Travel Allowance and Standard Travel Expense"]
["21"," Therapists (Line 3 times col 2, line 9)",{"$nulls":10},"21"]
["22"," Assistants (Line 4 times col 3, line 9)",{"$nulls":10},"22"]
["23"," Subtotal (Sum of lines 21 and 22)",{"$nulls":10},"23"]
["24"," Standard Travel Expense (Line 5 times sum of lines 3 and 4)",{"$nulls":10},"24"]
[null," Optional Travel Allowance and Optional Travel Expense"]
["25"," Therapists (Sum of cols 1 and 2, line 10 times col 2, line 8)",{"$nulls":10},"25"]
["26"," Assistants (Col 3, line 10 times col 3, line 8)",{"$nulls":10},"26"]
["27"," Subtotal (Sum of lines 25 and 26)",{"$nulls":10},"27"]
["28"," Optional Travel Expense (Line 6 times sum of cols 1-3, line 11)",{"$nulls":10},"28"]
[null," Total Travel Allowance and Travel Expenses - HHA Services; Complete one of the following"]
[null," three lines 29, 30 or 31, as appropriate"]
["29"," Standard Travel Allowance and Standard Travel Expenses (Sum of lines 23 and 24 - See Instructions)",{"$nulls":10},"29"]
["30"," Optional Travel Allowance and Standard Travel Expenses (Sum of lines 27 and 24 - See Instructions)",{"$nulls":10},"30"]
["31"," Optional Travel Allowance and Optional Travel Expenses (Sum of lines 27 and 28 - See Instructions)",{"$nulls":10},"31"]
[]
[]
[]
[]
[]
["FORM CMS-1728-94-A-8-3  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3219-3219.3) "]
[]
["32-316",{"$nulls":11},"Rev. 7"]

{"sheet":"A83-2","index":16,"n_rows":62,"n_cols":12,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":5},"3290 (Cont.)"]
["REASONABLE COST DETERMINATION FOR THERAPY",{"$nulls":5},"  PROVIDER NO.:",null,"  PERIOD:",null,"WORKSHEET A-8-3"]
["SERVICES FURNISHED BY OUTSIDE SUPPLIERS",{"$nulls":7},"From:  ___________",null,"PART IV & V"]
[{"$nulls":6},"  ________________",null,"To: ___________"]
["Check applicable box:",null,null,"[   ]  Physical Therapy services rendered before 4/10/98  [   ]  Occupational Therapy  [   ]  Speech Pathology"]
[null,null,null,"[   ]  Physical Therapy services rendered on or after 4/10/98"]
[]
[null,"PART IV - OVERTIME COMPUTATION"]
[{"$nulls":7},"Therapists","Assistants","Aides","TOTAL"]
[null,null,"Description",{"$nulls":4},"1","2","3","4"]
["32"," Overtime hours worked during cost reporting period (If col 4, line 32, is zero or equal to or greater",{"$nulls":9},"32"]
[null," than 2,080, do not complete lines 33-40 and enter zero in each column of line 41)"]
["33"," Overtime rate (Multiply the amounts in cols 2-4, line 8 (AHSEA) times 1.5)",{"$nulls":9},"33"]
["34"," Total overtime (Including base and overtime allowance) (Multiply line 32 times line 33)",{"$nulls":9},"34"]
[null,"CALCULATION OF LIMIT"]
["35"," Percentage of overtime hours by category (Divide the hours in each column on line 32 by the total",{"$nulls":9},"35"]
[null," overtime worked - col. 4, line 32)"]
["36"," Allocation of provider's standard workyear for one full-time employee times the percentage on line 35)",{"$nulls":9},"36"]
[null," (See Instructions)"]
[null,"DETERMINATION OF OVERTIME ALLOWANCE"]
["37"," Adjusted hourly salary equivalency amount (AHSEA) (From Part I, cols 2-4, line 8)",{"$nulls":9},"37"]
["38"," Overtime cost limitation (Line 36 times line 37)",{"$nulls":9},"38"]
["39"," Maximum overtime cost (Enter the lesser of line 34 or line 38)",{"$nulls":9},"39"]
["40"," Portion of overtime already included in hourly computation at the AHSEA (Multiply line 32 times line 37)",{"$nulls":9},"40"]
["41"," Overtime allowance (Line 39 minus line 40 - if negative enter zero) (Col 4, sum of cols 1-3)",{"$nulls":9},"41"]
[]
[null,"PART V - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT"]
["42"," Salary equivalency amount (from Part II, line 20)",{"$nulls":9},"42"]
["43"," Travel allowance and expense - HHA services (from Part III, lines 29, 30 or 31)",{"$nulls":9},"43"]
["44"," Overtime allowance (from Part IV, col. 4, line 41)",{"$nulls":9},"44"]
["45"," Equipment cost (See Instructions)",{"$nulls":9},"45"]
["46"," Supplies (See Instructions)",{"$nulls":9},"46"]
["47"," Total allowance (Sum of lines 42-46)",{"$nulls":9},"47"]
["48"," Total cost of outside supplier services (from provider records)",{"$nulls":9},"48"]
["49"," Excess over limitation (line 48 minus line 47 - transfer amount to A-5, line 10, 10.1, or 10.2 as applicable - if negative, enter zero -- See Instructions)",{"$nulls":9},"49"]
{"$rows_empty":24}
["FORM CMS-1728-94-A-8-3  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS 3219.4 AND 3219.5) "]
[]
["Rev. 7",{"$nulls":10},"32-317"]

{"sheet":"B,B-1","index":17,"n_rows":99,"n_cols":14,"rows_kept":99,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":6},"FORM CMS 1728-94",{"$nulls":5},"08-99"]
[{"$nulls":8},"    PROVIDER NO.:",null,"  PERIOD:"]
[null,"COST ALLOCATION - GENERAL SERVICE COST",{"$nulls":8},"From:  ___________",null,"WORKSHEET B"]
[{"$nulls":8},"    _____________",null,"To: ___________"]
[{"$nulls":5},"NET EXPENSES","CAPITAL"]
[{"$nulls":5},"FOR COST","RELATED COSTS",null,"PLANT"]
[{"$nulls":5},"ALLOCATION",null,null,"OPERATION",null,null,"ADMINISTRA-"]
[{"$nulls":5},"(FR.WKST","BLDGS &","MOVABLE","&","TRANS-","SUBTOTAL","TIVE "]
[{"$nulls":5},"A, COL10)","& FIXTURES","EQUIPMENT","MAINTENANCE","PORTATION","(cols. 0-4)","& GENERAL","TOTAL"]
[{"$nulls":5},"0","1","2","3",4,"4A",5,6]
[null,"GENERAL SERVICE COST CENTERS"]
[" 1"," Capital Related - Bldg. and Fixtures",{"$nulls":4},0,{"$nulls":6}," 1"]
[" 2"," Capital Related - Movable Equipment",{"$nulls":4},0,0,{"$nulls":5}," 2"]
[" 3"," Plant Operation & Maintenance",{"$nulls":4},0,0,0,{"$nulls":4}," 3"]
[" 4"," Transportation (See Instructions)",{"$nulls":4},0,0,0,{"$nulls":4}," 4"]
[" 5"," Administrative and General ",{"$nulls":11}," 5"]
[null,"   HHA REIMBURSABLE SERVICES"]
[" 6"," Skilled Nursing Care",{"$nulls":4},0,0,0,null,null,0,null," 6"]
[" 7"," Physical Therapy",{"$nulls":4},0,0,0,null,null,0,null," 7"]
[" 8"," Occupational Therapy",{"$nulls":4},0,0,0,null,null,0,null," 8"]
[" 9"," Speech Pathology",{"$nulls":4},0,0,0,null,null,0,null," 9"]
["10"," Medical Social Services",{"$nulls":4},0,0,0,null,null,0,null,"10"]
["11"," Home Health Aide",{"$nulls":4},0,0,0,null,null,0,null,"11"]
["12"," Supplies (See Instructions)",{"$nulls":4},0,0,0,null,null,0,null,"12"]
["13"," Drugs",{"$nulls":4},0,0,0,null,null,0,null,"13"]
["14"," DME",{"$nulls":4},0,0,0,null,null,0,null,"14"]
[null,"   HHA NONREIMBURSABLE SERVICES"]
["15"," Home Dialysis Aide Services",{"$nulls":11},"15"]
["16"," Respiratory Therapy",{"$nulls":11},"16"]
["17"," Private Duty Nursing",{"$nulls":11},"17"]
["18"," Clinic",{"$nulls":11},"18"]
["19"," Health Promotion Activities",{"$nulls":11},"19"]
["20"," Day Care Program",{"$nulls":11},"20"]
["21"," Home Delivered Meals Program",{"$nulls":11},"21"]
["22","Homemaker Services",{"$nulls":11},"22"]
["23","Other",{"$nulls":11},"23"]
[null,"   SPECIAL PURPOSE COST CENTER"]
["24","CORF",{"$nulls":11},"24"]
["25","Hospice",{"$nulls":11},"25"]
["26","CMHC",{"$nulls":11},"26"]
["27","RHC",{"$nulls":11},"27"]
["28","FQHC",{"$nulls":11},"28"]
["29"," Total",{"$nulls":4},0,0,0,null,null,0,null,"29"]
[]
[]
[]
[]
["FORM CMS-1728-94-B  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3214)"]
[]
["32-318",{"$nulls":12},"Rev. 7"]
["03-04",{"$nulls":6},"FORM CMS 1728-94",{"$nulls":5},"3290 (Cont.)"]
[{"$nulls":8},"    PROVIDER NO.:",null,"  PERIOD:"]
[null,null,"COST ALLOCATION - STATISTICAL BASIS",{"$nulls":7},"From:  ___________",null,"WORKSHEET B-1"]
[" ",{"$nulls":7},"    _____________",null,"To: ___________"]
[{"$nulls":6},"CAPITAL"]
[{"$nulls":6},"RELATED COSTS",null,"PLANT",null,null,"ADMINISTRA-"]
[{"$nulls":6},"BLDGS &","MOVABLE","OPERATION",null,null,"TIVE "]
[{"$nulls":6},"& FIXTURES","EQUIPMENT","MAINTENANCE","TRANS-",null,"& GENERAL "]
[null,null,"COST CENTER",null,null,null,"(SQUARE","(DOLLAR","(SQUARE","PORTATION","RECONCIL-","(ACCUMU-"]
[{"$nulls":6},"FEET)","VALUE)","FEET)","(MILEAGE)","IATION","LATED COST)","TOTAL"]
[{"$nulls":6},1,2,"3","4","5A",5,6," "]
[null,"   GENERAL SERVICE COST CENTER"]
[" 1"," Capital Related - Bldg. and Fixtures",{"$nulls":11}," 1"]
[" 2"," Capital Related - Movable Equipment",{"$nulls":11}," 2"]
[" 3"," Plant Operation & Maintenance",{"$nulls":11}," 3"]
[" 4"," Transportation (See Instructions)",{"$nulls":11}," 4"]
[" 5"," Administrative and General ",{"$nulls":11}," 5"]
[null,"   HHA REIMBURSABLE SERVICES"]
[" 6"," Skilled Nursing Care",{"$nulls":11}," 6"]
[" 7"," Physical Therapy",{"$nulls":11}," 7"]
[" 8"," Occupational Therapy",{"$nulls":11}," 8"]
[" 9"," Speech Pathology",{"$nulls":11}," 9"]
["10"," Medical Social Services",{"$nulls":11},"10"]
["11"," Home Health Aide",{"$nulls":11},"11"]
["12"," Supplies (See Instructions)",{"$nulls":11},"12"]
["13"," Drugs",{"$nulls":11},"13"]
["14","DME",{"$nulls":11},"14"]
[null,"   HHA NONREIMBURSABLE SERVICES"]
["15"," Home Dialysis Aide Services",{"$nulls":11},"15"]
["16"," Respiratory Therapy",{"$nulls":11},"16"]
["17"," Private Duty Nursing",{"$nulls":11},"17"]
["18"," Clinic",{"$nulls":11},"18"]
["19"," Health Promotion Activities",{"$nulls":11},"19"]
["20"," Day Care Program",{"$nulls":11},"20"]
["21"," Home Delivered Meals Program",{"$nulls":11},"21"]
["22","Homemaker Services",{"$nulls":11},"22"]
["23","Other",{"$nulls":11},"23"]
[null,"   SPECIAL PURPOSE COST CENTER"]
["24","CORF",{"$nulls":11},"24"]
["25","Hospice",{"$nulls":11},"25"]
["26","CMHC",{"$nulls":11},"26"]
["27","RHC",{"$nulls":11},"27"]
["28","FQHC",{"$nulls":11},"28"]
["29"," Total",{"$nulls":11},"29"]
["30"," Cost To Be Allocated (Per Wkst B)",{"$nulls":11},"30"]
["31"," Unit Cost Multiplier",null,null," ",{"$nulls":8},"31"]
["FORM CMS-1728-94-B-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3214)"]
[]
["Rev. 12",{"$nulls":12},"32-319"]

{"sheet":"C^","index":18,"n_rows":128,"n_cols":17,"rows_kept":128,"cut":false,"hidden":false,"merged":[[70,13,70,15]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":8},"FORM CMS 1728-94",{"$nulls":6},"03-04"]
["APPORTIONMENT OF PATIENT SERVICE COSTS",{"$nulls":9},"PROVIDER NO.: ",null,"     PERIOD:",null,null,"WORKSHEET C"]
[{"$nulls":12},"From: ______________",null,null,"PARTS I & II"]
[{"$nulls":10},"______________",null,"To: ______________"]
["PART I - AGGREGATE AGENCY COST PER VISIT COMPUTATION"]
[{"$nulls":15},"Average"]
["Cost Per Visit Computation",{"$nulls":11},"From Wkst ",null,null,"Cost"]
[{"$nulls":12},"B, Col. 6,","Total",null,"Per Visit"]
[null,"    Patient Services",{"$nulls":10},"Line:","Cost","Visits","(Cols 2 ÷ 3) (1)"]
[{"$nulls":12},"1","2","3","4"]
[" 1"," Skilled Nursing",{"$nulls":10},"6",null,null,null," 1"]
[" 2"," Physical Therapy",{"$nulls":10},"7",null,null,null," 2"]
[" 3"," Occupational Therapy",{"$nulls":10},"8",null,null,null," 3"]
[" 4"," Speech Pathology",{"$nulls":10},"9",null,null,null," 4"]
[" 5"," Medical Social Services",{"$nulls":10},"10",null,null,null," 5"]
[" 6"," Home Health Aide Services",{"$nulls":10},"11",null,null,null," 6"]
[" 7"," Total (Sum of lines 1-6)",{"$nulls":14}," 7"]
[]
["PART II - COMPUTATION OF THE AGGREGATE MEDICARE COST AND THE AGGREGATE OF THE MEDICARE LIMITATION  (2)"]
[{"$nulls":9},"Medicare  Program Visits",null,null,"Cost of Medicare Services"]
[null,"MSA CODE:  ",{"$nulls":8},"Part B",null,null,"Part B"]
[{"$nulls":7},"From Wkst. C,","Average",null,"Not Subject","Subject",null,"Not Subject","Subject","Total"]
[{"$nulls":7},"Part I, Col. 4,","Cost",null,"to Deductibles","to Deductibles",null,"to Deductibles","to Deductibles","(Sum of"]
[null,"    Total Medicare Patient Service Cost Computation",{"$nulls":5},"Line:","Per Visit","Part A","& Coinsurance","& Coinsurance","Part A","& Coinsurance","& Coinsurance","Cols 8 & 9)"]
[{"$nulls":8},"4","5","6","7","8","9",10,11]
[" 1"," Skilled Nursing",{"$nulls":5},1,{"$nulls":8}," 1"]
[" 2"," Physical Therapy",{"$nulls":5},2,{"$nulls":8}," 2"]
[" 3"," Occupational Therapy",{"$nulls":5},3,{"$nulls":8}," 3"]
[" 4"," Speech Pathology",{"$nulls":5},4,{"$nulls":8}," 4"]
[" 5"," Medical Social Services",{"$nulls":5},5,{"$nulls":8}," 5"]
[" 6"," Home Health Aide Services",{"$nulls":5},6,{"$nulls":8}," 6"]
[" 7"," Total (Sum of lines 1-6)",{"$nulls":14}," 7"]
[]
[{"$nulls":9},"Medicare  Program Visits",null,null,"Cost of Medicare Services"]
[{"$nulls":10},"Part B",null,null,"Part B"]
[{"$nulls":8},"Program",null,"Not Subject","Subject",null,"Not Subject","Subject","Total"]
[{"$nulls":8},"Cost",null,"to Deductibles","to Deductibles",null,"to Deductibles","to Deductibles","(Sum of"]
[null,"    Total Medicare Patient Service Cost Limitation Computation",{"$nulls":6},"Limits","Part A","& Coinsurance","& Coinsurance","Part A","& Coinsurance","& Coinsurance","Cols 8 & 9"]
[{"$nulls":8},"4","5","6","7","8","9",10,11]
[" 8"," Skilled Nursing",{"$nulls":14}," 8"]
[" 9"," Physical Therapy",{"$nulls":14}," 9"]
["10"," Occupational Therapy",{"$nulls":14},"10"]
["11"," Speech Pathology ",{"$nulls":14},"11"]
["12"," Medical Social Services",{"$nulls":14},"12"]
["13"," Home Health Aide Services",{"$nulls":14},"13"]
["14"," Total (Sum of lines 8-13 plus the subscripts of lines 1-6, respectively)",{"$nulls":14},"14"]
[null,"(1) Compute the average cost per visit one time for each discipline (column 4, lines 1 through  6) for the entire home health agency. "]
[null,"(2) Complete Worksheet C, Part II once for each MSA where Medicare covered services were furnished during the cost reporting period."]
{"$rows_empty":13}
["FORM CMS-1728-94-C  (2-2002)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3215 - 3215.5)"]
[]
["32-320",{"$nulls":15},"Rev. 12"]
["03-04",{"$nulls":8},"FORM CMS 1728-94",{"$nulls":6},"3290 (Cont.)"]
["APPORTIONMENT OF PATIENT SERVICE COSTS",{"$nulls":9},"PROVIDER NO.: ",null,"     PERIOD:",null,null,"WORKSHEET C"]
[{"$nulls":12},"From: ______________",null,null,"PARTS III, IV & V"]
[{"$nulls":10},"______________",null,"To: ______________"]
["PART III - SUPPLIES AND DRUGS COST COMPUTATION"]
[{"$nulls":8},"Medicare Covered Charges ",null,null,null,"Cost of Services "]
[{"$nulls":6},"Total",null,null,"Part B",null,null,null,"Part B"]
[{"$nulls":4},"From Wkst ",null,"Charges",null,null,"Not Subject","Not Subject","Subject",null,"Not Subject","Not Subject","Subject"]
[{"$nulls":4},"B, Col. 6,","Total","from HHA","Ratio",null,"to Deductibles","to Deductibles","to Deductibles",null,"to Deductibles","to Deductibles","to Deductibles"]
[null,"   Other Patient Services",null,null,"Line:","Cost","Record)","(Col 2 ÷ 3)","Part A","& Coinsurance ","& Coinsurance","& Coinsurance","Part A","& Coinsurance","& Coinsurance","& Coinsurance"]
[{"$nulls":4},"1","2","3","4","5","6",6.01,"7","8","9",9.01,"10"]
["15"," Cost of Medical Supplies",null,null,"12",{"$nulls":11},"15"]
["16"," Cost of Drugs",null,null,"13",{"$nulls":11},"16"]
[]
["PART IV - COMPARISON OF THE LESSER OF THE AGGREGATE MEDICARE COST, THE AGGREGATE OF THE MEDICARE COST PER VISIT LIMITATION AND THE AGGREGATE PER BENEFICIARY COST LIMITATION"]
[{"$nulls":10},"Medicare Program","Per Beneficiary"]
[{"$nulls":10},"Unduplicated","Annual","Cost of Medicare Services"]
[{"$nulls":10},"Census Count","Limitation Per",null,"Part B"]
[{"$nulls":10},"For Each MSA","MSA/Non-MSA",null,"Not Subject","Subject","Total"]
[{"$nulls":10},"Pre 10/1/2000","(From Your",null,"to Deductibles","to Deductibles","(Sum of"]
[{"$nulls":10},"(4)","Intermediary)","Part  A","& Coinsurance","& Coinsurance","Cols 3 & 4"]
[{"$nulls":10},1,2,3,4,5,6]
["17","Total Cost of Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 & 11, respectively, lines",{"$nulls":14},"17"]
[null,"1-6 (exculsive of subscripts))"]
["18","Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))",{"$nulls":14},"18"]
["19","Total (Sum of lines 17 and 18)",{"$nulls":14},"19"]
[]
["20","Total Cost Per Visit Limitation for Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 &11, respectively, line 14)",{"$nulls":14},"20"]
["21","Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))",{"$nulls":14},"21"]
["22","Total (Sum of lines 20 and 21)",{"$nulls":14},"22"]
[]
[{"$nulls":9},"MSA Code (3)",{"$nulls":5},"(Col 1 x 2)"]
[{"$nulls":9},0,1,2,3,4,5,6]
["23","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23"]
["23.01","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.01"]
["23.02","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.02"]
["23.03","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.03"]
["23.04","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.04"]
["23.05","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.05"]
["23.06","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.06"]
["23.07","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.07"]
["23.08","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.08"]
["23.09","Per Beneficiary Cost Limitation for MSA:",{"$nulls":14},"23.09"]
["24","Aggregate Per Beneficiary Cost Limitation (Sum of lines 23 and subscripts thereof)",{"$nulls":14},"24"]
[]
["PART V - OUTPATIENT THERAPY REDUCTION COMPUTATION"]
[{"$nulls":8},"Part B"]
[{"$nulls":8},"Subject to Deductibles and Coinsurance"]
[{"$nulls":8},"Medicare","Medicare","Medicare","Medicare","Medicare","Medicare"]
[{"$nulls":6},"From Wkst. C,","Average","Program Visits","Program Costs","Program Visits","Program Visits","Program Visits","Program Costs","Application of","Reasonable"]
[{"$nulls":6},"Part I, Col. 4,","Cost","for Services","for Services","for Services","for Services","for Services on ","for Services","the Reasonable ","Costs Net of "]
[null,"    Patient Services",{"$nulls":4},"Line:","Per Visit","Before 1/1/98","Before 1/1/98","1/1/98-12/31/98","1/1/99-9/30/00","or after 10/1/00","1/1/98-12/31/98","Cost Reduction","Adjustments"]
[{"$nulls":6},1,2,3,4,5,5.01,5.02,6,7,8]
["25"," Physical Therapy",{"$nulls":4},2,{"$nulls":9},"25"]
["26"," Occupational Therapy",{"$nulls":4},3,{"$nulls":9},"26"]
["27"," Speech Pathology",{"$nulls":4},4,{"$nulls":9},"27"]
["28"," Total (Sum of lines 25-27)",{"$nulls":14},"28"]
[null,"(3) The MSA codes flow from Worksheet S-3, Part III, line 29 and subscripts as indicated."]
[null,"(4) The sum of column 1, line 24 must equal Worksheet S-3, Part I, column 2, line 10.01."]
["FORM CMS-1728-94-C  (3-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3215 - 3215.5)"]
[]
[]
[]
["Rev. 12",{"$nulls":15},"32-321"]

{"sheet":"D^","index":19,"n_rows":73,"n_cols":8,"rows_kept":73,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",null,"FORM CMS 1728-94",{"$nulls":4},"03-04"]
["CALCULATION OF REIMBURSEMENT SETTLEMENT - ",null,null," PROVIDER NO.:",null," PERIOD:"]
["PART A AND PART B SERVICES",{"$nulls":4},"From:  ___________","WORKSHEET D"]
[null,null,null," ________________",null,"To: ___________"]
["PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES"]
[{"$nulls":4},"PART B"]
[{"$nulls":4},"Not Subject",null,"Subject"]
[{"$nulls":4},"to Deductibles",null,"to Deductibles"]
[null,null,null,"PART A","& Coinsurance",null,"& Coinsurance"]
[null,"        Description",null,1,2,null,"3"]
["Reasonable Cost of Title XVIII - Part A & Part B Services"]
[" 1"," Reasonable Cost of Services (See Instructions)",{"$nulls":5}," 1"]
[" 2","Cost of Services, RHC & FQHC",{"$nulls":5}," 2"]
[" 3","Sum of Lines 1 and 2",{"$nulls":5}," 3"]
[" 4"," Total charges for title XVIII - Part A and Part B Services - Pre 10/1/2000",{"$nulls":5}," 4"]
[" 4.01"," Total charges for title XVIII - Part A and Part B Services - Post 9/30/2000",{"$nulls":5}," 4.01"]
[null,"Customary Charges"]
[" 5","Amount actually collected from patients liable for payment for services on a",{"$nulls":5}," 5"]
[null,"charge basis (From your records)"]
[" 6","Amount that would have been realized from patients liable for payment for services on",{"$nulls":5}," 6"]
[null,"a charge basis had such payment been made in accordance with 42 CFR 413.13(b)"]
[" 7"," Ratio of line 5 to 6 (Not to exceed 1.000000)",{"$nulls":5}," 7"]
[" 8","Total customary charges - title XVIII (Multiply line 7 by line 4 for column 1) (Multiply line 7",{"$nulls":5}," 8"]
[null,"by the sum of lines 4 & 4.01 for columns 2 & 3, respectively)  (See Instructions)"]
[" 9","Excess of total customary charges over total reasonable cost (Complete only if",{"$nulls":5}," 9"]
[null,"line 8 exceeds line 3)"]
[" 10","Excess of reasonable cost over customary charges (Complete only if line 3 exceeds line 8)",{"$nulls":5}," 10"]
[" 11","Primary Payer Amounts",{"$nulls":5}," 11"]
[]
["PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT"]
[{"$nulls":4},"PART A",null,"PART B"]
[{"$nulls":4},"Services",null,"Services"]
[null,"        Description",null,null,1,null,"2"]
[12," Total reasonable cost (See Instructions)",{"$nulls":5},12]
[12.01," Total PPS Payment - Full Episodes without Outliers",{"$nulls":5},12.01]
[12.02," Total PPS Payment - Full Episodes with Outliers",{"$nulls":5},12.02]
[12.03," Total PPS Payment - LUPA Episodes",{"$nulls":5},12.03]
[12.04," Total PPS Payment - PEP Only Episodes",{"$nulls":5},12.04]
[12.05," Total PPS Payment - SCIC within a PEP Episodes",{"$nulls":5},12.05]
[12.06," Total PPS Payment - SCIC Only Episodes",{"$nulls":5},12.06]
[12.07," Total PPS Outlier Payment - Full Episodes with Outliers",{"$nulls":5},12.07]
[12.08," Total PPS Outlier Payment - PEP Only Episodes ",{"$nulls":5},12.08]
[12.09," Total PPS Outlier Payment - SCIC within a PEP Episodes",{"$nulls":5},12.09]
[12.1," Total PPS Outlier Payment - SCIC Only Episodes",{"$nulls":5},12.1]
[12.11," Total Other Payments",{"$nulls":5},12.11]
[12.12," DME Payment",{"$nulls":5},12.12]
[12.13," Oxygen Payment",{"$nulls":5},12.13]
[12.14," Prosthetics and Orthotics Payment",{"$nulls":5},12.14]
[13," Part B deductibles billed to Medicare patients (exclude coinsurance)",{"$nulls":5},13]
[14," Subtotal (Sum of lines 12-12.14 minus line 13)",{"$nulls":5},14]
[15," Excess reasonable cost (from line 10)",{"$nulls":5},15]
[16," Subtotal (Line 14 minus line 15)",{"$nulls":5},16]
[17," Coinsurance billed to Medicare patients (From your records)",{"$nulls":5},17]
[18," Net cost (Line 16 minus line 17)",{"$nulls":5},18]
[19," Reimbursable bad debts (From your records)",{"$nulls":5},19]
[20," Pneumococcal Vaccine",{"$nulls":5},20]
[21," Total Costs - Current cost reporting period (See Instructions)",{"$nulls":5},21]
[22,"Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets",{"$nulls":5},22]
[23,"Recovery of excess depreciation resulting from agencies' termination or decrease in Medicare utilization",{"$nulls":5},23]
[24,"Unrefunded charges to beneficiaries for excess costs erroneously collected based on correction of cost limit",{"$nulls":5},24]
[25,"Total cost before sequestration and other adjustments- (line 21",{"$nulls":5},25]
[null,"plus/minus line 22 minus sum of lines 23 and 24)"]
[25.5,"Other Adjustments (see instructions) (specify)",{"$nulls":5},25.5]
[26," Sequestration Adjustment (See Instructions)",{"$nulls":5},26]
[27,"Amount reimbursable after sequestration and other adjustments (Line 25 plus line 25.5 minus line 26)",{"$nulls":5},27]
[28," Total interim payments (From Worksheet D-1, line 4)",{"$nulls":5},28]
[28.5," Tentative settlement (For intermediary use only)",{"$nulls":5},28.5]
[29,"Balance due HHA/Medicare program (Line 27 minus line 28) (Indicate overpayments in brackets)",{"$nulls":5},29]
[30,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2",{"$nulls":5},30]
[31,"Balance due HHA/Medicare program (Line 29 minus line 30) (Indicate overpayments in brackets)",{"$nulls":5},31]
["FORM CMS-1728-94-D  (3-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3216 - 3216.2)"]
[]
["32-322",{"$nulls":6},"Rev. 12"]

{"sheet":"D-1","index":20,"n_rows":69,"n_cols":13,"rows_kept":69,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":6},"FORM CMS 1728-94",{"$nulls":4},"3290 (Cont.)"]
[" ANALYSIS OF PAYMENTS TO HHAs",{"$nulls":5}," PROVIDER NO.:",null,null," PERIOD:",null,"WORKSHEET D-1"]
["FOR SERVICES RENDERED TO",{"$nulls":5},"    _______________",null,null,"From:  ___________"]
["PROGRAM BENEFICIARIES",{"$nulls":5}," ",null,null,"To: ___________"]
[]
[null,null,"     Description",{"$nulls":5},"              PART A",null,"              PART B"]
[{"$nulls":8},"mm/dd/yyyy","Amount","mm/dd/yyyy","Amount"]
[{"$nulls":8},"1","2","3","4"]
[1,"  Total interim payments paid to provider ",{"$nulls":10},"1"]
[2,"  Interim pymts payable on individual bills either submitted or to",{"$nulls":10},"2"]
[null,"  be submitted to the intermediary, for services rendered in the"]
[null,"  cost reporting period.  If none, write \"NONE\" or enter a zero."]
[3,"  List separately each retroactive lump sum ",{"$nulls":5},".01",{"$nulls":4},"3.01"]
[null,"  adjustment amount based on subsequent revision",{"$nulls":5},".02",{"$nulls":4},"3.02"]
[null,"  of the interim rate for the cost reporting period.",{"$nulls":4},"Program ",".03",{"$nulls":4},"3.03"]
[null,"  Also show date of each payment.  If none write",{"$nulls":4},"       to   ",".04",{"$nulls":4},"3.04"]
[null,"  \"NONE\" or enter a zero.(1)",{"$nulls":4},"Provider",".05",{"$nulls":4},"3.05"]
[{"$nulls":7},".50",{"$nulls":4},"3.50"]
[null,"                                ",{"$nulls":5},".51",{"$nulls":4},"3.51"]
[{"$nulls":6},"Provider",".52",{"$nulls":4},"3.52"]
[null,"                                 ",{"$nulls":4},"       to   ",".53",{"$nulls":4},"3.53"]
[{"$nulls":6},"Program ",".54",{"$nulls":4},"3.54"]
[null,"  SUBTOTAL (Sum of lines 3.01-3.49, minus sum",{"$nulls":5},".99"]
[null,"  of lines 3.50-3.98)                         ",{"$nulls":10},"3.99"]
[4,"  TOTAL INTERIM PAYMENTS (Sum of lines 1, 2",{"$nulls":10},"4"]
[null,"  and 3.99)(Transfer to Wkst D, Part II,"]
[null,"  column as appropriate, line 28)"]
[]
[{"$nulls":4},"TO BE COMPLETED BY INTERMEDIARY"]
[]
[5,"  List separately each tentative settlement payment ",{"$nulls":4},"Program",".01",{"$nulls":4},"5.01"]
[null,"  after desk review.  Also show date of each ",{"$nulls":4},"  to",".02",{"$nulls":4},"5.02"]
[null,"  payment.  If none, write \"NONE\" or enter     ",{"$nulls":4},"Provider",".03",{"$nulls":4},"5.03"]
[null,"  a zero. (1)",{"$nulls":4},"Provider",".50",{"$nulls":4},"5.50"]
[null,"  \"NONE\" or enter a zero. (1) ",{"$nulls":4},"  to",".51",{"$nulls":4},"5.51"]
[{"$nulls":6},"Program",".52",{"$nulls":4},"5.52"]
[null,"  SUBTOTAL (Sum of lines 5.01-5.49 minus sum  ",{"$nulls":5},".99"]
[null,"  of lines 5.50-5.98)      ",{"$nulls":10},"5.99"]
[6,"  Determine net settlement   ",{"$nulls":4},"Program"]
[null,"  amount (balance due) based  ",{"$nulls":4},"  to",".01"]
[null,"  on the cost report (See   ",{"$nulls":4},"Provider",{"$nulls":5},"6.01"]
[null,"  Instructions)",{"$nulls":4},"Provider"]
[{"$nulls":6},"  to",".02"]
[{"$nulls":6},"Program",{"$nulls":5},"6.02"]
[7,"  TOTAL MEDICARE PROGRAM LIABILITY ",{"$nulls":10},"7"]
[null,"  (See Instructions) "]
[null," Name of Intermediary",{"$nulls":7},"    Intermediary Number"]
[]
[]
[null," Signature of Authorized Person",{"$nulls":7},"    Date:   Month, Day, Year"]
[]
[]
[" (1)  On lines 3, 5 and 6, where an amount is due \"Provider to Program,\" show the amount and date on which the provider"]
["      agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
[]
["FORM CMS-1728-94-D-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3217)"]
{"$rows_empty":12}
["Rev. 7",{"$nulls":11},"32-323"]

{"sheet":"F","index":21,"n_rows":85,"n_cols":12,"rows_kept":85,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":5},"FORM CMS 1728-94        ",{"$nulls":4},"08-99"]
[null,"              BALANCE SHEET",{"$nulls":4}," PROVIDER NO.:",null,"  PERIOD:"]
[" (To be completed by all providers maintaining fund type",{"$nulls":7},"From:  ___________",null,"WORKSHEET F"]
[" accounting records.  Nonproprietary providers not",{"$nulls":5}," ___________",null,"To: ___________"]
[" maintaining fund type accounting records, should"]
[" complete the \"General Fund\" column only.)"]
[{"$nulls":7},"      SPECIFIC"]
[null,null,null,"   ASSETS",null,null,"GENERAL","      PURPOSE",null,"ENDOWMENT","PLANT"]
[null,null,null,"(Omit Cents)",null,null,"FUND","         FUND",null,"FUND","FUND"]
[{"$nulls":6},"1",null,"2","3","4"]
[null,null,null,"CURRENT ASSETS"]
[" 1"," Cash on hand and in banks",{"$nulls":9}," 1"]
[" 2"," Temporary investments",{"$nulls":9}," 2"]
[" 3"," Notes receivable",{"$nulls":9}," 3"]
[" 4"," Accounts Receivable",{"$nulls":9}," 4"]
[" 5"," Other Receivables",{"$nulls":9}," 5"]
[" 6"," Less: Allowance for uncollectible notes",{"$nulls":9}," 6"]
[null," and accounts receivable",{"$nulls":4},"(                        )"]
[" 7"," Inventory",{"$nulls":9}," 7"]
[" 8"," Prepaid Expenses",{"$nulls":9}," 8"]
[" 9"," Other current assets",{"$nulls":9}," 9"]
["10"," Due from other funds",{"$nulls":9},"10"]
["11"," TOTAL CURRENT ASSETS (Sum of lines 1-10)",{"$nulls":9},"11"]
[null,null,null,"FIXED ASSETS"]
["12"," Land",{"$nulls":9},"12"]
["13"," Land Improvements",{"$nulls":9},"13"]
["14"," Less: Accumulated Depreciation",{"$nulls":4},"(                        )",{"$nulls":4},"14"]
["15"," Buildings",{"$nulls":9},"15"]
["16"," Less: Accumulated Depreciation",{"$nulls":4},"(                        )",{"$nulls":4},"16"]
["17"," Leasehold improvements",{"$nulls":9},"17"]
["18"," Less: Accumulated Depreciation",{"$nulls":4},"(                        )",{"$nulls":4},"18"]
["19"," Fixed equipment",{"$nulls":9},"19"]
["20"," Less: Accumulated Depreciation",{"$nulls":4},"(                        )",{"$nulls":4},"20"]
["21"," Automobiles and trucks",{"$nulls":9},"21"]
["22"," Less: Accumulated Depreciation",{"$nulls":4},"(                        )",{"$nulls":4},"22"]
["23"," Major movable equipment",{"$nulls":9},"23"]
["24"," Less: Accumulated Depreciation",{"$nulls":4},"(                        )",{"$nulls":4},"24"]
["25"," Minor equipment nondepreciable",{"$nulls":9},"25"]
["26"," Other fixed assets",{"$nulls":9},"26"]
["27"," TOTAL FIXED ASSETS (Sum of lines 12-26)",{"$nulls":9},"27"]
[null,null,null,"OTHER ASSETS"]
["28"," Investments",{"$nulls":9},"28"]
["29"," Deposits on leases",{"$nulls":9},"29"]
["30"," Due from owners/officers",{"$nulls":9},"30"]
["31",{"$nulls":10},"31"]
["32","TOTAL OTHER ASSETS (Sum of lines 28-31)",{"$nulls":9},"32"]
["33","TOTAL ASSETS (Sum of lines 11, 27 and 32)",{"$nulls":9},"33"]
[null,null,"   LIABILITIES AND FUND BALANCE"]
[null,null,null,"(Omit Cents)"]
[null,null,null,"CURRENT LIABILITIES"]
["34"," Accounts payable",{"$nulls":9},"34"]
["35"," Salaries, wages & fees payable",{"$nulls":9},"35"]
["36"," Payroll taxes payable",{"$nulls":9},"36"]
["37"," Notes & loans payable (short term)",{"$nulls":9},"37"]
["38"," Deferred income",{"$nulls":9},"38"]
["39"," Accelerated payments",{"$nulls":9},"39"]
["40"," Due to other funds",{"$nulls":9},"40"]
["41","Other (Specify)",{"$nulls":9},"41"]
["42"," TOTAL CURRENT LIABILITIES (Sum of lines 34-41)",{"$nulls":9},"42"]
[null,null,"       LONG TERM LIABILITIES"]
["43"," Mortgage payable",{"$nulls":9},"43"]
["44"," Notes payable",{"$nulls":9},"44"]
["45"," Unsecured Loans",{"$nulls":9},"45"]
["46"," Loans from owners - prior to 7/1/66",{"$nulls":9},"46"]
["47","Loans from owners - on or after 7/1/66",{"$nulls":9},"47"]
["48","Other (Specify)",{"$nulls":9},"48"]
["49"," TOTAL LONG TERM LIABILITIES ",{"$nulls":9},"49"]
[null," (Sum of lines 43-48)"]
["50"," TOTAL LIABILITIES (Sum of lines 42 and 49)",{"$nulls":9},"50"]
[null,null,"       CAPITAL ACCOUNTS"]
["51"," General fund balance",{"$nulls":9},"51"]
["52"," Specific purpose fund balance",{"$nulls":9},"52"]
["53"," Donor created--Endowment fund balance--restricted",{"$nulls":9},"53"]
["54"," Donor created--Endowment fund balance--unrestricted",{"$nulls":9},"54"]
["55"," Governing body created--Endowment fund balance",{"$nulls":9},"55"]
["56"," Plant fund balance--Invested in plant",{"$nulls":9},"56"]
["57"," Plant fund balance-- Reserve for plant improvement,",{"$nulls":9},"57"]
[null," replacement and expansion"]
["58"," TOTAL FUND BALANCES (Sum of lines 51 thru 57)",{"$nulls":9},"58"]
["59"," TOTAL LIABILITIES AND FUND BALANCE (Sum ",{"$nulls":9},"59"]
[null," of lines 50 and 58)"]
[{"$nulls":5},"(             ) = contra amount"]
["FORM CMS-1728-94-F  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3218)"]
[]
["32-324",{"$nulls":10},"Rev. 7"]

{"sheet":"F-1","index":22,"n_rows":75,"n_cols":9,"rows_kept":75,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",null,null,null,"FORM CMS 1728-94",null,null,null,"3290 (Cont.)"]
["STATEMENT OF",null,null,null,"   PROVIDER NO.:",null," PERIOD"]
["REVENUE AND EXPENSES",{"$nulls":5},"From:  ___________"," WORKSHEET F-1"]
[{"$nulls":4}," ___________",null,"To: ___________"]
[" 1"," Total patient revenues",{"$nulls":6}," 1"]
[]
[" 2"," Less:  Allowances and discounts on patients' accounts",{"$nulls":6}," 2"]
[]
[" 3"," Net patient revenues (Line 1 minus line 2)",{"$nulls":6}," 3"]
[]
[" 4"," Operating expenses (From Worksheet A, column 6, line 29)",{"$nulls":6}," 4"]
[]
[" 5"," Additions to operating expenses (Specify)",{"$nulls":6}," 5"]
[]
[" 6",{"$nulls":7}," 6"]
[]
[" 7",{"$nulls":7}," 7"]
[]
[" 8",{"$nulls":7}," 8"]
[]
[" 9",{"$nulls":7}," 9"]
[]
["10",{"$nulls":7},"10"]
[]
["11"," Subtractions from operating expenses (Specify)",{"$nulls":6},"11"]
[]
["12",{"$nulls":7},"12"]
[]
["13",{"$nulls":7},"13"]
[]
["14",{"$nulls":7},"14"]
[]
["15",{"$nulls":7},"15"]
[]
["16",{"$nulls":7},"16"]
[]
["17"," Less total operating expenses (net of lines 4 thru 16)",{"$nulls":6},"17"]
[]
["18"," Net income from service to patients (Line 3 minus line 17)",{"$nulls":6},"18"]
[]
[null," Other income:"]
[]
[19," Contributions, donations, bequests, etc.",{"$nulls":6},19]
[]
[20," Income from investments",{"$nulls":6},20]
[]
[21," Purchase discounts",{"$nulls":6},21]
[]
[22," Rebates and refunds of expenses",{"$nulls":6},22]
[]
[23," Sale of Medical and Nursing Supplies to other than patients",{"$nulls":6},23]
[]
[24," Sale of durable medical equipment to other than patients",{"$nulls":6},24]
[]
[25," Sale of drugs to other than patients",{"$nulls":6},25]
[]
[26," Sale of medical records and abstracts",{"$nulls":6},26]
[]
[27,"Other revenues (Specify)",{"$nulls":6},27]
[]
[28,{"$nulls":7},28]
[]
[29,{"$nulls":7},29]
[]
[30,{"$nulls":7},30]
[]
[31,{"$nulls":7},31]
[]
[32," Total Other Income (Sum of lines 19 thru 31)",{"$nulls":6},32]
[]
[33," Net Income or Loss for the period (Line 18 plus line 32)",{"$nulls":6},33]
[]
["FORM CMS-1728-94  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SEC. 3218)"]
[]
["Rev. 7",{"$nulls":7},"32-325"]

{"sheet":"F-2","index":23,"n_rows":51,"n_cols":15,"rows_kept":51,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":7},"FORM CMS 1728-94        ",{"$nulls":5},"08-99"]
[{"$nulls":9},"  PROVIDER NO.:",null,"  PERIOD:"]
["STATEMENT OF CHANGES IN FUND BALANCES",{"$nulls":10},"From:  ___________",null," WORKSHEET F-2"]
[{"$nulls":9}," ___________",null,"To: ___________"]
[{"$nulls":6},"GENERAL FUND",null,"SPECIFIC PURPOSE FUND",null,"ENDOWMENT FUND",null,"PLANT FUND"]
[{"$nulls":6},"1","2","3","4","5","6","7","8"]
[]
[" 1"," Fund balances at beginning of period",{"$nulls":12},"  1"]
[]
[" 2"," Net Income (loss) (From Worksheet F-1, line 33)",{"$nulls":12},"  2"]
[]
[" 3"," Total (Sum of line 1 and line 2)",{"$nulls":12},"  3"]
[]
[" 4"," Additions (Credit adjustments) (Specify)",{"$nulls":12},"  4"]
[]
[" 5",{"$nulls":13},"  5"]
[]
[" 6",{"$nulls":13},"  6"]
[]
[" 7",{"$nulls":13},"  7"]
[]
[" 8",{"$nulls":13},"  8"]
[]
["9"," Total Additions (Sum of lines 4-8)",{"$nulls":12},"  9"]
[]
["10"," Subtotal (line 3 plus line 9)",{"$nulls":12}," 10"]
[]
["11"," Deductions (Debit adjustments) (Specify)",{"$nulls":12}," 11"]
[]
["12",{"$nulls":13}," 12"]
[]
["13",{"$nulls":13}," 13"]
[]
["14",{"$nulls":13}," 14"]
[]
["15",{"$nulls":13}," 15"]
[]
["16"," Total Deductions (Sum of lines 11-15)",{"$nulls":12}," 16"]
[null," Fund balance at end of period per balance sheet"]
["17"," (line 10 minus line 16)",{"$nulls":12}," 17"]
{"$rows_empty":8}
["FORM CMS-1728-94-F-2  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3218)"]
[]
["32-326",{"$nulls":13},"Rev. 7"]

{"sheet":"J-1 & J-2","index":24,"n_rows":112,"n_cols":16,"rows_kept":112,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"3290 (Cont.)"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null,"WORKSHEET J-1"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________",null,null,"PARTS I & II"]
["COSTS TO CORF REIMBURSABLE COST CENTERS",{"$nulls":7},"  CORF NO.:",null,null,"  TO:  _________________"]
[{"$nulls":8},"  ___________________"]
["PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CORF REIMBURSABLE COST CENTERS"]
[{"$nulls":5},"NET","CAPITAL",null,"PLANT",{"$nulls":4},"ALLOCATED"]
[{"$nulls":5},"EXPENSES","RELATED COSTS",null,"OPERATION",null,null,"A&G",null,"CORF","TOTAL"]
[null,"CORF COST CENTER",null,null,null,"FOR COST","BLDGS &","MOVABLE","& MAINTE-","TRANSPOR-","SUBTOTAL","SHARED","SUB-","A&G (SEE","(SUM OF"]
[null,"(OMIT CENTS)",null,null,null,"ALLOCATION (1)","FIXTURES","EQUIPMENT","NANCE","TATION","(cols. 0-4)","COSTS","TOTAL","PART II)","COLS 6 & 7)"]
[{"$nulls":5},"0","1","2","3","4","4A","5","6","7","8"]
[" 1"," Administrative and General",{"$nulls":13}," 1"]
[" 2"," Skilled Nursing Care",{"$nulls":13}," 2"]
[" 3"," Physical Therapy",{"$nulls":13}," 3"]
[" 4"," Occupational Therapy",{"$nulls":13}," 4"]
[" 5"," Speech Pathology",{"$nulls":13}," 5"]
[" 6"," Medical Social Services",{"$nulls":13}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":13}," 7"]
[" 8"," Psychological Services",{"$nulls":13}," 8"]
[" 9"," Prosthetic and Orthotic Devices",{"$nulls":13}," 9"]
["10"," Drugs and Biologicals",{"$nulls":13},"10"]
["11"," Medical Supplies",{"$nulls":13},"11"]
["12"," Durable Medical Equipment-Rented",{"$nulls":13},"12"]
["13"," Durable Medical Equipment-Sold",{"$nulls":13},"13"]
["14"," Other Part B Services",{"$nulls":13},"14"]
["15"," TOTALS (Sum of lines 1-14) (2)",{"$nulls":13},"15"]
[null,"(1) Column 0, line 15 must agree with Wkst. A, column 10, line 24."]
[null,"(2) Columns 0 through 5, line 15 must agree with the corresponding columns of Wkst. B, line 24"]
[]
[{"$nulls":6},0,0,0,0,0]
["PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF CORF ADMINISTRATIVE AND GENERAL COSTS"]
[" 1"," Amount from Part I, column 6, line 15",{"$nulls":13}," 1"]
[" 2"," Amount from Part I, column 6, line 1",{"$nulls":13}," 2"]
[" 3"," Line 1 minus line 2",{"$nulls":13}," 3"]
[" 4"," Unit cost multiplier for CORF A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,",{"$nulls":13}," 4"]
[null," lines 2 through 14, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)"]
{"$rows_empty":17}
["FORM CMS 1728-94-J-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3221-3221.2)"]
[]
["Rev. 7",{"$nulls":14},"32-327"]
["05-00",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"3290 (Cont.)"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null,"   WORKSHEET J-2"]
["COMPUTATION OF CORF COSTS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________"]
[{"$nulls":8},"  CORF NO.:",null,null,"  TO:  __________________"]
[{"$nulls":8},"  ___________________"]
["PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION"]
[{"$nulls":11},"TITLE XVIII",null,null,"TITLE XVIII"]
[{"$nulls":6},"TOTAL COSTS",null,"RATIO OF",null,"TITLE XVIII","CORF","TITLE XVIII","REASONABLE","COST NET OF"]
[{"$nulls":6},"(FROM SUPP.","TOTAL","COSTS TO","TITLE XVIII","CORF COSTS","CHARGES ON","CORF","COST","REASONABLE"]
[null,"CORF COST CENTER",{"$nulls":4},"WKST. J-1, PT.","CORF","CHARGES","CORF","(COL. 3 X","OR AFTER","COSTS ON OR","REDUCTION","COST"]
[null,"(OMIT CENTS)",{"$nulls":4},"I, COL. 8) (1)","CHARGES (2)","(COL. 1 / COL. 2)","CHARGES *","COL. 4)","1/1/98 *","AFTER 1/1/98","AMOUNT ","REDUCTION"]
[{"$nulls":6},"1","2","3","4","5","6","7","8","9"]
[" 1"," Administrative and General",{"$nulls":13}," 1"]
[" 2"," Skilled Nursing Care",{"$nulls":13}," 2"]
[" 3"," Physical Therapy",{"$nulls":13}," 3"]
[" 4"," Occupational Therapy",{"$nulls":13}," 4"]
[" 5"," Speech Pathology",{"$nulls":13}," 5"]
[" 6"," Medical Social Services",{"$nulls":13}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":13}," 7"]
[" 8"," Psychological Services",{"$nulls":13}," 8"]
[" 9"," Prosthetic and Orthotic Devices",{"$nulls":13}," 9"]
["10"," Drugs and Biologicals",{"$nulls":13},"10"]
["11"," Medical Supplies",{"$nulls":13},"11"]
["12"," Durable Medical Equipment-Rented",{"$nulls":13},"12"]
["13"," Durable Medical Equipment-Sold",{"$nulls":13},"13"]
["14"," Other Part B Services",{"$nulls":13},"14"]
["15"," TOTALS (Sum of lines 2-14)",{"$nulls":13},"15"]
[]
["PART II - APPORTIONMENT OF COST OF CORF"]
["SERVICES FURNISHED BY HHA DEPARTMENTS",{"$nulls":4},"Fr. Wkst. B,"]
[{"$nulls":5},"Col 6, Line:"]
["16"," Respiratory Therapy",null,null,null,"16",{"$nulls":9},"16"]
["17"," Physical Therapy",null,null,null,"7",{"$nulls":9},"17"]
["18"," Occupational Therapy",null,null,null,"8",{"$nulls":9},"18"]
["19"," Speech Pathology",null,null,null,"9",{"$nulls":9},"19"]
["20"," Supplies",null,null,null,"12",{"$nulls":9},"20"]
["21"," Drugs Charged to Patients",null,null,null,"13",{"$nulls":9},"21"]
[]
["23"," Total (Sum of lines 16 through 21)",{"$nulls":13},"23"]
[null,"(1) Cost for Part II, lines 16-22 are obtained from Worksheet B, column 6, lines as appropriate"]
[null,"(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records"]
[]
["PART III- TOTAL CORF COSTS",{"$nulls":8},"4","5","6","7","8","9"]
["24","Total CORF costs - Add the amount from Part I, column 9, line 15 and the amount from Part II, column 9, line 23.",{"$nulls":13},"24"]
[null,"Add the amounts from Part I, line 15 and Part II, line 23 for columns 4 through 8, respectively."]
["Transfer the amount in Part III, column 9 to Worksheet J-3, line 1."]
[]
["* See instructions for fee scheduled payment basis items for services rendered on or after January 1, 1999. "]
[]
[]
[]
[]
[]
["FORM CMS 1728-94-J-A932  (8-1999)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3222-3222.3)"]
[]
["Rev. 9",{"$nulls":14},"32-329"]

{"sheet":"J-1, PT3","index":25,"n_rows":57,"n_cols":16,"rows_kept":57,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":6},"FORM CMS 1728-94        ",{"$nulls":7},"08-99"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  PROVIDER NO.:",null,null,"  PERIOD:",null,"   WORKSHEET J-1"]
["COSTS TO CORF COST CENTERS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _____________",null,"   PART III"]
[{"$nulls":8},"  CORF NO.:",null,null,"  TO:  ________________"]
[{"$nulls":8},"  ___________________"]
["PART III - ALLOCATION OF GENERAL SERVICE COSTS TO CORF COST CENTERS - STATISTICAL BASIS"]
[null,null,null,"CAPITAL"]
[null,null,null,"RELATED COSTS",null,null,null,"PLANT"]
[{"$nulls":7},"OPERATION"]
[null,null,null,"BLDGS &",null,"MOVABLE",null,"& MAINTE-",{"$nulls":5},"ADMINISTRATIVE"]
[null,null,null,"FIXTURES",null,"EQUIPMENT",null,"NANCE",null,"TRANSPOR-",null,null,null,"& GENERAL"]
[null,"CORF COST CENTER",null,"(SQUARE",null,"(SQUARE",null,"(SQUARE",null," TATION",null,"RECONCIL-",null,"(ACCUMULATED"]
[null,"(OMIT CENTS)",null,"FEET)",null,"FEET)",null,"FEET)",null,"(MILEAGE)",null,"IATION",null,"COST)"]
[null,null,null,1,null,2,null,3,null,4,null,"5A",null,5]
[" 1"," Administrative and General",{"$nulls":13}," 1"]
[" 2"," Skilled Nursing Care",{"$nulls":13}," 2"]
[" 3"," Physical Therapy",{"$nulls":13}," 3"]
[" 4"," Occupational Therapy",{"$nulls":13}," 4"]
[" 5"," Speech Pathology",{"$nulls":13}," 5"]
[" 6"," Medical Social Services",{"$nulls":13}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":13}," 7"]
[" 8"," Psychological Services",{"$nulls":13}," 8"]
[" 9"," Prosthetic and Orthotic Devices",{"$nulls":13}," 9"]
["10"," Drugs and Biologicals",{"$nulls":13},"10"]
["11"," Medical Supplies",{"$nulls":13},"11"]
["12"," Durable Medical Equipment-Rented",{"$nulls":13},"12"]
["13"," Durable Medical Equipment-Sold",{"$nulls":13},"13"]
["14"," Other Part B Services",{"$nulls":13},"14"]
["15"," TOTALS (Sum of lines 1-14)",{"$nulls":13},"15"]
["16"," Total Cost to be Allocated",{"$nulls":13},"16"]
["17"," Unit Cost Multiplier",{"$nulls":13},"17"]
{"$rows_empty":23}
["FORM CMS 1728-94-J-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SEC. 3221.3)"]
[]
["32-328",{"$nulls":14},"Rev. 7"]

{"sheet":"J-3","index":26,"n_rows":65,"n_cols":9,"rows_kept":65,"cut":false,"hidden":false,"merged":[[64,3,64,5]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",null,null,null,"FORM CMS 1728-94        ",null,null,null,"05-00"]
[null,null,null,"  CORF NO.:","  FROM:  _______________",null,null,"  WORKSHEET J-3"]
["CALCULATION OF REIMBURSEMENT",null,null,"  ___________________","  TO:  _________________"]
["SETTLEMENT - CORF SERVICES"]
[]
[]
[]
["PART I-COMPUTATION OF CUSTOMARY CHARGES FOR CORF SERVICES"]
[]
[]
["1","Total reasonable cost of CORF services (See instructions)",{"$nulls":6},"1"]
["1.1","Total reasonable cost of CORF services prior to 1/1/1998 (Reasonable cost basis) (See instructions)",{"$nulls":6},"1.1"]
["1.2","Total reasonable cost of CORF services on or after 1/1/1998 (Subject to LCC) (See instructions)",{"$nulls":6},"1.2"]
["2","Primary payment amounts (CORF services)",{"$nulls":6},"2"]
["3","Net cost (Line 1 minus line 2)",{"$nulls":6},"3"]
["4","Total CORF charges",{"$nulls":6},"4"]
[null,"Customary Charges"]
["5","Amounts actually collected from patients liable",{"$nulls":6},"5"]
[null,"for payments for CORF services on a charge basis (From"]
[null,"your records)"]
["6","Amount that would have been realized from patients",{"$nulls":6},"6"]
[null,"liable for payment for CORF services on a charge basis "]
[null,"had such payment been made in accordance with"]
[null,"42 CFR 413.13(b)"]
["7","Ratio of line 5 to line 6 (Not to exceed 1.000000)",{"$nulls":6},"7"]
["8","Total customary charges - CORF services (Multiply line 7 x line 4)",{"$nulls":6},"8"]
["8.1","Total customary charges - CORF services prior to 1/1/1998 (Reasonable cost basis) (See instructions)",{"$nulls":6},"8.1"]
["8.2","Total customary charges - CORF services on or after 1/1/1998 (Subject to LCC) (See instructions)",{"$nulls":6},"8.2"]
[]
[null,"COMPUTATION OF LESSER OF REASONABLE COSTS OR CUSTOMARY CHARGES FOR CORF"]
[null,"SERVICES FURNISHED IN CALENDAR YEAR 1998"]
["8.3","Excess of customary charges over reasonable costs (Complete only if line 8.2 exceeds line 1.2) (See instructions)",{"$nulls":6},8.3]
["8.4","Excess of reasonable costs over customary charges (Complete only if line 1.2 exceeds line 8.2) (See instructions)",{"$nulls":6},8.4]
[]
[]
[]
["PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT"]
[]
[" 9","Cost of CORF services (From line 3 )",{"$nulls":6},"9"]
["10","Part B deductible billed to Program patients (exclude coinsurance amounts)",{"$nulls":6},"10"]
["11","Net Cost (Line 9 minus line 10)",{"$nulls":6},"11"]
["11.1","Excess of reasonable costs over customary charges for services rendered on or after 1/1/1998 (from line 8.4)",{"$nulls":6},"11.1"]
["11.2","Subtotal (line11 minus line 11.1)",{"$nulls":6},"11.2"]
["12","80% of Part B cost (80% x line 11.2)",{"$nulls":6},"12"]
["13","Actual coinsurance billed to Program patients (From your records)",{"$nulls":6},"13"]
["14","Net cost less actual billed coinsurance (Line 11 minus line 13)",{"$nulls":6},"14"]
["15","Reimbursable bad debts (See instructions)",{"$nulls":6},"15"]
["16","Net reimbursable amount (Line 15 plus the lesser of line 12 or line 14)",{"$nulls":6},"16"]
["17","Amounts applicable to prior cost reporting periods resulting from disposition",{"$nulls":6},"17"]
[null,"of depreciable assets"]
["18","Recovery of excess depreciation resulting from facility's termination or a decrease in ",{"$nulls":6},"18"]
[null,"Program utilization"]
["19","Other adjustments (specify)",{"$nulls":6},"19"]
["20","Total Cost - reimbursable to provider (Line 16 minus lines 17 and 18 and plus or minus line 19)",{"$nulls":6},"20"]
["21","Sequestration Adjustment (See instructions)",{"$nulls":6},"21"]
["22","Amount due provider after sequestration adjustment (Amount on line 20 minus line 21)",{"$nulls":6},"22"]
["23","Interim payments",{"$nulls":6},"23"]
[23.5,"Tentative settlement (For intermediary use only)",{"$nulls":6},23.5]
["24","Balance due CORF/Program (Line 22 minus line 23) (Indicate overpayments in brackets)",{"$nulls":6},"24"]
["25","Protested amounts (nonallowable cost report items) in accordance with PRM II, Sec. 115.2(B)",{"$nulls":6},"25"]
["26","Balance due CORF/Program (Line 24 minus line 25) (Indicate overpayments in brackets)",{"$nulls":6},"26"]
["FORM CMS 1728-94-J-3 (5-2000) (INSTRUCTIONS PUBLISHED IN THIS WORKSHEET ARE PUBLISHED IN CMS"]
["PUB. 15-II, SEC. 3223-3223.2"]
[]
["32-330",{"$nulls":7},"Rev. 9"]

{"sheet":"J-4","index":27,"n_rows":63,"n_cols":9,"rows_kept":63,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["06-01",null,null,"FORM CMS 1728-94",{"$nulls":4},"3290 (Cont.)"]
["ANALYSIS OF PAYMENTS TO",null,null,"  CORF NO.:","  FROM:  _______________",null,null,"  WORKSHEET J-4"]
["PROVIDER-BASED CORF FOR",null,null,"  ___________________","  TO:  _________________"]
["SERVICES RENDERED TO PROGRAM"]
["BENEFICIARIES"]
[]
[null,"DESCRIPTION",{"$nulls":4},"PART B"]
[{"$nulls":6},"1","2"]
[{"$nulls":6},"mm/dd/yyyy","Amount"]
["1","Total interim payments paid to CORF ",{"$nulls":6},"1"]
["2","Interim payments payable on individual bills either, submitted or to",{"$nulls":6},"2"]
[null,"be submitted to the intermediary, for services rendered in the"]
[null,"cost reporting period.  If none, write \"NONE\" or enter a zero."]
["3","List separately each retroactive lump sum ",null,null,null,".01",null,null,"3.01"]
[null,"adjustment amount based on subsequent revision",null,null,"Program ",".02",null,null,"3.02"]
[null,"of the interim rate for the cost reporting period.",null,null,"to",".03",null,null,"3.03"]
[null,"Also show date of each payment.  If none write",null,null,"Provider",".04",null,null,"3.04"]
[null,"\"NONE\" or enter a zero. (1)",null,null,null,".05",null,null,"3.05"]
[{"$nulls":5},".50",null,null,"3.50"]
[{"$nulls":4},"Provider ",".51",null,null,"3.51"]
[{"$nulls":4},"to",".52",null,null,"3.52"]
[{"$nulls":4},"Program",".53",null,null,"3.53"]
[{"$nulls":5},".54",null,null,"3.54"]
[null,"SUBTOTAL (Sum of lines 3.01-3.49, minus sum"]
[null,"of lines 3.50-3.98)                         ",null,null,null,".99",null,null,"3.99"]
["4","TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)",{"$nulls":6},"4"]
[null,"(Transfer to Supp. Wkst J-3, Part II, line 23)"]
[]
[null,null,"TO BE COMPLETED BY INTERMEDIARY"]
[]
["5","List separately each tentative settlement payment ",null,null,"Program ",".01",null,null,"5.01"]
[null,"after desk review.  Also show date of each ",null,null,"to",".02",null,null,"5.02"]
[null,"payment.  If none, write \"NONE\" or enter     ",null,null,"Provider",".03",null,null,"5.03"]
[null,"a zero. (1)",null,null,"Provider ",".50",null,null,"5.50"]
[{"$nulls":4},"to",".51",null,null,"5.51"]
[{"$nulls":4},"Program",".52",null,null,"5.52"]
[null,"SUBTOTAL (Sum of lines 5.01-5.49, minus sum  "]
[null,"of lines 5.50-5.98)      ",null,null,null,".99",null,null,"5.99"]
["6","Determine net settlement amount (balance due) based",null,null,"Program "]
[null,"on the cost report (SEE INSTRUCTIONS). (1)",null,null,"to"]
[{"$nulls":4},"Provider",".01",null,null,"6.01"]
[{"$nulls":4},"Provider "]
[{"$nulls":4},"to"]
[{"$nulls":4},"Program",".02",null,null,"6.02"]
["7","TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)",{"$nulls":6},"7"]
[]
[" Name of Intermediary",{"$nulls":4},"    Intermediary Number"]
[]
[]
[" Signature of Authorized Person",{"$nulls":4},"    Date:   (Month, Day, Year)"]
[]
[]
[" (1)  On lines 3, 5 and 6, where an amount is due \"Provider to Program,\" show the amount and date on which the provider"]
["      agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
[]
[]
[]
[]
[]
["FORM CMS-1728-94-J-4  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,"]
["SEC. 3224"]
[]
["Rev. 10",{"$nulls":7},"32-331"]

{"sheet":"K","index":28,"n_rows":55,"n_cols":13,"rows_kept":55,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":6},"06-01"]
["RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES",{"$nulls":6},"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K"]
[{"$nulls":7},"_",null,"FROM: ____________"]
[{"$nulls":7},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":7},"_"]
[{"$nulls":5},"CON-"]
[null,null,null,"EMPLOYEE",null,"TRACTED"]
[null,null,"SALARIES","BENEFITS","TRANSPOR-","SERVICES",null,null,null,"SUBTOTAL",null,"TOTAL"]
[null,"COST CENTER DESCRIPTIONS","(From","(From","TATION","(From",null,"TOTAL","RECLAS-","(col. 6","ADJUST-","(col. 8"]
[null,null,"Wkst.K-1)","Wkst. K-2)","(See inst.)","Wkst. K-3)","OTHER","(cols. 1-5)","SIFICATION","± col. 7)","MENTS","± col. 9)"]
[null,null,"1","2","3","4","5","6","7","8","9","10"]
[null,"GENERAL SERVICE COST CENTERS",null," "," "," ",{"$nulls":4}," "]
[1,"Capital Related Costs-Bldg and Fixt.",null," "," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Movable Equip.",null," "," "," ",{"$nulls":6},2]
[3,"Plant Operation and Maintenance",{"$nulls":10},3]
[4,"Transportation - Staff",{"$nulls":10},4]
[5,"Volunteer Service Coordination",{"$nulls":10},5]
[6,"Administrative and General",{"$nulls":10},6]
[null,"INPATIENT CARE SERVICE"]
[7,"Inpatient - General Care",{"$nulls":10},7]
[8,"Inpatient - Respite Care",{"$nulls":10},8]
[null,"VISITING SERVICES"]
[9,"Physician Services",{"$nulls":10},9]
[10,"Nursing Care",{"$nulls":10},10]
[11,"Physical Therapy",{"$nulls":10},11]
[12,"Occupational Therapy",{"$nulls":10},12]
[13,"Speech/ Language Pathology",{"$nulls":10},13]
[14,"Medical Social Services ",{"$nulls":10},14]
[15,"Spiritual Counseling",null," "," "," ",{"$nulls":4}," ",null,15]
[16,"Dietary Counseling",{"$nulls":10},16]
[17,"Counseling - Other",{"$nulls":10},17]
[18,"Home Health Aide and Homemaker",{"$nulls":10},18]
[19,"Other",{"$nulls":10},19]
[null,"OTHER HOSPICE SERVICE COSTS"]
[20,"Drugs, Biological and Infusion Therapy",{"$nulls":10},20]
[21,"Durable Medical Equipment/Oxygen",{"$nulls":10},21]
[22,"Patient Transportation",{"$nulls":10},22]
[23,"Imaging Services",{"$nulls":10},23]
[24,"Labs and Diagnostics",{"$nulls":10},24]
[25,"Medical Supplies",{"$nulls":10},25]
[26,"Outpatient Services (incl. E/R Dept.)",{"$nulls":10},26]
[27,"Radiation Therapy",{"$nulls":10},27]
[28,"Chemotherapy",{"$nulls":10},28]
[29,"Other",{"$nulls":10},29]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[30,"Bereavement Program Costs",{"$nulls":10},30]
[31,"Volunteer Program Costs",{"$nulls":10},31]
[32,"Fundraising",{"$nulls":10},32]
[33,"Other Program Costs",{"$nulls":10},33]
[34,"Total (sum of line 1 thru 33)",{"$nulls":10},34]
[null,"The net expenses for cost allocation on Worksheet A for the Hospice cost center line must equal the total facility costs in column 10, line 34 of this worksheet."]
[]
["FORM CMS-1728-94-K (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3240)"]
[]
["32-331.1",{"$nulls":11},"Rev. 10"]

{"sheet":"K-1","index":29,"n_rows":52,"n_cols":12,"rows_kept":52,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["02-02",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":5},"3290 (Cont.)"]
["COMPENSATION ANALYSIS - SALARIES AND WAGES",{"$nulls":5},"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K-1"]
[{"$nulls":6},"_",null,"FROM: ____________"]
[{"$nulls":6},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":6},"_"]
[]
[null,"COST CENTER DESCRIPTIONS","ADMINIS",null,"SOCIAL","SUPER-",null,"TOTAL"]
[null,"(omit cents)","TRATOR","DIRECTOR","SERVICES","VISORS","NURSES","THERAPISTS","AIDES","ALL OTHER","TOTAL (1)"]
[null,null,"1","2","3","4","5","6","7","8","9"]
[null,"GENERAL SERVICE COST CENTERS",null," "," "," ",null,null,null," "]
[1,"Capital Related Costs-Bldg and Fixt.",null," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Movable Equip.",null," "," ",{"$nulls":6},2]
[3,"Plant Operation and Maintenance",{"$nulls":9},3]
[4,"Transportation - Staff",{"$nulls":9},4]
[5,"Volunteer Service Coordination",{"$nulls":9},5]
[6,"Administrative and General",{"$nulls":9},6]
[null,"INPATIENT CARE SERVICE"]
[7,"Inpatient - General Care",{"$nulls":9},7]
[8,"Inpatient - Respite Care",{"$nulls":9},8]
[null,"VISITING SERVICES"]
[9,"Physician Services",{"$nulls":9},9]
[10,"Nursing Care",{"$nulls":9},10]
[11,"Physical Therapy",{"$nulls":9},11]
[12,"Occupational Therapy",{"$nulls":9},12]
[13,"Speech/ Language Pathology",{"$nulls":9},13]
[14,"Medical Social Services ",{"$nulls":9},14]
[15,"Spiritual Counseling",null," "," "," ",null,null,null," ",null,15]
[16,"Dietary Counseling",{"$nulls":9},16]
[17,"Counseling - Other",{"$nulls":9},17]
[18,"Home Health Aide and Homemaker",{"$nulls":9},18]
[19,"Other",{"$nulls":9},19]
[null,"OTHER HOSPICE SERVICE COSTS"]
[20,"Drugs Biological and Infusion Therapy",{"$nulls":9},20]
[21,"Durable Medical Equipment/ Oxygen",{"$nulls":9},21]
[22,"Patient Transportation",{"$nulls":9},22]
[23,"Imaging Services",{"$nulls":9},23]
[24,"Labs and Diagnostics",{"$nulls":9},24]
[25,"Medical Supplies",{"$nulls":9},25]
[26,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},26]
[27,"Radiation Therapy",{"$nulls":9},27]
[28,"Chemotherapy",{"$nulls":9},28]
[29,"Other",{"$nulls":9},29]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[30,"Bereavement Program Costs",{"$nulls":9},30]
[31,"Volunteer Program Costs",{"$nulls":9},31]
[32,"Fundraising",{"$nulls":9},32]
[33,"Other Program Costs",{"$nulls":9},33]
[34,"Total (sum of line 1 thru 33)",{"$nulls":9},34]
["(1) Transfer the amount in column 9 to Wkst K, column 1"]
["FORM CMS-1728-94-K-1 (2-2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3241)"]
[]
["Rev. 11",{"$nulls":10},"32-331.2"]

{"sheet":"K-2","index":30,"n_rows":52,"n_cols":12,"rows_kept":52,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":5},"02-02"]
["COMPENSATION ANALYSIS - EMPLOYEE BENEFITS (PAYROLL RELATED)",{"$nulls":5},"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K-2"]
[{"$nulls":6},"_",null,"FROM: ____________"]
[{"$nulls":6},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":6},"_"]
[]
[null,"COST CENTER DESCRIPTIONS","ADMINIS",null,"SOCIAL","SUPER-",null,"TOTAL"]
[null,"(omit cents)","TRATOR","DIRECTOR","SERVICES","VISORS","NURSES","THERAPISTS","AIDES","ALL OTHER","TOTAL (1)"]
[null,null,"1","2","3","4","5","6","7","8","9"]
[null,"GENERAL SERVICE COST CENTERS",null," "," "," ",null,null,null," "]
[1,"Capital Related Costs-Bldg and Fixt.",null," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Movable Equip.",null," "," ",{"$nulls":6},2]
[3,"Plant Operation and Maintenance",{"$nulls":9},3]
[4,"Transportation - Staff",{"$nulls":9},4]
[5,"Volunteer Service Coordination",{"$nulls":9},5]
[6,"Administrative and General",{"$nulls":9},6]
[null,"INPATIENT CARE SERVICE"]
[7,"Inpatient - General Care",{"$nulls":9},7]
[8,"Inpatient - Respite Care",{"$nulls":9},8]
[null,"VISITING SERVICES"]
[9,"Physician Services",{"$nulls":9},9]
[10,"Nursing Care",{"$nulls":9},10]
[11,"Physical Therapy",{"$nulls":9},11]
[12,"Occupational Therapy",{"$nulls":9},12]
[13,"Speech/ Language Pathology",{"$nulls":9},13]
[14,"Medical Social Services ",{"$nulls":9},14]
[15,"Spiritual Counseling",null," "," "," ",null,null,null," ",null,15]
[16,"Dietary Counseling",{"$nulls":9},16]
[17,"Counseling - Other",{"$nulls":9},17]
[18,"Home Health Aide and Homemaker",{"$nulls":9},18]
[19,"Other",{"$nulls":9},19]
[null,"OTHER HOSPICE SERVICE COSTS"]
[20,"Drugs Biological and Infusion Therapy",{"$nulls":9},20]
[21,"Durable Medical Equipment/ Oxygen",{"$nulls":9},21]
[22,"Patient Transportation",{"$nulls":9},22]
[23,"Imaging Services",{"$nulls":9},23]
[24,"Labs and Diagnostics",{"$nulls":9},24]
[25,"Medical Supplies",{"$nulls":9},25]
[26,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},26]
[27,"Radiation Therapy",{"$nulls":9},27]
[28,"Chemotherapy",{"$nulls":9},28]
[29,"Other",{"$nulls":9},29]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[30,"Bereavement Program Costs",{"$nulls":9},30]
[31,"Volunteer Program Costs",{"$nulls":9},31]
[32,"Fundraising",{"$nulls":9},32]
[33,"Other Program Costs",{"$nulls":9},33]
[34,"Total (sum of line 1 thru 33)",{"$nulls":9},34]
["(1) Transfer the amount in column 9 to Wkst K, column 2"]
["FORM CMS-1728-94-K-2 (2-2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3242)"]
[]
["32-331.3",{"$nulls":10},"Rev. 11"]

{"sheet":"K-3","index":31,"n_rows":52,"n_cols":12,"rows_kept":52,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["02-02",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":5},"3290 (Cont.)"]
["COMPENSATION ANALYSIS - CONTRACTED SERVICES/PURCHASED SERVICES",{"$nulls":5},"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K-3"]
[{"$nulls":6},"_",null,"FROM: ____________"]
[{"$nulls":6},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":6},"_"]
[]
[null,"COST CENTER DESCRIPTIONS","ADMINIS",null,"SOCIAL","SUPER-",null,"TOTAL"]
[null,"(omit cents)","TRATOR","DIRECTOR","SERVICES","VISORS","NURSES","THERAPISTS","AIDES","ALL OTHER","TOTAL (1)"]
[null,null,"1","2","3","4","5","6","7","8","9"]
[null,"GENERAL SERVICE COST CENTERS",null," "," "," ",null,null,null," "]
[1,"Capital Related Costs-Bldg and Fixt.",null," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Movable Equip.",null," "," ",{"$nulls":6},2]
[3,"Plant Operation and Maintenance",{"$nulls":9},3]
[4,"Transportation - Staff",{"$nulls":9},4]
[5,"Volunteer Service Coordination",{"$nulls":9},5]
[6,"Administrative and General",{"$nulls":9},6]
[null,"INPATIENT CARE SERVICE"]
[7,"Inpatient - General Care",{"$nulls":9},7]
[8,"Inpatient - Respite Care",{"$nulls":9},8]
[null,"VISITING SERVICES"]
[9,"Physician Services",{"$nulls":9},9]
[10,"Nursing Care",{"$nulls":9},10]
[11,"Physical Therapy",{"$nulls":9},11]
[12,"Occupational Therapy",{"$nulls":9},12]
[13,"Speech/ Language Pathology",{"$nulls":9},13]
[14,"Medical Social Services ",{"$nulls":9},14]
[15,"Spiritual Counseling",null," "," "," ",null,null,null," ",null,15]
[16,"Dietary Counseling",{"$nulls":9},16]
[17,"Counseling - Other",{"$nulls":9},17]
[18,"Home Health Aide and Homemaker",{"$nulls":9},18]
[19,"Other",{"$nulls":9},19]
[null,"OTHER HOSPICE SERVICE COSTS"]
[20,"Drugs, Biological and Infusion Therapy",{"$nulls":9},20]
[21,"Durable Medical Equipment/Oxygen",{"$nulls":7}," ",null,21]
[22,"Patient Transportation",{"$nulls":9},22]
[23,"Imaging Services",{"$nulls":9},23]
[24,"Labs and Diagnostics",{"$nulls":9},24]
[25,"Medical Supplies",{"$nulls":9},25]
[26,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},26]
[27,"Radiation Therapy",{"$nulls":9},27]
[28,"Chemotherapy",{"$nulls":9},28]
[29,"Other",{"$nulls":9},29]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[30,"Bereavement Program Costs",{"$nulls":9},30]
[31,"Volunteer Program Costs",{"$nulls":9},31]
[32,"Fundraising",{"$nulls":9},32]
[33,"Other Program Costs",{"$nulls":9},33]
[34,"Total (sum of line 1 thru 33)",{"$nulls":9},34]
["(1) Transfer the amount in column 9 to Wkst K, column 4"]
["FORM CMS-1728-94-K-3 (2-2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3243)"]
[]
["Rev. 11",{"$nulls":10},"32-331.4"]

{"sheet":"K-4I","index":32,"n_rows":54,"n_cols":12,"rows_kept":54,"cut":false,"hidden":false,"merged":[[7,3,7,4],[8,3,8,4]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":5},"02-02"]
["COST ALLOCATION - HOSPICE GENERAL SERVICE COST",{"$nulls":5},"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K-4"]
[{"$nulls":6},"_",null,"FROM: ____________",null,"PART I"]
[{"$nulls":6},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":6},"_"]
[null,null,"NET"]
[null,null,"EXPENSES"]
[null,null,"FOR COST","CAPITAL RELATED",null,null,null,"VOLUNTEER"]
[null,"COST CENTER DESCRIPTIONS","ALLOC.","COST",null,"PLANT",null,"SERVICES",null,"ADMINIS-"]
[null,null,"(FR. WKST K,","BUILDINGS","MOVABLE","OPERATION","TRANS-","COORDI-","SUBTOTAL","TRATIVE &"]
[null,null,"COL. 10)","& FIXTURES","EQUIPMENT","& MAINT.","PORTATION","NATOR","(col. 0 - 5)","GENERAL","TOTAL"]
[null,null,"0","1","2","3",4,5,"5A",6,7]
[null,"GENERAL SERVICE COST CENTERS",null," "," "]
[1,"Capital Related Costs-Bldg and Fixt.",null," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Movable Equip.",null," "," ",{"$nulls":6},2]
[3,"Plant Operation and Maintenance",{"$nulls":9},3]
[4,"Transportation - Staff",{"$nulls":9},4]
[5,"Volunteer Service Coordination",{"$nulls":9},5]
[6,"Administrative and General",{"$nulls":9},6]
[null,"INPATIENT CARE SERVICE"]
[7,"Inpatient - General Care",{"$nulls":9},7]
[8,"Inpatient - Respite Care",{"$nulls":9},8]
[null,"VISITING SERVICES"]
[9,"Physician Services",{"$nulls":9},9]
[10,"Nursing Care",{"$nulls":9},10]
[11,"Physical Therapy",{"$nulls":9},11]
[12,"Occupational Therapy",{"$nulls":9},12]
[13,"Speech/ Language Pathology",{"$nulls":9},13]
[14,"Medical Social Services - Direct",{"$nulls":9},14]
[15,"Spiritual Counseling",null," "," ",{"$nulls":6},15]
[16,"Dietary Counseling",{"$nulls":9},16]
[17,"Counseling - Other",{"$nulls":9},17]
[18,"Home Health Aide and Homemakers",{"$nulls":9},18]
[19,"Other",{"$nulls":9},19]
[null,"OTHER HOSPICE SERVICE COSTS"]
[20,"Drugs, Biologicals and Infusion",{"$nulls":9},20]
[21,"Durable Medical Equipment/Oxygen",{"$nulls":9},21]
[22,"Patient Transportation",{"$nulls":9},22]
[23,"Imaging Services",{"$nulls":9},23]
[24,"Labs and Diagnostics",{"$nulls":9},24]
[25,"Medical Supplies",{"$nulls":9},25]
[26,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},26]
[27,"Radiation Therapy",{"$nulls":9},27]
[28,"Chemotherapy",{"$nulls":9},28]
[29,"Other",{"$nulls":9},29]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[30,"Bereavement Program Costs",{"$nulls":9},30]
[31,"Volunteer Program Costs",{"$nulls":9},31]
[32,"Fundraising",{"$nulls":9},32]
[33,"Other Program Costs",{"$nulls":9},33]
[34,"Total (sum of line 1 thru 33)",{"$nulls":9},34]
["FORM CMS-1728-94-K-4 (2-2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3244)"]
[]
["32-331.5",{"$nulls":10},"Rev. 11"]

{"sheet":"K-4II","index":33,"n_rows":56,"n_cols":10,"rows_kept":56,"cut":false,"hidden":false,"merged":[[5,2,5,3],[6,2,6,3]],"flags":["formulas_cached_only"]}
["06-01",null,null,null,"FORM CMS-1728-94",{"$nulls":4},"3290 (Cont.)"]
["COST ALLOCATION - HOSPICE STATISTICAL BASIS",null,null,null,"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K-4"]
[{"$nulls":4},"_",null,"FROM: ____________",null,"PART II"]
[{"$nulls":4},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":4},"_"]
[null,null,"CAPITAL RELATED"]
[null,null,"COST",null,null,null,"VOLUNTEER"]
[null,null,"BUILDINGS","MOVABLE","PLANT",null,"SERVICES",null,"ADMINIS-"]
[null,null,"& FIXTURES","EQUIPMENT","OPERATION","TRANS-","COORDI-",null,"TRATIVE  &"]
[null,"COST CENTER DESCRIPTIONS","(SQUARE","(DOLLAR","& MAINT.","PORTATION","NATOR","RECON-","GENERAL"]
[null,null,"FEET)","VALUE)","(SQ. FT.)","(MILEAGE)","(HOURS)","CILIATION","(ACC. COST)"]
[null,null,"1","2","3",4,5,"6A",6]
[null,"GENERAL SERVICE COST CENTERS"," "," "]
[1,"Capital Related Costs-Buildings and Fixtures"," "," ",{"$nulls":5},1]
[2,"Capital Related Costs-Movable Equipment"," "," ",{"$nulls":5},2]
[3,"Plant Operation and Maintenance",{"$nulls":7},3]
[4,"Transportation-staff",{"$nulls":7},4]
[5,"Volunteer Service Coordination",{"$nulls":7},5]
[6,"Administrative and General",{"$nulls":7},6]
[null,"INPATIENT CARE SERVICE"]
[7,"Inpatient - General Care",{"$nulls":7},7]
[8,"Inpatient - Respite Care",{"$nulls":7},8]
[null,"VISITING SERVICES"]
[9,"Physician Services",{"$nulls":7},9]
[10,"Nursing Care",{"$nulls":7},10]
[11,"Physical Therapy",{"$nulls":7},11]
[12,"Occupational Therapy",{"$nulls":7},12]
[13,"Speech/ Language Pathology",{"$nulls":7},13]
[14,"Medical Social Services - Direct",{"$nulls":7},14]
[15,"Spiritual Counseling"," "," ",{"$nulls":5},15]
[16,"Dietary Counseling",{"$nulls":7},16]
[17,"Counseling - Other",{"$nulls":7},17]
[18,"Home Health Aide and Homemakers",{"$nulls":7},18]
[19,"Other",{"$nulls":7},19]
[null,"OTHER HOSPICE SERVICE COSTS"]
[20,"Drugs, Biologicals and Infusion",{"$nulls":7},20]
[21,"Durable Medical Equipment/Oxygen",{"$nulls":7},21]
[22,"Patient Transportation",{"$nulls":7},22]
[23,"Imaging Services",{"$nulls":7},23]
[34,"Labs and Diagnostics",{"$nulls":7},24]
[25,"Medical Supplies",{"$nulls":7},25]
[26,"Outpatient Services (incl. E/R Dept.)",{"$nulls":7},26]
[27,"Radiation Therapy",{"$nulls":7},27]
[28,"Chemotherapy",{"$nulls":7},28]
[29,"Other",{"$nulls":7},29]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[30,"Bereavement Program Costs",{"$nulls":7},30]
[31,"Volunteer Program Costs",{"$nulls":7},31]
[32,"Fundraising",{"$nulls":7},32]
[33,"Other Program Costs",{"$nulls":7},33]
[34,"Cost To be Allocated (per Wkst K-4, Part I)",{"$nulls":7},34]
[35,"Unit Cost Multiplier",{"$nulls":7},35]
[]
["FORM CMS-1728-94-K-4 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3244)"]
[]
["Rev. 10",{"$nulls":8},"32-331.6"]

{"sheet":"K-5I","index":34,"n_rows":56,"n_cols":15,"rows_kept":56,"cut":false,"hidden":false,"merged":[[6,5,6,6],[7,5,7,6]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":5},"      FORM CMS 1728-94",{"$nulls":7},"06-01"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":8},"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K-5"]
["COSTS TO HOSPICE COST CENTERS",{"$nulls":8},"_",null,"FROM: ____________",null,"PART I"]
[{"$nulls":9},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":9},"_"]
[]
[null,null,null,"From","HOSPICE","CAPITAL RELATED",null,"PLANT",{"$nulls":4},"ALLOCATED","TOTAL"]
[null,"HOSPICE COST CENTER",null,"Wkst. K-4","TRIAL","COST",null,"OPERATION",null,null,"ADMINIS-",null,"HOSPICE","HOSPICE"]
[null,"(omit cents)",null,"Part I,","BALANCE","BUILDINGS","MOVABLE","& MAIN-","TRANS-","SUBTOTAL","TRATIVE  &","SUB-","A&G (see","COSTS"]
[null,null,null,"col. 7,","(1)","& FIXTURES","EQUIPMENT","TENANCE","PORTATION","(cols. 0-4)","GENERAL","TOTAL","Part II)","(col 6 + col. 7)"]
[null,null,null,"line","0","1","2","3","4","4A",5,6,7,8]
[1,"Administrative and General",null,6,{"$nulls":10},1]
[2,"Inpatient - General Care",null,7,{"$nulls":10},2]
[3,"Inpatient - Respite Care",null,8,{"$nulls":10},3]
[4,"Physician Services",null,9,{"$nulls":10},4]
[5,"Nursing Care",null,10,{"$nulls":10},5]
[6,"Physical Therapy",null,11,{"$nulls":10},6]
[7,"Occupational Therapy",null,12,{"$nulls":10},7]
[8,"Speech/ Language Pathology",null,13,{"$nulls":10},8]
[9,"Medical Social Services - Direct",null,14,{"$nulls":10},9]
[10,"Spiritual Counseling",null,15,{"$nulls":10},10]
[11,"Dietary Counseling",null,16,{"$nulls":10},11]
[12,"Counseling - Other",null,17,{"$nulls":10},12]
[13,"Home Health Aide and Homemakers",null,18,{"$nulls":10},13]
[14,"Other",null,19,{"$nulls":10},14]
[15,"Drugs, Biologicals and Infusion",null,20,{"$nulls":10},15]
[16,"Durable Medical Equipment/Oxygen",null,21,{"$nulls":10},16]
[17,"Patient Transportation",null,22,{"$nulls":10},17]
[18,"Imaging Services",null,23,{"$nulls":10},18]
[19,"Labs and Diagnostics",null,24,{"$nulls":10},19]
[20,"Medical Supplies",null,25,{"$nulls":10},20]
[21,"Outpatient Services (incl. E/R Dept.)",null,26,{"$nulls":10},21]
[22,"Radiation Therapy",null,27,{"$nulls":10},22]
[23,"Chemotherapy",null,28,{"$nulls":10},23]
[24,"Other",null,29,{"$nulls":10},24]
[25,"Bereavement Program Costs",null,30,{"$nulls":10},25]
[26,"Volunteer Program Costs",null,31,{"$nulls":10},26]
[27,"Fundraising",null,32,{"$nulls":10},27]
[28,"Other Program Costs",null,33,{"$nulls":10},28]
[29,"Totals (sum of lines 1-28) (2)",{"$nulls":12},29]
[30,"Unit Cost Multiplier: column 6, line 1 divided by the sum of column 6, line 29",{"$nulls":12},30]
[null,"minus column 6, line 1, rounded to 6 decimal places."]
[]
["(1) Column 0, line 29 must agree with Wkst. A, column 10, line 25."]
["(2) Columns 0 through 5, line 29 must agree with the corresponding columns of Wkst. B, line 25."]
[]
[]
[]
[]
[]
["FORM CMS 1728-94-K-5 (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245-3245.1)"]
[]
["32-331.7",{"$nulls":13},"Rev. 10"]
[]
[]
[" "]

{"sheet":"K-5II","index":35,"n_rows":53,"n_cols":12,"rows_kept":53,"cut":false,"hidden":false,"merged":[[5,5,5,6],[6,5,6,6]],"flags":["formulas_cached_only"]}
["06-01",null,null,null,"FORM CMS-1728-94",{"$nulls":6},"3290 (Cont.)"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":5},"PROVIDER NO:",null,"PERIOD:",null,"WORKSHEET K-5"]
["COSTS TO HOSPICE COST CENTERS",{"$nulls":5},"_",null,"FROM: ____________",null,"PART II"]
["STATISTICAL BASIS",{"$nulls":5},"HOSPICE NO.:",null,"TO: _______________"]
[{"$nulls":6},"_"]
[{"$nulls":5},"CAPITAL RELATED",null,"PLANT",null," "]
[{"$nulls":5},"COST",null,"OPERATION",null,null,"ADMINIS-"]
[{"$nulls":5},"BUILDINGS","MOVABLE","& MAIN-",null,null,"TRATIVE &"]
[null,"HOSPICE COST CENTER",null,null,null,"& FIXTURES","EQUIPMENT","TENANCE","TRANS-",null,"GENERAL"]
[{"$nulls":5},"(SQUARE","(DOLLAR","(SQUARE","PORTATION","RECONCIL-","(ACCUM."]
[{"$nulls":5},"FEET)","VALUE)","FEET)","(MILAGE)","IATION","COST)"]
[{"$nulls":5},"1","2","3","4","5A",5]
[1,"Administrative and General",{"$nulls":9},1]
[2,"Inpatient - General Care",{"$nulls":9},2]
[3,"Inpatient - Respite Care",{"$nulls":9},3]
[4,"Physician Services",{"$nulls":9},4]
[5,"Nursing Care",{"$nulls":9},5]
[6,"Physical Therapy",{"$nulls":9},6]
[7,"Occupational Therapy",{"$nulls":9},7]
[8,"Speech/ Language Pathology",{"$nulls":9},8]
[9,"Medical Social Services - Direct",{"$nulls":9},9]
[10,"Spiritual Counseling",{"$nulls":9},10]
[11,"Dietary Counseling",{"$nulls":9},11]
[12,"Counseling - Other",{"$nulls":9},12]
[13,"Home Health Aide and Homemakers",{"$nulls":9},13]
[14,"Other",{"$nulls":9},14]
[15,"Drugs, Biologicals and Infusion",{"$nulls":9},15]
[16,"Durable Medical Equipment/Oxygen",{"$nulls":9},16]
[17,"Patient Transportation",{"$nulls":9},17]
[18,"Imaging Services",{"$nulls":9},18]
[19,"Labs and Diagnostics",{"$nulls":9},19]
[20,"Medical Supplies",{"$nulls":9},20]
[21,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},21]
[22,"Radiation Therapy",{"$nulls":9},22]
[23,"Chemotherapy",{"$nulls":9},23]
[24,"Other",{"$nulls":9},24]
[25,"Bereavement Program Costs",{"$nulls":9},25]
[26,"Volunteer Program Costs",{"$nulls":9},26]
[27,"Fundraising",{"$nulls":9},27]
[28,"Other Program Costs",{"$nulls":9},28]
[29,"Totals (sum of lines 1-28)",{"$nulls":9},29]
[30,"Total  cost to be allocated",{"$nulls":9},30]
[31,"Unit Cost Multiplier",{"$nulls":9},31]
{"$rows_empty":7}
["FORM CMS-1728-94-K-5 (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245.2)"]
[]
["Rev. 10",{"$nulls":10},"32-331.8"]

{"sheet":"K-5III","index":36,"n_rows":52,"n_cols":12,"rows_kept":52,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":4},"FORM CMS-1728-94",{"$nulls":5},"06-01"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":4},"PROVIDER NO.: _____________",null,null,"PERIOD:",null,"WORKSHEET K-5"]
["COSTS TO HOSPICE COST CENTERS",{"$nulls":4},"HOSPICE NO.: ____________",null,null,"FROM: ___________",null,"Part III"]
["COMPUTATION OF TOTAL HOSPICE SHARED COSTS",{"$nulls":7},"TO: ___________"]
["Hospice shared cost computation",{"$nulls":8},"Total","Hospice"]
[{"$nulls":7},"Total HHA","Cost to","Hospice","Shared"]
[{"$nulls":7},"Charges","Charge","Charges","Ancillary "]
[{"$nulls":5},"From Wkst B, ","Total HHA","(from Provider","Ratio","(from Provider","Costs"]
[null,"COST CENTER ",null,null,null,"col. 6, line:","Costs","Records)","(col. 2/col.3)","Records)","(col. 4 x col. 5)"]
[{"$nulls":5},1,2,3,4,5,6]
["ANCILLARY SERVICE COST CENTERS"]
[1,"Physical Therapy",null,null,null,7,{"$nulls":5},1]
[2,"Occupational Therapy",null,null,null,8,{"$nulls":5},2]
[3,"Speech/ Language Pathology",null,null,null,9,{"$nulls":5},3]
[4,"Medical Social Services - Direct",null,null,null,10,{"$nulls":5},4]
[5,"Durable Medical Equipment/Oxygen",null,null,null,14,{"$nulls":5},5]
[6,"Medical Supplies",null,null,null,12,{"$nulls":5},6]
[7,"Totals (sum of lines 1-7) ",{"$nulls":9},7]
{"$rows_empty":31}
["FORM CMS-1728-94-K-5  (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245.3)"]
[]
["32-331.9",{"$nulls":10},"Rev. 10"]

{"sheet":"K-6","index":37,"n_rows":64,"n_cols":9,"rows_kept":64,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["06-01",null,null,"FORM CMS 1728-94",{"$nulls":4}," 3290 (Cont.)"]
["CALCULATION OF PER DIEM COST",null,null,"PROVIDER NO:",null,"PERIOD:",null," WORKSHEET  K-6"]
[null,null,null,"_",null,"FROM: ____________"]
[null,null,null,"HOSPICE NO.:",null,"TO: _______________"]
[null,null,null,"_"]
[]
[]
[null,"COMPUTATION OF PER DIEM COST",null,null,"TITLE XVIII","TITLE XIX","OTHER","TOTAL"]
[{"$nulls":4},1,2,3,4]
["1","Total cost (Worksheet K-5, Part I, col. 8, line 29 less col. 8, line 28",{"$nulls":6},"1"]
[null,"plus Worksheet K-5, Part III, col. 6, line 7)  (see instructions)"]
["2","Total Unduplicated Days (Worksheet S-5, line 5, col. 4)",{"$nulls":6},"2"]
["3","Average cost per diem (line 1 divided by line 2)",{"$nulls":6},"3"]
["4","Unduplicated Medicare Days (Worksheet S-5, line 5, col. 1)",{"$nulls":6},"4"]
["5","Aggregate Medicare cost (line 3 times line 4)",{"$nulls":6},5]
["6","Unduplicated Medicaid Days (Not Applicable)",{"$nulls":6},6]
["7","Aggregate Medicaid cost (Not Applicable)",{"$nulls":6},"7"]
["8","Unduplicated SNF days (Worksheet S-5, line 5, col. 2)",{"$nulls":6},"8"]
[9,"Aggregate SNF cost (line 3 times line 8)",{"$nulls":6},9]
[10,"Unduplicated NF days (Not Applicable)",{"$nulls":6},10]
[11,"Aggregate NF cost (Not Applicable)",{"$nulls":6},11]
[12,"Other unduplicated days (Worksheet S-5, line 5, col. 3)",{"$nulls":6},12]
[13,"Aggregate cost for other days (line 3 times line 12)",{"$nulls":6},13]
[]
[]
["NOTE:  The data for the SNF on line 8 & 9 are included in the Medicare lines 4 & 5. "]
{"$rows_empty":35}
["FORM  CMS-1728-94 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3246)"]
[]
["Rev. 10",{"$nulls":7},"32-331.10"]

{"sheet":"CM-1 & CM-2^","index":38,"n_rows":109,"n_cols":16,"rows_kept":109,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"06-01"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null,"WORKSHEET CM-1"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________",null,null,"PARTS I & II"]
["COSTS TO CMHC COST CENTERS",{"$nulls":7},"  CMHC NO.:",null,null,"  TO:  _________________"]
[{"$nulls":8},"  ___________________"]
["PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CMHC COST CENTERS"]
[{"$nulls":5},"NET","CAPITAL",null,"PLANT",{"$nulls":4},"ALLOCATED"]
[{"$nulls":5},"EXPENSES","RELATED COSTS",null,"OPERATION",null,null,"A&G",null,"CMHC","TOTAL"]
[null,"CMHC COST CENTER",null,null,null,"FOR COST","BLDGS &","MOVABLE","& MAINTE-","TRANSPOR-","SUBTOTAL","SHARED","SUB-","A&G (SEE","(SUM OF"]
[null,"(OMIT CENTS)",null,null,null,"ALLOCATION (1)","FIXTURES","EQUIPMENT","NANCE","TATION","(cols. 0-4)","COSTS","TOTAL","PART II)","COLS 6 & 7)"]
[{"$nulls":5},"0","1","2","3","4","4A","5","6","7","8"]
[" 1"," Administrative and General",{"$nulls":13}," 1"]
[" 2"," Drugs and Biologicals",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 2"]
[" 3"," Occupational Therapy",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 3"]
[" 4"," Psychiatric/Psychological Services",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 4"]
[" 5"," Individual Therapy",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 5"]
[" 6"," Group Therapy",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 6"]
[" 7"," Family Counseling",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 7"]
[" 8"," Individualized Activity Therapy",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 8"]
[" 9"," Diagnostic Therapy",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8}," 9"]
["10"," Patient Training and Education",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8},"10"]
[11," Other Part B Services",{"$nulls":13},11]
[12," TOTALS (Sum of lines 1-11) (2)",{"$nulls":4},{"$error":"#REF!"},{"$nulls":8},12]
[null,"(1) Column 0, line 12 must agree with Wkst. A, column 10, line 26.",{"$nulls":8},{"$error":"#REF!"}]
[null,"(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 26."]
[]
[{"$nulls":6},{"$error":"#REF!"},0,0,0,0]
["PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF CMHC ADMINISTRATIVE AND GENERAL COSTS"]
[" 1"," Amount from Part I, column 6, line 12",{"$nulls":13}," 1"]
[" 2"," Amount from Part I, column 6, line 1",{"$nulls":13}," 2"]
[" 3"," Line 1 minus line 2",{"$nulls":13}," 3"]
[" 4"," Unit cost multiplier for CMHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,",{"$nulls":13}," 4"]
[null," lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)"]
{"$rows_empty":16}
["FORM CMS 1728-94-CM-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3225-3225.2)"]
[]
["32-332",{"$nulls":14},"Rev. 10"]
[]
[]
["3290 (Cont.)",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"03-04"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null,"WORKSHEET CM-2"]
["COMPUTATION OF CMHC COSTS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________"]
[{"$nulls":8},"  CMHC NO.:",null,null,"  TO:  __________________"]
[{"$nulls":8},"  ___________________"]
["PART I - APPORTIONMENT OF CMHC COST CENTERS "]
[{"$nulls":9},"RATIO OF",null,"TOTAL","TITLE XVIII","TITLE XVIII"]
[{"$nulls":7},"TOTAL COSTS",null,"COSTS TO","TOTAL","TITLE XVIII","CMHC","CMHC COSTS","TITLE XVIII"]
[{"$nulls":7},"(FROM SUPP.","TOTAL","CHARGES","TITLE XVIII","CMHC COSTS","CHARGES ON","ON OR AFTER","CMHC"]
[null,"CMHC COST CENTER",{"$nulls":5},"WKST. CM-1, PT.","CMHC","(COL. 1 /","CMHC","(COL. 3 x","OR AFTER","8/1/00, 1/1/02,","COSTS PRIOR"]
[null,"(OMIT CENTS)",{"$nulls":5},"I, COL. 8) (1)","CHARGES (2)"," COL. 2)","CHARGES","COL. 3.01)","8/1/00, 1/1/02,","1/1/03, or 1/1/04","8/1/00, 1/1/02,"]
[{"$nulls":12},"1/1/03, or 1/1/04","(COL 3 xCOL. 4)","1/1/03, or 1/1/04"]
[{"$nulls":7},"1","2","3",3.01,3.02,"4","5","6"]
[" 1"," Administrative and General",{"$nulls":13}," 1"]
[" 2"," Drugs and Biologicals",{"$nulls":5},100000,120000,0.833333,75000,62499.975,0,0,62499.975," 2"]
[" 3"," Occupational Therapy",{"$nulls":13}," 3"]
[" 4"," Psychiatric/Psychological Services",{"$nulls":5},47000,59000,0.7966101694915254,{"$nulls":5}," 4"]
[" 5"," Individual Therapy",{"$nulls":5},52000,65000,0.8,{"$nulls":5}," 5"]
[" 6"," Group Therapy",{"$nulls":5},26000,37000,0.7027027027027027,{"$nulls":5}," 6"]
[" 7"," Family Counseling",{"$nulls":13}," 7"]
[" 8"," Individualized Activity Therapy",{"$nulls":13}," 8"]
[" 9"," Diagnostic Therapy",{"$nulls":13}," 9"]
["10"," Patient Training and Education",{"$nulls":13},"10"]
["11"," Other Part B Services",{"$nulls":13},"11"]
["12"," TOTALS (Sum of lines 2-11)",{"$nulls":13},"12"]
[]
[]
["PART II - APPORTIONMENT OF COST OF CMHC"]
["SERVICES FURNISHED SHARED BY HHA DEPARTMENTS",{"$nulls":5},"Fr. Wkst. B,"]
[{"$nulls":6},"Col 6, Line:"]
[13," Occupational Therapy",{"$nulls":4},8,{"$nulls":8},13]
[14," Medical Social Services",{"$nulls":4},10,{"$nulls":8},14]
[15," Supplies",{"$nulls":4},12,{"$nulls":8},15]
[16," Total (Sum of lines 13-15)",{"$nulls":13},16]
[null,"(1) Cost for Part II, lines 13-15 are obtained from Worksheet B, column 6, lines as appropriate"]
[null,"(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records"]
[]
["PART III - TOTAL CMHC COSTS",{"$nulls":9},3.01,3.02,4,5,6]
[17,"Total CMHC costs - Add the amount from Part I, column 6, line 12 and the amount from Part II, column 6, line 16.",{"$nulls":13},"17"]
[null," Add the amounts from Part I, line 12 and Part II, line 16 for columns 3.01, 3.02 and 4 through 6, respectively."]
[]
["Transfer the amount in Part III, column 6 to Worksheet CM-3, line 1, column 1. (see instructions)"]
{"$rows_empty":10}
["FORM CMS 1728-94-CM-2  (3-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3226-3226.3)"]
[]
["32-334",{"$nulls":14},"Rev. 12"]

{"sheet":"CM-1, PT3^","index":39,"n_rows":57,"n_cols":16,"rows_kept":57,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["03-04",{"$nulls":5},"FORM CMS 1728-94",{"$nulls":8},"3290 (Cont.)"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  PROVIDER NO.:",null,null,"  PERIOD:",null,"   WORKSHEET CM-1"]
["COSTS TO CMHC COST CENTERS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _____________",null,"   PART III"]
[{"$nulls":8},"  CMHC NO.:",null,null,"  TO:  ______________"]
[{"$nulls":8},"  ___________________"]
["PART III - ALLOCATION OF GENERAL SERVICE COSTS TO CMHC COST CENTERS - STATISTICAL BASIS"]
[null,null,null,"CAPITAL"]
[null,null,null,"RELATED COSTS",null,null,null,"PLANT"]
[{"$nulls":7},"OPERATION"]
[null,null,null,"BLDGS &",null,"MOVABLE",null,"& MAINTE-",{"$nulls":5},"ADMINISTRATIVE"]
[null,null,null,"FIXTURES",null,"EQUIPMENT",null,"NANCE",null,"TRANSPOR-",null,null,null,"& GENERAL"]
[null,"CMHC COST CENTER",null,"(SQUARE",null,"(SQUARE",null,"(SQUARE",null," TATION",null,"RECONCIL-",null,"(ACCUMULATED"]
[null,"(OMIT CENTS)",null,"FEET)",null,"FEET)",null,"FEET)",null,"(MILEAGE)",null,"IATION",null,"COST)"]
[null,null,null,1,null,2,null,3,null,4,null,"5A",null,5]
[" 1"," Administrative and General",{"$nulls":13}," 1"]
[" 2"," Drugs and Biologicals",{"$nulls":13}," 2"]
[" 3"," Occupational Therapy",{"$nulls":13}," 3"]
[" 4"," Psychiatric/Psychological Services",{"$nulls":13}," 4"]
[" 5"," Individual Therapy",{"$nulls":13}," 5"]
[" 6"," Group Therapy",{"$nulls":13}," 6"]
[" 7"," Family Counseling",{"$nulls":13}," 7"]
[" 8"," Individualized Activity Therapy",{"$nulls":13}," 8"]
[" 9"," Diagnostic Therapy",{"$nulls":13}," 9"]
["10"," Patient Training and Education",{"$nulls":13},"10"]
["11"," Other Part B Services",{"$nulls":13},"11"]
["12"," TOTALS (Sum of lines 1-11)",{"$nulls":13},"12"]
["13"," Total Cost to be Allocated",{"$nulls":13},"13"]
["14"," Unit Cost Multiplier",{"$nulls":13},"14"]
{"$rows_empty":26}
["FORM CMS 1728-94-CM-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SEC. 3225.3)"]
[]
["Rev. 12",{"$nulls":14},"32-333"]

{"sheet":"CM-3^","index":40,"n_rows":66,"n_cols":9,"rows_kept":66,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["03-04",null,null,"FORM CMS 1728-94",{"$nulls":4},"3290 (Cont.)"]
[null,null,null,"  PROVIDER NO.:","  PERIOD:",null,null,"WORKSHEET CM-3"]
["CALCULATION OF REIMBURSEMENT",null,null,"  ___________________","  FROM:  _______________"]
["SETTLEMENT - CMHC SERVICES",null,null,"  CMHC NO.:","  TO:  _________________"]
[]
[]
["PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES"]
[]
[null,"DESCRIPTION",{"$nulls":4},1,1.01]
["1","Total reasonable cost (see instructions)",{"$nulls":6},"1"]
[1.01,"CMHC PPS payments including outlier payments",{"$nulls":6},1.01]
[1.02,"1996 CMHC specific payment to cost ratio (obatin this ratio from your intermediary) ",{"$nulls":6},1.02]
[1.03,"Line 1, column 1 times 1.02",{"$nulls":6},1.03]
[1.04,"Line 1.01 divided by line 1.03",{"$nulls":6},1.04]
[1.05,"CMHC transitional corridor payment (see instructions)",{"$nulls":6},1.05]
[2,"Total charges for CMHC Services",{"$nulls":6},2]
[]
[null,"CUSTOMARY CHARGES",{"$nulls":4},1,1.01]
[3,"Amounts actually collected from patients liable",{"$nulls":6},3]
[null,"for payments for services on a charge basis (from"]
[null,"your records)"]
[4,"Amount that would have been realized from patients",{"$nulls":6},4]
[null,"liable for payment for services on a charge basis "]
[null,"had such payment been made in accordance with"]
[null,"42 CFR 413.13(b)"]
[5,"Ratio of line 3 to line 4 (not to exceed 1.000000)",{"$nulls":6},5]
[6,"Total Customary charges - title XVIII",{"$nulls":6},6]
[null,"(see instructions)"]
[7,"Excess of total customary charges over total",{"$nulls":6},7]
[null,"reasonable cost (complete only if line 6"]
[null,"exceeds line 1)"]
[8,"Excess of reasonable costs over customary charges",{"$nulls":6},8]
[null,"(complete only if line 1 exceeds line 6)"]
[9,"Primary payer amounts",{"$nulls":6},9]
[]
[]
[]
[]
["PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT",{"$nulls":5},1,1.01]
[10,"Cost of CMHC services (see instructions)",{"$nulls":6},10]
[11,"Part B deductible billed to Program patients (exclude coinsurance amounts)",{"$nulls":6},11]
[12,"Excess of reasonable costs (see instructions)",{"$nulls":6},12]
[13,"Net cost (line10 minus lines 11 and 12)",{"$nulls":6},13]
[14,"80% of Part B cost (80% x line 13) (see instructions)",{"$nulls":6},14]
[15,"Actual coinsurance billed to Program patients (from your records)",{"$nulls":6},15]
[16,"Net cost less actual billed coinsurance (Line 13 minus line 15)",{"$nulls":6},16]
[17,"Reimbursable bad debts (see instructions)",{"$nulls":6},17]
[18,"Net reimbursable amount (see instructions)",{"$nulls":6},18]
[19,"Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets",{"$nulls":6},19]
[20,"Recovery of excess depreciation resulting from facility's termination or a decrease in Program utilization",{"$nulls":6},20]
[21,"Other adjustments (specify)",{"$nulls":6},21]
[22,"Total Cost (Sum of line 18, columns 1 and 2, minus lines 19 and 20, plus line 21)",{"$nulls":6},22]
[23,"Sequestration adjustment",{"$nulls":6},23]
[24,"Amount due provider (Line 22 minus line 23)",{"$nulls":6},24]
[25,"Interim payments",{"$nulls":6},25]
[25.5,"Tentative settlement (for intermediary use only)",{"$nulls":6},25.5]
[26,"Balance due CMHC/Program (Line 24 minus line 25) (Indicate overpayments in brackets)",{"$nulls":6},26]
[27,"Protested amounts (see instructions)",{"$nulls":6},27]
[28,"Balance due CMHC/Program (Line 26 minus line 27) (Indicate overpayments in brackets)",{"$nulls":6},28]
[]
[]
[]
["FORM CMS 1728-94-CM-3 (3-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC."]
["3227-3227.2)"]
[]
["Rev. 12",{"$nulls":7},"32-335"]

{"sheet":"CM-4^","index":41,"n_rows":62,"n_cols":9,"rows_kept":62,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",null,null,null,"FORM CMS 1728-94        ",null,null,null,"03-04"]
["ANALYSIS OF PAYMENTS TO PROVIDER",null,null,"  PROVIDER NO.:","  PERIOD:",null,null,"WORKSHEET CM-4"]
["FOR CMHC SERVICES RENDERED",null,null,"  ___________________","  FROM:  _______________"]
["TO PROGRAM BENEFICIARIES",null,null,"  CMHC NO.:","  TO:  _________________"]
[]
[]
[{"$nulls":6},"PART B"]
[{"$nulls":6},"1","2"]
[{"$nulls":6},"mm/dd/yyyy","Amount"]
["1","Total interim payments paid to provider (CMHC services)",{"$nulls":6},"1"]
["2","Interim payments payable on individual bills either, submitted or to",{"$nulls":6},"2"]
[null,"be submitted to the intermediary, for services rendered in the"]
[null,"cost reporting period.  If none, write \"NONE\" or enter a zero."]
["3","List separately each retroactive lump sum ",null,null,null,".01",null,null,"3.01"]
[null,"adjustment amount based on subsequent revision",null,null,"Program ",".02",null,null,"3.02"]
[null,"of the interim rate for the cost reporting period.",null,null,"to",".03",null,null,"3.03"]
[null,"Also show date of each payment.  If none write",null,null,"Provider",".04",null,null,"3.04"]
[null,"\"NONE\" or enter a zero. (1)",null,null,null,".05",null,null,"3.05"]
[{"$nulls":5},".50",null,null,"3.50"]
[{"$nulls":4},"Provider ",".51",null,null,"3.51"]
[{"$nulls":4},"to",".52",null,null,"3.52"]
[{"$nulls":4},"Program",".53",null,null,"3.53"]
[{"$nulls":5},".54",null,null,"3.54"]
[null,"SUBTOTAL (Sum of lines 3.01-3.05, minus sum"]
[null,"of lines 3.50-3.54)",null,null,null,".99",null,null,"3.99"]
["4","TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)",{"$nulls":6},"4"]
[null,"(Transfer to Supp. Wkst CM-3, Part II, line 25)"]
[]
[null,null,"TO BE COMPLETED BY INTERMEDIARY"]
[]
["5","List separately each tentative settlement payment ",null,null,"Program ",".01",null,null,"5.01"]
[null,"after desk review.  Also show date of each ",null,null,"to",".02",null,null,"5.02"]
[null,"payment.  If none, write \"NONE\" or enter     ",null,null,"Provider",".03",null,null,"5.03"]
[null,"a zero. (1)",null,null,"Provider ",".50",null,null,"5.50"]
[{"$nulls":4},"to",".51",null,null,"5.51"]
[{"$nulls":4},"Program",".52",null,null,"5.52"]
[null,"SUBTOTAL (Sum of lines 5.01-5.03, minus sum  "]
[null,"of lines 5.50-5.52)",null,null,null,".99",null,null,"5.99"]
["6","Determine net settlement amount (balance due) based",null,null,"Program "]
[null,"on the cost report (SEE INSTRUCTIONS). (1)",null,null,"to"]
[{"$nulls":4},"Provider",".01",null,null,"6.01"]
[{"$nulls":4},"Provider "]
[{"$nulls":4},"to"]
[{"$nulls":4},"Program",".02",null,null,"6.02"]
["7","TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)",{"$nulls":6},"7"]
[]
[" Name of Intermediary",{"$nulls":4},"    Intermediary Number"]
[]
[]
[" Signature of Authorized Person",{"$nulls":4},"    Date:   (Month, Day, Year)"]
[]
[]
[" (1)  On lines 3, 5 and 6, where an amount is due \"Provider to Program,\" show the amount and date on which the provider"]
["      agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
[]
[]
[]
[]
["FORM CMS-1728-94-CM-4  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB."]
["PUB. 15-II, SEC. 3228"]
[]
["32-336",{"$nulls":7},"Rev. 12"]

{"sheet":"RHC","index":42,"n_rows":108,"n_cols":16,"rows_kept":108,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"3290 (Cont.)"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null," WORKSHEET RH-1"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________",null,null," PARTS I & II"]
["COSTS TO RHC COST CENTERS",{"$nulls":7},"  RHC NO.:",null,null,"  TO:  _________________"]
[{"$nulls":8},"  ___________________"]
["PART I - ALLOCATION OF GENERAL SERVICE COSTS TO RHC COST CENTERS"]
[]
[{"$nulls":5},"NET","CAPITAL",null,"PLANT",{"$nulls":4},"ALLOCATED"]
[{"$nulls":5},"EXPENSES","RELATED COSTS",null,"OPERATION",null,null,"A&G",null,"RHC","TOTAL"]
[null,"CMHC COST CENTER",null,null,null,"FOR COST","BLDGS &","MOVABLE","& MAINTE-","TRANSPOR-","SUBTOTAL","SHARED","SUB-","A&G (SEE","(SUM OF"]
[null,"(OMIT CENTS)",null,null,null,"ALLOCATION (1)","FIXTURES","EQUIPMENT","NANCE","TATION","(cols. 0-4)","COSTS","TOTAL","PART II)","COLS 6 & 7)"]
[{"$nulls":5},"0","1","2","3","4","4A","5","6","7","8"]
["1"," Administrative and General",{"$nulls":13},"1"]
["2"," Physicians",{"$nulls":13},"2"]
["3"," Nurse Practitioner",{"$nulls":13},"3"]
["4"," Physician Assistant",{"$nulls":13},"4"]
["5"," Clinical Psychologist",{"$nulls":13},"5"]
["6"," Clinical Social Worker",{"$nulls":13},"6"]
["7"," Visiting Nurses",{"$nulls":13},"7"]
["8"," Other Part B Services",{"$nulls":13},"8"]
["9",{"$nulls":14},"9"]
["10"," Drugs Charged to Patients",{"$nulls":13},"10"]
["11"," TOTALS (Sum of lines 1-10) (2)",{"$nulls":13},"11"]
[null,"(1) Column 0, line 11 must agree with Wkst. A, column 10, line 27. "]
[null,"(2) Columns 0 through 5, line 11 must agree with the corresponding columns of Wkst. B, line 27."]
[]
[{"$nulls":6},0,0,0,0,0]
["PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF RHC ADMINISTRATIVE AND GENERAL COSTS"]
[" 1"," Amount from Part I, column 6, line 11",{"$nulls":13}," 1"]
[" 2"," Amount from Part I, column 6, line 1",{"$nulls":13}," 2"]
[" 3"," Line 1 minus line 2",{"$nulls":13}," 3"]
[" 4"," Unit cost multiplier for RHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,",{"$nulls":13}," 4"]
[null," lines 2 through 10, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)"]
{"$rows_empty":18}
["FORM CMS 1728-94-RH-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3229-3229.2)"]
[]
["Rev. 7",{"$nulls":14},"32-337"]
["08-99",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"3290 (Cont.)"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null,"   WORKSHEET RH-2"]
["COMPUTATION OF RHC COSTS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________"]
[{"$nulls":8},"  RHC NO.:",null,null,"  TO:  __________________"]
[{"$nulls":8},"  ___________________"]
["PART I - APPORTIONMENT OF RHC COST CENTERS"]
[]
[{"$nulls":10},"TOTAL COSTS",null,"RATIO OF",null,"TITLE XVIII"]
[null,"RHC COST CENTER",{"$nulls":8},"(FROM SUPP.","TOTAL","COSTS TO","TITLE XVIII","RHC COSTS"]
[null,"(OMIT CENTS)",{"$nulls":8},"WKST. RH-1, PT.","RHC","CHARGES","RHC","(COL. 3 X"]
[{"$nulls":10},"I, COL. 8) (1)","CHARGES (2)","(COL. 1 / COL. 2)","CHARGES","COL. 4)"]
[{"$nulls":10},"1","2","3","4","5"]
["1"," Administrative and General",{"$nulls":13},"1"]
["2"," Physicians",{"$nulls":13},"2"]
["3"," Nurse Practitioner",{"$nulls":13},"3"]
["4"," Physician Assistant",{"$nulls":13},"4"]
["5"," Clinical Psychologist",{"$nulls":13},"5"]
["6"," Clinical Social Worker",{"$nulls":13},"6"]
["7"," Visiting Nurses",{"$nulls":13},"7"]
["8"," Other Part B Services",{"$nulls":13},"8"]
["9"," Subtotal (sum of lines 1-8)",{"$nulls":13},"9"]
["10"," Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)",{"$nulls":13},"10"]
["11"," TOTALS (Sum of lines 9 and 10)",{"$nulls":13},"11"]
[]
[]
["PART II - APPORTIONMENT OF COST OF RHC SERVICES FURNISHED BY HHA DEPARTMENTS",{"$nulls":8},"Fr. Wkst. B"]
[{"$nulls":9},"Col 6, Line:"]
["12"," Physical Therapy",{"$nulls":7},"7",{"$nulls":5},"12"]
["13"," Occupational Therapy",{"$nulls":7},"8",{"$nulls":5},"13"]
["14"," Speech Pathology",{"$nulls":7},"9",{"$nulls":5},"14"]
["15"," Supplies",{"$nulls":7},"12",{"$nulls":5},"15"]
[]
["17"," Total (Sum of lines 12-15)",{"$nulls":13},"17"]
[null,"(1) Cost for Part II, lines 12-15 are obtained from Worksheet B, column 6, lines as appropriate"]
[null,"(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records"]
[]
["PART III - TOTAL RHC COSTS"]
["18","Total RHC costs - Add the amount from Part I, column 5, line 9 and the amounts from Part II, column 5, line 17",{"$nulls":13},"18"]
["Transfer the amount in Part III, column 5 to Supplemental Worksheet D, column 3, line 2"]
{"$rows_empty":12}
["FORM CMS 1728-94-RH-2  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3230-3230.3)"]
[]
["Rev. 7",{"$nulls":14},"32-339"]

{"sheet":"RH-1, PT3","index":43,"n_rows":56,"n_cols":16,"rows_kept":56,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":6},"FORM CMS 1728-94        ",{"$nulls":7},"08-99"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  PROVIDER NO.:",null,null,"  PERIOD:",null,"   WORKSHEET RH-1"]
["COSTS TO RHC COST CENTERS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _____________",null,"   PART III"]
[{"$nulls":8},"  RHC NO.:",null,null,"  TO:  _____________"]
[{"$nulls":8},"  ___________________"]
["PART III - ALLOCATION OF GENERAL SERVICE COSTS TO RHC COST CENTERS - STATISTICAL BASIS"]
[null,null,null,"CAPITAL-"]
[null,null,null,"RELATED COSTS",null,null,null,"PLANT"]
[{"$nulls":7},"OPERATION"]
[null,null,null,"BLDGS &",null,"MOVABLE",null,"& MAINTE-",{"$nulls":5},"ADMINISTRATIVE"]
[null,null,null,"FIXTURES",null,"EQUIPMENT",null,"NANCE",null,"TRANSPOR-",null,null,null,"& GENERAL"]
[null,"RHC COST CENTER",null,"(SQUARE",null,"(SQUARE",null,"(SQUARE",null," TATION",null,"RECONCIL-",null,"(ACCUMULATED"]
[null,"(OMIT CENTS)",null,"FEET)",null,"FEET)",null,"FEET)",null,"(MILEAGE)",null,"IATION",null,"COST)"]
[null,null,null,1,null,2,null,3,null,4,null,"5A",null,5]
["1"," Administrative and General",{"$nulls":13},"1"]
["2"," Physicians",{"$nulls":13},"2"]
["3"," Nurse Practitioner",{"$nulls":13},"3"]
["4"," Physician Assistant",{"$nulls":13},"4"]
["5"," Clinical Psychologist",{"$nulls":13},"5"]
["6"," Clinical Social Worker",{"$nulls":13},"6"]
["7"," Visiting Nurses",{"$nulls":13},"7"]
["8"," Other Part B Services",{"$nulls":13},"8"]
["9",{"$nulls":14},"9"]
["10"," Drugs Charged to Patients",{"$nulls":13},"10"]
["11"," TOTALS (Sum of lines 1-10) ",{"$nulls":13},"11"]
["12"," Total Cost to be Allocated",{"$nulls":13},"12"]
["13"," Unit Cost Multiplier",{"$nulls":13},"13"]
{"$rows_empty":26}
["FORM CMS 1728-94-RH-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15 -II, SEC. 3229.3)"]
[]
["32-338",{"$nulls":14},"Rev. 7"]

{"sheet":"FQHC","index":44,"n_rows":108,"n_cols":16,"rows_kept":108,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["3290 (Cont.)",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"08-99"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null," WORKSHEET FQ-1"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________",null,null," PARTS I & II"]
["COSTS TO FQHC COST CENTERS",{"$nulls":7},"  FQHC NO.:",null,null,"  TO:  _________________"]
[{"$nulls":8},"  ___________________"]
["PART I - ALLOCATION OF GENERAL SERVICE COSTS TO FQHC COST CENTERS"]
[{"$nulls":5},"NET","CAPITAL",null,"PLANT",{"$nulls":4},"ALLOCATED"]
[{"$nulls":5},"EXPENSES","RELATED COSTS",null,"OPERATION",null,null,"A&G",null,"FQHC","TOTAL"]
[null,"FQHC COST CENTER",null,null,null,"FOR COST","BLDGS &","MOVABLE","& MAINTE-","TRANSPOR-","SUBTOTAL","SHARED","SUB-","A&G (SEE","(SUM OF"]
[null,"(OMIT CENTS)",null,null,null,"ALLOCATION (1)","FIXTURES","EQUIPMENT","NANCE","TATION","(cols. 0-4)","COSTS","TOTAL","PART II)","COLS 6 & 7)"]
[{"$nulls":5},"0","1","2","3","4","4A","5","6","7","8"]
["1"," Administrative and General",{"$nulls":13},"1"]
["2"," Physicians",{"$nulls":13},"2"]
["3"," Nurse Practitioner",{"$nulls":13},"3"]
["4"," Physician Assistant",{"$nulls":13},"4"]
["5"," Clinical Psychologist",{"$nulls":13},"5"]
["6"," Clinical Social Worker",{"$nulls":13},"6"]
["7"," Visiting Nurses",{"$nulls":13},"7"]
["8"," Preventative Primary Services",{"$nulls":13},"8"]
["9"," Other Part B Services",{"$nulls":13},"9"]
["10",{"$nulls":14},"10"]
["11"," Drugs Charged to Patients",{"$nulls":13},"11"]
["12"," TOTALS (Sum of lines 1-11) (2)",{"$nulls":13},"12"]
[null,"(1) Column 0, line 12 must agree with Wkst. A, column 10, line 28. ",{"$nulls":8},{"$error":"#REF!"}]
[null,"(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 28."]
[]
[{"$nulls":6},0,0,0,0,0]
["PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF FQHC ADMINISTRATIVE AND GENERAL COSTS"]
[" 1"," Amount from Part I, column 6, line 12",{"$nulls":13}," 1"]
[" 2"," Amount from Part I, column 6, line 1",{"$nulls":13}," 2"]
[" 3"," Line 1 minus line 2",{"$nulls":13}," 3"]
[" 4"," Unit cost multiplier for FQHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,",{"$nulls":13}," 4"]
[null," lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)"]
{"$rows_empty":18}
["FORM CMS 1728-94-FQ-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3231-3231.2)"]
[]
["32-340",{"$nulls":14},"Rev. 7"]
["3290 (Cont.)",{"$nulls":7},"FORM CMS 1728-94",{"$nulls":6},"08-99"]
[{"$nulls":8},"  PROVIDER NO.:",null,null,"  PERIOD:",null,null,"   WORKSHEET FQ-2"]
["COMPUTATION OF FQHC COSTS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _______________"]
[{"$nulls":8},"  FQHC NO.:",null,null,"  TO:  __________________"]
[{"$nulls":8},"  ___________________"]
["PART I - APPORTIONMENT OF RHC COST CENTERS"]
[]
[{"$nulls":10},"TOTAL COSTS",null,"RATIO OF",null,"TITLE XVIII"]
[null,"FQHC COST CENTER",{"$nulls":8},"(FROM SUPP.","TOTAL","COSTS TO","TITLE XVIII","FQHC COSTS"]
[null,"(OMIT CENTS)",{"$nulls":8},"WKST. FQ-1, PT.","FQHC","CHARGES","FQHC","(COL. 3 X"]
[{"$nulls":10},"I, COL. 8) (1)","CHARGES (2)","(COL. 1 / COL. 2)","CHARGES","COL. 4)"]
[{"$nulls":10},"1","2","3","4","5"]
["1"," Administrative and General",{"$nulls":13},"1"]
["2"," Physicians",{"$nulls":13},"2"]
["3"," Nurse Practitioner",{"$nulls":13},"3"]
["4"," Physician Assistant",{"$nulls":13},"4"]
["5"," Clinical Psychologist",{"$nulls":13},"5"]
["6"," Clinical Social Worker",{"$nulls":13},"6"]
["7"," Visiting Nurses",{"$nulls":13},"7"]
["8"," Preventative Primary Services",{"$nulls":13},"8"]
["9"," Other Part B Services",{"$nulls":13},"9"]
["10"," Subtotal (sum of lines 1-9)",{"$nulls":13},"10"]
["11"," Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)",{"$nulls":13},"11"]
["12"," TOTALS (Sum of lines 10and 11)",{"$nulls":13},"12"]
[]
[]
["PART II - APPORTIONMENT OF COST OF FQHC SERVICES FURNISHED BY HHA DEPARTMENTS",{"$nulls":8},"Fr. Wkst. B"]
[{"$nulls":9},"Col 6, Line:"]
["13"," Physical Therapy",{"$nulls":7},"7",{"$nulls":5},"13"]
["14"," Occupational Therapy",{"$nulls":7},"8",{"$nulls":5},"14"]
["15"," Speech Pathology",{"$nulls":7},"9",{"$nulls":5},"15"]
["16"," Supplies",{"$nulls":7},"12",{"$nulls":5},"16"]
[]
["18"," Total (Sum of lines 13-16)",{"$nulls":13},"18"]
[null,"(1) Cost for Part II, lines 13-16 are obtained from Worksheet B, column 6, lines as appropriate"]
[null,"(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records"]
[]
["PART III - TOTAL FQHC COSTS"]
{"$rows_empty":13}
["FORM CMS 1728-94-FQ-2  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3232-3232.3)"]
[]
["32-342",{"$nulls":14},"Rev. 7"]

{"sheet":"FQ-1, PT3","index":45,"n_rows":56,"n_cols":16,"rows_kept":56,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",{"$nulls":5},"FORM CMS 1728-94",{"$nulls":8},"3290 (Cont.)"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":7},"  PROVIDER NO.:",null,null,"  PERIOD:",null,"   WORKSHEET FQ-1"]
["COSTS TO FQHC COST CENTERS",{"$nulls":7},"  ___________________",null,null,"  FROM:  _____________",null,"   PART III"]
[{"$nulls":8},"  FQHC NO.:",null,null,"  TO:  ________________"]
[{"$nulls":8},"  ___________________"]
["PART III - ALLOCATION OF GENERAL SERVICE COSTS TO FQHC COST CENTERS - STATISTICAL BASIS"]
[null,null,null,"CAPITAL-"]
[null,null,null,"RELATED COSTS",null,null,null,"PLANT"]
[{"$nulls":7},"OPERATION"]
[null,null,null,"BLDGS &",null,"MOVABLE",null,"& MAINTE-",{"$nulls":5},"ADMINISTRATIVE"]
[null,null,null,"FIXTURES",null,"EQUIPMENT",null,"NANCE",null,"TRANSPOR-",null,null,null,"& GENERAL"]
[null,"FQHC COST CENTER",null,"(SQUARE",null,"(SQUARE",null,"(SQUARE",null," TATION",null,"RECONCIL-",null,"(ACCUMULATED"]
[null,"(OMIT CENTS)",null,"FEET)",null,"FEET)",null,"FEET)",null,"(MILEAGE)",null,"IATION",null,"COST)"]
[null,null,null,1,null,2,null,3,null,4,null,"5A",null,5]
["1"," Administrative and General",{"$nulls":13},"1"]
["2"," Physicians",{"$nulls":13},"2"]
["3"," Nurse Practitioner",{"$nulls":13},"3"]
["4"," Physician Assistant",{"$nulls":13},"4"]
["5"," Clinical Psychologist",{"$nulls":13},"5"]
["6"," Clinical Social Worker",{"$nulls":13},"6"]
["7"," Visiting Nurses",{"$nulls":13},"7"]
["8"," Preventative Primary Services",{"$nulls":13},"8"]
["9"," Other Part B Services",{"$nulls":13},"9"]
["10",{"$nulls":14},"10"]
["11"," Drugs Charged to Patients",{"$nulls":13},"11"]
["12"," TOTALS (Sum of lines 1-11)",{"$nulls":13},"12"]
["13"," Cost to be Allocated",{"$nulls":13},"13"]
["14"," Unit Cost Multiplier",{"$nulls":13},"14"]
{"$rows_empty":25}
["FORM CMS 1728-94-FQ-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15 -II, SEC. 3231.3)"]
[]
["Rev. 7",{"$nulls":14},"32-341"]

{"sheet":"RF-1","index":46,"n_rows":56,"n_cols":13,"rows_kept":56,"cut":false,"hidden":false,"merged":[[55,2,55,9]],"flags":["formulas_cached_only"]}
["05-00",{"$nulls":4},"FORM CMS 1728-94",{"$nulls":6},"3290 (Cont.)"]
["ANALYSIS OF HHA-BASED RURAL HEALTH CLINIC/",{"$nulls":6},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET RF-1"]
["FEDERALLY QUALIFIED HEALTH CENTER COSTS",{"$nulls":6},"_______________",null,"FROM: ____________"]
[{"$nulls":7},"COMPONENT NO.:",null,"TO: ____________"]
[{"$nulls":7},"_______________"]
["Check ",null,"  [  ]  RHC"]
["Applicable Box:",null,"  [  ]  FQHC"]
[{"$nulls":9},"RECLASSIFIED",null,"NET EXPENSES"]
[{"$nulls":5},"CONTRACTED/",null,"TOTAL",null,"TRIAL",null,"FOR"]
[null,null,null,"EMPLOYEE","TRANSPOR-","PURCHASED",null,"(sum of col. 1","RECLASSIFI-","BALANCE",null,"ALLOCATION"]
[null,null,"SALARIES","BENEFITS","TATION","SERVICES","OTHER COSTS","thru col. 5)","CATIONS","(col. 6 + col. 7)","ADJUSTMENTS","(col. 8 + col. 9)"]
[null,null,"1","2","3","4","5","6","7",8,9,10]
[" ","FACILITY HEALTH CARE STAFF COSTS",{"$nulls":10}," "]
[1,"Physician",{"$nulls":10},1]
[2,"Physician Assistant",{"$nulls":10},2]
[3,"Nurse Practitioner",{"$nulls":10},3]
[4,"Visiting Nurse",{"$nulls":10},4]
[5,"Other Nurse",{"$nulls":10},5]
[6,"Clinical Psychologist",{"$nulls":10},6]
[7,"Clinical Social Worker",{"$nulls":10},7]
[8,"Laboratory Technician",{"$nulls":10},8]
[9,"Other Facility Health Care Staff Costs",{"$nulls":10},9]
[10,"Subtotal (sum of lines 1-9)",{"$nulls":10},10]
[" ","COSTS UNDER AGREEMENT",{"$nulls":10}," "]
[11,"Physician Services Under Agreement",{"$nulls":10},11]
[12,"Physician Supervision Under Agreement",{"$nulls":10},12]
[13,"Other Costs Under Agreement",{"$nulls":10},13]
[14,"Subtotal (sum of lines 11-13)",{"$nulls":10},14]
[" ","OTHER HEALTH CARE COSTS",{"$nulls":10}," "]
[15,"Medical Supplies",{"$nulls":10},15]
[16,"Transportation (Health Care Staff)",{"$nulls":10},16]
[17,"Depreciation-Medical Equipment",{"$nulls":10},17]
[18,"Professional Liability Insurance",{"$nulls":10},18]
[19,"Other Health Care Costs",{"$nulls":10},19]
[20,"Allowable GME Pass Through Costs",{"$nulls":10},20]
[21,"Subtotal (sum of lines 15-20)",{"$nulls":10},21]
[22,"Total Cost of Health Care Services (sum of",{"$nulls":10},22]
[null,"lines 10, 14, and 21)"]
[null,"COSTS OTHER THAN RHC/FQHC SERVICES"]
[23,"Pharmacy",{"$nulls":10},23]
[24,"Dental",{"$nulls":10},24]
[25,"Optometry",{"$nulls":10},25]
[26,"All other nonreimbursable costs",{"$nulls":10},26]
[27,"Non-allowable GME Pass Through Costs",{"$nulls":10},27]
[28,"Total Nonreimbursable Costs (sum of lines 23-27)",{"$nulls":10},28]
[null,"FACILITY OVERHEAD"]
[29,"Facility Costs",{"$nulls":10},29]
[30,"Administrative Costs",{"$nulls":10},30]
[31,"Total Facility Overhead (sum of lines 29 and 30)",{"$nulls":10},31]
[32,"Total facility costs (sum of lines 22, 28 and 31)",{"$nulls":10},32]
[null,"The net expenses for cost allocation on Worksheet A for the applicable RHC/FQHC cost center line must equal the total facility costs in column 10, line 30 of this worksheet for cost reporting"]
[null,"periods beginning on or after January 1, 1998."]
[]
["FORM CMS-1728-94-RF-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3234)"]
[]
["Rev. 9",{"$nulls":11},"32-343"]

{"sheet":"RF-2","index":47,"n_rows":57,"n_cols":8,"rows_kept":57,"cut":false,"hidden":false,"merged":[[56,2,56,4]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",null,null,"FORM CMS 1728-94        ",null,null,null,"05-00"]
["ALLOCATION OF OVERHEAD",null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET RF-2"]
["TO RHC/FQHC SERVICES",null,"_______________",null,"FROM: ____________"]
[null,null,"COMPONENT NO.:",null,"TO: ____________"]
[null,null,"_______________"]
["Check ",null,"  [  ]  RHC"]
["Applicable Box:",null,"  [  ]  FQHC"]
["VISITS AND PRODUCTIVITY"]
[]
[null,null,"Number",null,null,"Minimum","Greater of"]
[null,null,"of FTE","Total","Productivity","Visits","Col. 2 or"]
[null,null,"Personnel","Visits","Standard (1)","(col. 1x col. 3)","Col. 4"]
[null,"    Positions","1","2","3","4","5"]
[1,"Physicians",{"$nulls":5},1]
[2,"Physician Assistants",{"$nulls":5},2]
[3,"Nurse Practitioners",{"$nulls":5},3]
[4,"Subtotal (sum of lines 1-3)",{"$nulls":5},4]
[5,"Visiting Nurse",{"$nulls":5},5]
[6,"Clinical Psychologist",{"$nulls":5},6]
[7,"Clinical Social Worker",{"$nulls":5},7]
[8,"Total FTEs and Visits (sum of lines 4-7)",{"$nulls":5},8]
[9,"Physician Services Under Agreements",{"$nulls":5},9]
[null,"(1) Productivity standards established by CMS are: 4200 visits for each physician and 2100 visits for each nonphysician"]
[null,"practitioner.  If an exception to the productivity standard has been granted, (Worksheet S-4, line 13 equals \"Y\"), then input"]
[null,"in column 3, lines 1-3, the productivity standards derived by the fiscal intermediary."]
[]
["DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES"]
[10,"Total costs of health care services (from Worksheet RF-1, column 10, line 22 less the amount",{"$nulls":5},10]
[null,"from Worksheet RF-1, column 10, line 20)"]
[11,"Total nonreimbursable costs (from Worksheet RF-1, column 10, line 28)",{"$nulls":5},11]
[12,"Cost of all services (excluding overhead) (sum of lines 10 and 11)",{"$nulls":5},12]
[13,"Ratio of RHC/FQHC services (line 10 divided by line 12)",{"$nulls":5},13]
[14,"Total facility overhead - (from Worksheet RF-1, column 10, line 31) (see instructions)",{"$nulls":5},14]
[15,"Allowable GME Overhead (see instructions)",{"$nulls":5},15]
[16,"Net Facility Overhead (line 14 minus line 15)",{"$nulls":5},16]
[17,"Parent provider overhead allocated to facility (see instructions)",{"$nulls":5},17]
[18,"Total overhead (sum of lines 16 and 17)",{"$nulls":5},18]
[19,"Overhead applicable to RHC/FQHC services (line 13 x line 18)",{"$nulls":5},19]
[20,"Total allowable cost of RHC/FQHC services (sum of lines 10 and 19)",{"$nulls":5},20]
{"$rows_empty":14}
["FORM CMS-1728-94-RF-2  (5-2000)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB."]
["15-II, SECTION 3235 - 3235.2)"]
[]
["32-344",{"$nulls":6},"Rev. 9"]

{"sheet":"RF-3^","index":48,"n_rows":58,"n_cols":7,"rows_kept":58,"cut":false,"hidden":false,"merged":[[57,2,57,4]],"flags":["formulas_cached_only"]}
["03-04",null,"FORM CMS 1728-94",null,null,null,"3290 (Cont.)"]
["CALCULATION OF",null,"PROVIDER NO.:","PERIOD:",null,"WORKSHEET RF-3"]
["REIMBURSEMENT SETTLEMENT",null,"_______________","FROM: ___________"]
["FOR RHC/FQHC SERVICES",null,"COMPONENT NO.:","TO: ___________"]
[null,null,"_______________"]
["Check ",null,"  [  ]  RHC"]
["Applicable Box:",null,"  [  ]  FQHC"]
["DETERMINATION OF RATE FOR RHC/FQHC SERVICES"]
[1,"Total Allowable Cost of RHC/FQHC Services (from Worksheet RF-2, line 20)",{"$nulls":4},1]
[2,"Cost of vaccines and their administration (from Worksheet RF-4, line 15)",{"$nulls":4},2]
[3,"Total allowable cost excluding vaccine (line 1 minus line 2)",{"$nulls":4},3]
[4,"Total FTEs and Visits (from Wkst. RF-2, col. 5, line 8)",{"$nulls":4},4]
[5,"Physicians visits under agreement (from Worksheet RF-2, column 5, line 9)",{"$nulls":4},5]
[6,"Total adjusted visits (line 4 plus line 5)",{"$nulls":4},6]
[7,"Adjusted cost per visit (line 3 divided by line 6)",{"$nulls":4},7]
[]
[null,null,null,"Calculation of Limit (1)"]
[null,null,null,"Rate","Rate","Rate"]
[null,null,null,"Period 1","Period 2","Period 3"]
[null,null,null,1,2,3]
[8,"Per visit payment limit (from your intermediary)",{"$nulls":4},8]
[9,"Rate for Medicare covered visits (lesser of line 7 or line 8) (See instructions)",{"$nulls":4},9]
[]
["CALCULATION OF SETTLEMENT"]
[10,"Medicare covered visits excluding mental health services",{"$nulls":4},10]
[null,"(from intermediary records)"]
[11,"Medicare cost excluding costs for mental health services",{"$nulls":4},11]
[null,"(line 9 x line 10)"]
[12,"Medicare covered visits for mental health services",{"$nulls":4},12]
[null,"(from intermediary records)"]
[13,"Medicare covered cost from mental health services (line 9 x line 12)",{"$nulls":4},13]
[14,"Limit adjustment for mental health services (line 13 x 62.5%)",{"$nulls":4},14]
[]
[{"$nulls":5},"1"]
[15,"Graduate Medical Education Pass Through Cost (see instructions)",{"$nulls":4},15]
[15.5,"Primary Payer Amounts",{"$nulls":4},15.5]
[16,"Total Medicare cost (line 11, columns 1, 2 & 3 plus line 14, columns 1, 2, & 3 plus column",{"$nulls":4},16]
[null," 1, line 15 minus \\line 15.5)"]
[17,"Less:  Beneficiary deductible (from intermediary records)",{"$nulls":4},17]
[18,"Net Medicare cost excluding vaccines (line 16 minus line 17)",{"$nulls":4},18]
[19,"Reimbursable cost of RHC/FQHC services, excluding vaccine (80% of line 18)",{"$nulls":4},19]
[20,"Medicare cost of vaccines and their administration (from Worksheet. RF-4, line 16)",{"$nulls":4},20]
[21,"Total reimbursable medicare cost (line 19 plus line 20)",{"$nulls":4},21]
[22,"Reimbursable bad debts",{"$nulls":4},22]
[23,"Other adjustments (specify)",{"$nulls":4},23]
[24,"Net reimbursable amounts (sum of lines 21, 22 and 23)",{"$nulls":4},24]
[25,"Interim payments (From Worksheet RF-5, line 4)",{"$nulls":4},25]
[25.5,"Tentative settlement (For intermediary use only)",{"$nulls":4},25.5]
[26,"Balance due component/program (line 24 minus line 25)",{"$nulls":4},26]
[27,"Protested amounts (nonallowable cost report items) in accordance with CMS Pub.",{"$nulls":4},27]
[null,"15-II, chapter I, section 115.2"]
[]
["(1)  Enter chronologically in columns 1, 2, and 3, as applicable, the payment limit and corresponding data."]
[]
["FORM CMS-1728-94-RF-3  (3-2004)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB."]
["15-II, SECTIONS 3236 - 3236.1)"]
[]
["Rev. 12",{"$nulls":5},"32-345"]

{"sheet":"RF-4^","index":49,"n_rows":64,"n_cols":6,"rows_kept":64,"cut":false,"hidden":false,"merged":[[63,2,63,3]],"flags":["formulas_cached_only"]}
["3290 (Cont.)",null,"FORM CMS 1728-94        ",null,null,"03-04"]
["COMPUTATION OF PNEUMOCOCCAL AND",null,"PROVIDER NO.:","PERIOD:","WORKSHEET RF-4"]
["INFLUENZA VACCINE COST",null,"_______________","FROM: __________"]
[null,null,"COMPONENT NO.:","TO: __________"]
[null,null,"_______________"]
["Check ",null,"  [  ]  RHC"]
["Applicable Box:",null,"  [  ]  FQHC"]
["DO NOT COMPLETE THIS WORKSHEET.  SEE INSTRUCTIONS."]
[]
[null,null,null,"PNEUMOCOCCAL","INFLUENZA"]
[null,null,null,1,2]
[1,"Health care staff cost (from Worksheet RF-1, column 10, line 10)",null,null,null,1]
[2,"Ratio of pneumococcal and influenza vaccine staff time to total",null,null,null,2]
[null,"health care staff time "]
[3,"Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)",null,null,null,3]
[4,"Medical supplies cost - pneumococcal and influenza vaccine",null,null,null,4]
[null,"(from your records)"]
[5,"Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4)",null,null,null,5]
[6,"Total direct cost of the facility (from Worksheet RF-1, column 10, line 22)",null,null,null,6]
[7,"Total overhead  (from Worksheet RF-2, line 18)",null,null,null,7]
[8,"Ratio of pneumococcal and influenza vaccine direct cost to total direct",null,null,null,8]
[null,"cost (line 5 divided by line 6)"]
[9,"Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)",null,null,null,9]
[10,"Total pneumococcal and influenza vaccine cost and its (their)",null,null,null,10]
[null,"administration  (sum of lines 5 and 9)"]
[11,"Total number of pneumococcal and influenza vaccine injections ",null,null,null,11]
[null,"(from your records)"]
[12,"Cost per pneumococcal and influenza vaccine injection (line 10/ line 11)",null,null,null,12]
[13,"Number of pneumococcal and influenza vaccine injections administered ",null,null,null,13]
[null,"to Medicare beneficiaries"]
[14,"Medicare cost of pneumococcal and influenza vaccine and its (their) ",null,null,null,14]
[null,"administration (line 12 x line 13)"]
[]
[15,"Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns",null,null,null,15]
[null,"1 and 2, line 10) (transfer this amount to Worksheet RF-3, line 2)"]
[16,"Total  Medicare cost of pneumococcal and influenza vaccine and its (their) administration (sum",null,null,null,16]
[null,"of columns 1 and 2, line 14)  (transfer this amount to Worksheet RF-3, line 20)"]
[null,null,null," "]
{"$rows_empty":22}
["FORM CMS-1728-94-RF-4  (3-2004) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3237)"]
[]
[]
["32-346",{"$nulls":4},"Rev. 12"]

{"sheet":"RF-5","index":50,"n_rows":67,"n_cols":9,"rows_kept":67,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["08-99",null,null,"FORM CMS 1728-94",{"$nulls":4},"3290 (Cont.)"]
["ANALYSIS OF PAYMENTS TO PROVIDER-BASED",null,null,null,"PROVIDER NO.:",null,"PERIOD:","  SUPPLEMENTAL"]
["RHC/FQHC FOR SERVICES RENDERED TO",null,null,null,"_______________",null,"FROM: __________","  WORKSHEET RF-5"]
["PROGRAM BENEFICIARIES",null,null,null,"COMPONENT NO.:",null,"TO: __________"]
[{"$nulls":4},"_______________"]
["Check Applicable Box:",null,null,"  [  ]  RHC      [  ]  FQHC"]
[{"$nulls":6},"PART B"]
[null,"DESCRIPTION",{"$nulls":4},"1","2"]
[{"$nulls":6},"mm/dd/yyyy","Amount"]
["1","Total interim payments paid to RHC/FQHC",{"$nulls":6},"1"]
["2","Interim payments payable on individual bills either, submitted or to",{"$nulls":6},"2"]
[null,"be submitted to the intermediary, for services rendered in the"]
[null,"cost reporting period.  If none, write \"NONE\" or enter a zero."]
["3","List separately each retroactive lump sum ",null,null,null,".01",null,null,"3.01"]
[null,"adjustment amount based on subsequent revision",null,null,"Program ",".02",null,null,"3.02"]
[null,"of the interim rate for the cost reporting period.",null,null,"to",".03",null,null,"3.03"]
[null,"Also show date of each payment.  If none write",null,null,"Provider",".04",null,null,"3.04"]
[null,"\"NONE\" or enter a zero. (1)",null,null,null,".05",null,null,"3.05"]
[{"$nulls":5},".50",null,null,"3.50"]
[{"$nulls":4},"Provider ",".51",null,null,"3.51"]
[{"$nulls":4},"to",".52",null,null,"3.52"]
[{"$nulls":4},"Program",".53",null,null,"3.53"]
[{"$nulls":5},".54",null,null,"3.54"]
[null,"SUBTOTAL (Sum of lines 3.01-3.49, minus sum"]
[null,"of lines 3.50-3.98)                         ",null,null,null,".99",null,null,"3.99"]
["4","TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)",{"$nulls":6},"4"]
[null,"(Transfer to Supp. Wkst RF-3, Part II, line 25)"]
[]
[null,null,"TO BE COMPLETED BY INTERMEDIARY"]
[]
["5","List separately each tentative settlement payment ",null,null,"Program ",".01",null,null,"5.01"]
[null,"after desk review.  Also show date of each ",null,null,"to",".02",null,null,"5.02"]
[null,"payment.  If none, write \"NONE\" or enter     ",null,null,"Provider",".03",null,null,"5.03"]
[null,"a zero. (1)",null,null,"Provider ",".50",null,null,"5.50"]
[{"$nulls":4},"to",".51",null,null,"5.51"]
[{"$nulls":4},"Program",".52",null,null,"5.52"]
[null,"SUBTOTAL (Sum of lines 5.01-5.49, minus sum  "]
[null,"of lines 5.50-5.98)      ",null,null,null,".99",null,null,"5.99"]
["6","Determine net settlement amount (balance due) based",null,null,"Program "]
[null,"on the cost report (SEE INSTRUCTIONS). (1)",null,null,"to"]
[{"$nulls":4},"Provider",".01",null,null,"6.01"]
[{"$nulls":4},"Provider "]
[{"$nulls":4},"to"]
[{"$nulls":4},"Program",".02",null,null,"6.02"]
["7","TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)",{"$nulls":6},"7"]
[]
[" Name of Intermediary",{"$nulls":4},"    Intermediary Number"]
[]
[]
[" Signature of Authorized Person",{"$nulls":4},"    Date:   (Month, Day, Year)"]
[]
[]
[" (1)  On lines 3, 5 and 6, where an amount is due \"Provider to Program,\" show the amount and date on which the provider"]
["      agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
{"$rows_empty":10}
["FORM CMS-1728-94-RF-5  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3238"]
[]
["Rev. 7",{"$nulls":7},"32-347"]