{"text_format":"2","workbook":"xls","n_sheets":62,"sheets":["S","S2","SII","S3","S-3II","S-3IV","S-3V","S4","S5","S6","S7a","S8","A","A6","A7","A8","A81","A82","B","B-1","B-II","B-2","C","D","DII","D-1","E-I","E-II","E1","G","GII","G-1","G-2","G-3","H","H1-1","H1-II","H2-1","H2-II","H3-I","H4","H5","I1","I2","I3","I4","I-5","J-1-I","J-1-II","J-2","J-3","J-4","K","K-1","K-2","K-3","K-4-1","K-4-2","K-5-1","K-5-II","K-5-III","K6"],"not_rendered":{"charts":3,"images":6,"macros":1,"external_links":1,"defined_names":63,"comments":1,"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":257,"n_cols":14,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",{"$nulls":6},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
["This report is required by law (42 USC 1395g; 42 CFR 413.20(b)).  Failure to report can result in all interim",{"$nulls":12},"FORM APPROVED"]
["payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).",{"$nulls":12},"OMB NO. 0938-0463"]
["SKILLED  NURSING  FACILITY  AND",{"$nulls":6}," PROVIDER  NO.:",null,null," PERIOD:"]
["SKILLED  NURSING  FACILITY  HEALTH",{"$nulls":9}," FROM  ___________________",null,"   WORKSHEET   S"]
["CARE  COMPLEX  COST  REPORT",{"$nulls":6},"______________________",{"$nulls":4},"   PARTS  I  II & III"]
["CERTIFICATION AND",{"$nulls":9}," TO  _________________"]
["SETTLEMENT SUMMARY"]
[]
["PART I - COST REPORT STATUS"]
["Provider",null,"[    ] ","Electronic filed cost report",{"$nulls":5},"Date:____________",null,null,"Time:____________"]
["  use only",null,"[    ]","Manually submitted cost report"]
["Contractor",null,"[    ]   Cost Report Status",{"$nulls":4}," If # 3 or 4:",null,null,"Date Received  _____________"]
["use only:",null,"[ 1 ]","As Submitted:",null,null,null,"  [  ]  Desk Reviewed",null,null,"Contractor No.  _____________"]
[null,null,"[ 2 ]","Amended:",null,null,null,"   [   ]  Audited",null,null,"[  ]  First Cost Report Processed by Contractor"]
[null,null,"[ 3 ]","Settled:",{"$nulls":6},"         "]
[null,null,"[ 4 ]","Reopened:    If number 4, Enter ",{"$nulls":6},"[  ]  Last Cost Report to be Processed by Contractor"]
[null,null,null,"Number of times reopened  [   ]"]
[]
["PART  II  -  CERTIFICATION"]
[]
["MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,  CIVAL, AND ADMINISTRATIVE"]
["ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW.  FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED THROUGH THE PAYMENT "]
["DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT."]
[]
[]
[null,"CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDERS)"]
[]
[null,"I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted cost report and the"]
[null,"Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Names) and Numbers)} for the cost reporting period"]
[null,"beginning _______________ and ending _______________ and to the best of my knowledge and belief, it is a true, correct and complete statement prepared from"]
[null,"the books and records of the provider in accordance with applicable instructions, except as noted.  I further certify that I am familiar with the laws and regulations "]
[null,"regarding the provision of health care services identified in this cost report were provided in  compliance with such laws and regulations."]
[]
[]
[null,"OFFICER OR ADMINISTRATOR OF PROVIDER"]
[]
[null,"        Printed Name",null,"___________________________________________",{"$nulls":5},"Signed________________________________________________"]
[]
[null,"        Title","_____________________________________________",{"$nulls":6},"Date","_______________"]
[]
[]
["PART  III  -  SETTLEMENT SUMMARY"]
[{"$nulls":9},"             TITLE   XVIII"]
[{"$nulls":7},"TITLE  V",null,"A",null,"B","TITLE XIX"," "]
[{"$nulls":7},"1",null,"2",null,"3","4"," "]
[1,"SKILLED  NURSING  FACILITY",{"$nulls":11},1]
["2","NURSING FACILITY",{"$nulls":11},"2"]
["3","I C F / M R",{"$nulls":11},"3"]
[4,"SNF - BASED  HHA",{"$nulls":11},4]
[5,"SNF - BASED  RHC",{"$nulls":11},5]
[6,"SNF - BASED  FQHC",{"$nulls":11},6]
[7,"SNF - BASED  CMHC",{"$nulls":11},7]
[8,"SNF - BASED  O.L.T.C.",{"$nulls":11},8]
[100,"TOTAL",{"$nulls":11},100]
["The above amounts represent \"due to\" or \"due from\" the applicable Program for the element of the above complex indicated."]
[" (Indicate Overpayments in Brackets.)"]
[]
["According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control"]
["number for this information collection is 0938-0463.  The time required to complete this information collection is estimated 202 hours per response, including the time to review instructions,"]
["search existing resources, gather the data needed, and complete and review the information collection.  If you have any comments concerning the accuracy of the time estimate's) or suggestions"]
["for improving this form, please write to:  CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop  C4-26-05, Baltimore, Maryland 21244-1850."]
[]
["FORM CMS-2540-10 ( 12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS"]
["PUB. 15-II,  SECTIONS 4103 )"]
["Rev. 1",{"$nulls":12},"41-303"]
{"$rows_empty":190}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S2","index":1,"n_rows":257,"n_cols":16,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",{"$nulls":7},"2011-02-11"]
["SKILLED NURSING FACILITY  AND SKILLED NURSING ",null,null,null,"PROVIDER NO.:",null,"PERIOD",null,null,"WORKSHEET"]
["FACILITY HEALTH CARE COMPLEX ",{"$nulls":5},"FROM_____________",null,null,"S - 2"]
["IDENTIFICATION DATA",null,null,null,"_______________","____________________","TO_____________",null,null,null,"Part I"]
["Skilled Nursing Facility and Skilled Nursing Facility Complex Address:"]
["1"," Street:",null,null,null,"  P.O.  Box:",{"$nulls":5},1]
["2"," City:         ",null,null,null,"  State:",null,"  Zip Code:",null,null,null,"2"]
["3"," County:",null,null,null," CBSA Code:",null,"  Urban / Rural:",null,null,null,"3"]
["SNF and SNF-Based Component Identification:"]
[{"$nulls":8},"Payment System"]
[null,null,"Component Name",null,null,"Provider No.","Date",null,"(P,  O, or  N)"]
[null,"Component",{"$nulls":4},"Certified",null,"V","XVIII","XIX"]
[null,"0",1,null,null,2,"3",null,"4","5","6"]
["4"," S N F ",{"$nulls":9},"4"]
["5"," Nursing Facility",{"$nulls":9},"5"]
["6"," I C F / M R",{"$nulls":9},"6"]
[7," SNF-Based H.H.A.",{"$nulls":9},7]
[8," SNF-Based RHC",{"$nulls":9},8]
[9," SNF-Based FQHC",{"$nulls":9},9]
[10," SNF-Based CMHC",{"$nulls":9},10]
[11," SNF-Based O.L.T.C.",{"$nulls":9},11]
[12," SNF-Based HOSPICE",{"$nulls":9},12]
[13," Cost Reporting Period (mm/dd/yyyy)         ",null,null,"From: ",null," To:",{"$nulls":4},13]
[14," Type of Control (See Instructions)",{"$nulls":9},14]
["Type of Freestanding Skilled Nursing Facility",{"$nulls":9},"Y / N"," "]
[15," Is this a distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?",{"$nulls":9},15]
[16," Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?",{"$nulls":9},16]
[17," Are there any costs included in Worksheet A which resulted from transactions with related",{"$nulls":9},17]
[null,"  organizations as defined in CMS Pub. 15-I, chapter 10?  If yes, complete Worksheet A-8-1."]
["Miscellaneous Cost Reporting information"]
[18," If this is a low or no Medicare utilization cost report, enter \"L\" for low Medicare Utilization, or",{"$nulls":9},18]
[null," enter \"N\" for No Medicare Utilization."]
[19,"Other",{"$nulls":9},19]
["Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on Lines 22 - 24."]
[20," Straight Line",{"$nulls":9},20]
[21," Declining Balance",{"$nulls":9},21]
[22," Sum of the Year's Digits",{"$nulls":9},22]
[23," Sum of line 20 through  22",{"$nulls":9},23]
[24," If depreciation is funded,  enter the balance as of the end of the period.",{"$nulls":9},24]
[25," Were there any disposal of capital assets during the cost reporting period? (Y/N)",{"$nulls":9},25,null,null,null,"CMS2540-10"]
[26," Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)",{"$nulls":9},26]
[27," Did you cease to participate in the Medicare program at end of the period to which this cost report applies",{"$nulls":9},27]
[28," Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports",{"$nulls":9},28]
["FORM  ( 12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4104)",{"$nulls":10},"EFG"]
["41-304",{"$nulls":10},"Rev. 1"]
[]
["2/11",null," ","FORM CMS-2540-10",{"$nulls":7},"4190 (Cont.)"]
["SKILLED NURSING FACILITY  AND SKILLED NURSING ",null,null,null,"PROVIDER NO.:",null,"PERIOD",null,null,"WORKSHEET"]
["FACILITY HEALTH CARE COMPLEX ",{"$nulls":5},"FROM_____________",null,null,"S - 2    Part I"]
["IDENTIFICATION DATA",null,null,null,"_______________","____________________","TO__________",null,null,"(Continued)"]
["If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of"]
["costs or charges enter \"Y\" for each component and type of service that qualifies for the exemption.",{"$nulls":7},"Part A","Part B","Other"]
[29," Skilled Nursing Facility",{"$nulls":9},29]
[30," Nursing Facility",{"$nulls":9},30]
[31," I C F / M R",{"$nulls":9},31]
[32," SNF-Based H.H.A.",{"$nulls":9},32]
[33," SNF-Based RHC",{"$nulls":9},33]
[34," SNF-Based FQHC",{"$nulls":9},34]
[35," SNF-Based CMHC",{"$nulls":9},35]
[" "," SNF-Based OLTC",{"$nulls":9},36]
[{"$nulls":10},"Y / N"]
[37," Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for Titles V & XIX patients.",{"$nulls":9},37]
[38," Are you legally-required to carry malpractice insurance?",{"$nulls":9},38]
[39," Is the malpractice a \"claims-made:\", or \"occurence\" policy? If the policy is \"claims-maid\" enter 1. If policy is \"occurence\", enter 2.",{"$nulls":9},39]
[40," What is the liability limit for the malpractice policy?  Enter in column 1 the monetary ",{"$nulls":9},40]
[null," limit per lawsuit. Enter in column 2 the monetary limit per policy year."]
[{"$nulls":4},"Premiums",null,"Paid Losses",null,"Self insurance"]
[41," List malpractice premiums and paid losses: ",{"$nulls":9},41]
[42,"Are malpractice premiums and paid losses reported in other than the Administrative and General cost center?",{"$nulls":8},"Y / N"]
[null," Enter Y or N. If yes, check box, and submit supporting schedule listing cost centers and amounts.",{"$nulls":9},42]
[43,"Are there any related organizations or home office costs as defined in CMS Pub. 15-1, chapter 10?  ",{"$nulls":9},43]
[44,"If yes, and there are costs, for the home office, enter the applicable provider number",{"$nulls":4},"Provider #",{"$nulls":4},44]
[null,"If this facility is part of a chain organization, enter the name and address of the home office on the lines below"]
[45,"Name:",null,"Contractor name",null,null,"Contractor Number",{"$nulls":4},45]
[46,"Street:",{"$nulls":4},"PO Box",{"$nulls":4},46]
[47,"City",{"$nulls":4},"State",null,"Zip",null,null,47]
{"$rows_empty":12}
[{"$nulls":8},"                                                                                                                                                                                                    "]
[]
["FORM  ( 12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4104)"]
["Rev.1",{"$nulls":10},"41-305"]
{"$rows_empty":164}
[{"$nulls":11},"Rev. 1"]

{"sheet":"SII","index":2,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
["SKILLED NURSING FACILITY AND SKILLED NURSING",null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET S-2"]
["FACILITY HEALTH CARE COMPLEX",{"$nulls":4},"FROM  ",null,"Part II"]
["IDENTIFICATION DATA",{"$nulls":4},"TO   "]
["General Instruction:  For all column 1 responses enter in column 1, \"Y\" for Yes or \"N\" for No"]
[null,null,"For all the dates responses the format will be (mm/dd/yyyy)"]
["Completed by All Skilled Nursing Facilities"]
[]
[null,"Provider Organization and Operation",{"$nulls":4},1,2]
[{"$nulls":6},"Y/N","Date"]
[1,"Has the Provider changed ownership immediately prior to the beginning of the cost reporting period? ",{"$nulls":7},1]
[null,"If column 1 is \"Y\", enter the date of the change in column 2. (see instructions)"]
[{"$nulls":6},1,2,3]
[{"$nulls":6},"Y/N","Date","V/I"]
[2,"Has the provider terminated participation in the Medicare Program?   If column 1 is yes,",{"$nulls":7},2]
[null," enter in column 2 the date of termination and in column 3, \"V\" for voluntary or \"I\" for involuntary"]
[3,"Is the provider involved in business transactions, including management contracts, with individuals or",{"$nulls":7},3]
[null,"entities (e.g., chain home offices, drug or medical supply companies) that are related to the provider or"]
[null,"its officers,  medical staff, management personnel, or members of the board of directors through"]
[null,"ownership, control, or family and other similar relationships? (see instructions)"]
[]
["Financial Data and Reports"]
[{"$nulls":6},1,2,3]
[{"$nulls":6},"Y/N","Type","Date"]
[4,"Were the financial statements prepared by a Certified Public Accountant? If column 1 is \"Y\" enter \"A\" ",{"$nulls":7},4]
[null,"for Audited,  \"C\" for Compiled, or \"R\" for Reviewed in column 2.  Submit a complete copy or enter "]
[null,"date available in column 3. (see instructions)  If column 1 is \"N\" see instructions."]
[5,"Are the cost report total expenses and total revenues different from those on the filed financial",{"$nulls":7},5]
[null,"statements?  If column 1 is \"Y\", submit reconciliation."]
[]
[{"$nulls":7},1,2]
["Approved Educational Activities",{"$nulls":6},"Y/N","Legal Oper."]
[6,"Were costs claimed for Nursing School? If column 1 is \"Y\", enter \"Y\" or \"N\" in column 2 to indicate whether the ",{"$nulls":7},6]
[null,"provider is the legal operator of the program"]
[7,"Were costs claimed for Allied Health Programs? If \"Y\" see instructions.",{"$nulls":7},7]
[8,"Were approvals and/or renewals obtained during the cost reporting period for Nursing School and/or ",{"$nulls":7},8]
[null,"Allied Health Program?   If \"Y\", see instructions."]
[]
["Bad Debts"]
[{"$nulls":8},1]
[{"$nulls":8},"Y/N"]
[9,"Is the provider seeking reimbursement for bad debts? If \"Y\", see instructions.",{"$nulls":7},9]
[10,"If line 9 is \"Y\", did the provider's bad debt collection policy change during this cost reporting period? If \"Y\", submit copy.",{"$nulls":7},10]
[11,"If line 9 is \"Y\", are  patient deductibles and/or coinsurance waived? If \"Y\", see instructions.",{"$nulls":7},11]
[]
["Bed Complement"]
[12,"Have total beds available changed from prior cost reporting period? If \"Y\", see instructions.",{"$nulls":7},12]
[]
[{"$nulls":5},1,2,3,4]
[{"$nulls":5},"Y/N","Date","Y/N","Date"]
["PS&R Data",{"$nulls":4},"Part A","Part A","Part B","Part B"]
[13,"Was the cost report prepared using the PS&R only?  ",{"$nulls":7},13]
[null," If either col. 1 or 3 is \"Y\", enter the paid through date of the PS&R used"]
[null," to prepare this cost report in cols. 2 and 4 .(see Instructions.)"]
[14,"Was the cost report prepared using the PS&R for total and the provider's records",{"$nulls":7},14]
[null,"for allocation?  If either col. 1 or 3 is \"Y\" enter the paid through date  of the PS&R"]
[null,"used to prepare this cost report in columns 2 and 4. "]
[15,"If line 13 or 14 is \"Y\", were adjustments made to PS&R data for additional claims that",{"$nulls":7},15]
[null,"have been billed but are not included on the PS&R used to file this cost report?"]
[" "," If \"Y\", see Instructions."]
[16,"If line 13 or 14 is \"Y\", then were adjustments made to PS&R data for corrections of other ",{"$nulls":7},16]
[null,"PS&R information? If \"Y\", see Instructions."]
[17,"If line 13 or 14 is \"Y\", then were adjustments made to PS&R data for Other?",{"$nulls":7},17]
[null,"Describe the other adjustments:",null,"_________________________________"]
[18,"Was the cost report prepared only using the provider's records? If \"Y\" see Instructions.",{"$nulls":7},18]
{"$rows_empty":11}
["41-306",{"$nulls":8},"Rev. 1"]
{"$rows_empty":179}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S3","index":3,"n_rows":257,"n_cols":15,"rows_kept":257,"cut":false,"hidden":false,"merged":[[0,13,0,14]],"flags":["formulas_cached_only"]}
["2011-02-11",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":6},"4190 (Cont.)"]
["SKILLED NURSING  FACILITY  AND",{"$nulls":5},"  PROVIDER  NO.:",null,null,"  PERIOD",null,null,"WORKSHEET   S-3"]
["SKILLED  NURSING  FACILITY  HEALTH  CARE  COMPLEX",{"$nulls":8},"  FROM____________________",null,null,"PART  I"]
["STATISTICAL  DATA"]
[null,null,"Number","Bed","I n p a t i e n t     D a y s",{"$nulls":4},"D i s c h a r g e s"]
[null,null,"of","Days","Title","Title","Title",null,"Total","Title","Title","Title",null,"Total"]
[null,"Component","Beds","Available","V","XVIII","XIX","Other",null,"V","  XVIII","XIX","Other"]
[null,null,"1","2","3","4","5","6","7","8","9","10","11","12"]
[1," Skilled Nursing Facility",{"$nulls":12},1]
[2," Nursing Facility",{"$nulls":12},2]
[3," ICF/MR",{"$nulls":12},3]
[4," Home Health Agency",{"$nulls":12},4]
[5,"Other Long Term Care",{"$nulls":12},5]
[6," SNF-Based CMHC",{"$nulls":12},6]
[7," Hospice",{"$nulls":12},7]
[8," Total (Sum of lines 1-7)",{"$nulls":12},8]
[]
[{"$nulls":12}," Full Time"]
[null,null," ","Average Length of Stay",null,null,null,"A d m i s s i o n s",{"$nulls":4}," Equivalent"]
[null,null,null,"Title","Title","Title","Total","Title","Title","Title",null,"Total","Employees","Nonpaid"]
[null,null,null,"V","XVIII","XIX",null,"V","XVIII","XIX","Other",null,"on Payroll","Workers"]
[null,null,null,"13","14","15","16","17","18","19","20","21","22","23"]
[1," Skilled Nursing Facility",{"$nulls":12},1]
[2," Nursing Facility",{"$nulls":12},2]
[3," ICF/MR",{"$nulls":12},3]
[4," Home Health Agency",{"$nulls":12},4]
[5,"Other Long Term Care",{"$nulls":12},5]
[6," SNF-Based CMHC",{"$nulls":12},6]
[7," Hospice",{"$nulls":12},7]
[8," Total (Sum of lines 1-7)",{"$nulls":12},8]
{"$rows_empty":10}
["FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,  SECTION 4105."]
[]
["Rev. 1",{"$nulls":13},"41-307"]
{"$rows_empty":16}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S-3II","index":4,"n_rows":259,"n_cols":12,"rows_kept":259,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[]
["4190(Cont.)",null,"     FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,null,"PROVIDER NO.:",null,"PERIOD:",null," WORKSHEET  S-3"]
["  SNF  WAGE  INDEX  INFORMATION",null,null,null,"FROM __________",null,"   PARTS II  &  III"]
["",null,"______________",null,"TO _____________"]
[null,null,null,"Reclass.","Adjusted","Paid Hours","Average"]
[null,null,null,"of Salaries","Salaries","Related","Hourly Wage"]
["PART  II    DIRECT  SALARIES",null,"Amount","from Wkst.","(col. 1 ±","to Salary","(col. 3 ÷"]
[null,null,"Reported","A-6","col. 2)","in col. 3","col. 4)"]
[null,null,"1","2","3","4","5"]
[null,"SALARIES"]
[1,"Total salary (See Instructions)",{"$nulls":5},1]
[2,"Physician salaries-Part A",{"$nulls":5},2]
[3,"Physician salaries-Part B",{"$nulls":5},3]
[4,"Interns & Residents (approved)",{"$nulls":5},4]
[5,"Home office personnel",{"$nulls":5},5]
[6,"Sum of lines 2 thru 5",{"$nulls":5},6]
[7,"Revised wages (line 1 minus line 6)",{"$nulls":5},7]
[8,"Other Long Term Care",{"$nulls":5},8]
[9,"H.H.A.",{"$nulls":5},9]
[10,"CMHC",{"$nulls":5},10]
[11,"Hospice",{"$nulls":5},11]
[12,"Non-reimbursable",{"$nulls":5},12]
[13,"Total Excluded salary",{"$nulls":5},13]
[null," (Sum of lines 8 through 12)"]
[14,"Subtotal (line 7 minus line 13)",{"$nulls":5},14]
[null,"OTHER WAGES AND RELATED COSTS"]
[15,"Contract Labor: Patient Related & Mgmt"]
[16,"Contract Labor: Physician services-Part A",{"$nulls":5},16]
[17,"Home office salaries & wage related costs",{"$nulls":5},17]
[null,"WAGE RELATED COSTS"]
[18,"Wage related costs core. (See Part IV)",{"$nulls":5},18]
[19,"Wage related costs other (See Part IV)",{"$nulls":5},19]
[20,"Wage related costs  (excluded units)",{"$nulls":5},20]
[21,"Physicians Part A - WRC",{"$nulls":5},21]
[22,"Physicians Part B - WRC",{"$nulls":5},22]
[23,"Subtotal (see instructions)",{"$nulls":5},23]
["PART  III  -  OVERHEAD  COST  -  DIRECT  SALARIES"]
[null,null,null,"Reclass.","Adjusted","Paid Hours","Average"]
[null,null,null,"of Salaries","Salaries","Related","Hourly Wage"]
[null,null,"Amount","from ","(col. 1 ±","to Salary","(col. 3 ÷"]
[null,null,"Reported","Wkst. A-6","col. 2)","in col. 3","col. 4)"]
[null,null,"1","2","3","4","5"]
[1,"Employee Benefits",{"$nulls":5},1]
[2,"Administrative & General",{"$nulls":5},2]
[3,"Plant Operation, Maintenance & Repairs",{"$nulls":5},3]
[4,"Laundry & Linen Service",{"$nulls":5},4]
[5,"Housekeeping",{"$nulls":5},5]
[6,"Dietary",{"$nulls":5},6]
[7,"Nursing Administration",{"$nulls":5},7]
[8,"Central Services and Supply",{"$nulls":5},8]
[9,"Pharmacy",{"$nulls":5},9]
[10,"Medical Records & Medical Records Library",{"$nulls":5},10]
[11,"Social Service",{"$nulls":5},11]
[12,"Interns & Records (Apprvd Tching Prog)",{"$nulls":5},12]
[13,"Other General Service (specify)",{"$nulls":5},13]
[14,"Total (sum lines 1 thru 13)",{"$nulls":5},14]
["FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II,"]
["SECTION 4105.1 - 4105.2)"]
[]
["41-308",{"$nulls":6},"Rev. 1"]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S-3IV","index":5,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,"FORM CMS-2540-10",{"$nulls":4},"4190 (Cont.)"]
[null,null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET"]
["SNF  WAGE RELATED COSTS",{"$nulls":4},"FROM __________",null,"  S-3"]
[null,null,null,"______________",null,"TO _____________",null,"PART IV"]
["PART IV - Wage Related Cost "]
[]
["Part A - Core List"]
[]
[]
[{"$nulls":7},"Amount"]
[{"$nulls":7},"Reported"]
[]
[null,"RETIREMENT COST"]
[1,"401K Employer Contributions ",{"$nulls":6},1]
[2,"Tax Sheltered Annuity (TSA) Employer Contribution",{"$nulls":6},2]
[3,"Qualified and Non-Qualified Pension Plan Cost ",{"$nulls":6},3]
[4,"Prior Year Pension Service Cost              ",{"$nulls":6},4]
[null,"PLAN ADMINISTRATIVE COSTS (Paid to External Organization):"]
[5,"401K/TSA Plan Administration fees                    ",{"$nulls":6},5]
[6,"Legal/Accounting/Management Fees-Pension Plan        ",{"$nulls":6},6]
[7,"Employee Managed Care Program Administration Fees   ",{"$nulls":6},7]
[null,"HEALTH AND  INSURANCE COST"]
[8,"Health Insurance (Purchased or Self Funded)",{"$nulls":6},8]
[9,"Prescription Drug Plan",{"$nulls":6},9]
[10,"Dental, Hearing and Vision Plan",{"$nulls":6},10]
[11,"Life Insurance (If employee is owner or beneficiary)",{"$nulls":6},11]
[12,"Accidental Insurance (If employee is owner or beneficiary)",{"$nulls":6},12]
[13,"Disability Insurance (If employee is owner or beneficiary)",{"$nulls":6},13]
[14,"Long-Term Care Insurance (If employee is owner or beneficiary)",{"$nulls":6},14]
[15,"Workers' Compensation Insurance",{"$nulls":6},15]
[16,"Retirement Health Care Cost (Only current year, not the extraordinary ",{"$nulls":6},16]
[null," accrual required by FASB 106  Non cumulative portion)"]
[" ","TAXES",{"$nulls":6}," "]
[17,"FICA-Employers Portion Only",{"$nulls":6},17]
[18,"Medicare Taxes - Employers Portion Only",{"$nulls":6},18]
[19,"Unemployment Insurance",{"$nulls":6},19]
[20,"State or Federal Unemployment Taxes",{"$nulls":6},20]
[null,"OTHER"]
[21,"Executive Deferred Compensation",{"$nulls":6},21]
[22,"Day Care Cost and Allowances",{"$nulls":6},22]
[23,"Tuition Reimbursement",{"$nulls":6},23]
[24,"Total Wage Related cost (Sum of lines 1 -23)",{"$nulls":6},24]
[]
["Part B Other than Core Related Cost"]
[25,"Other Wage Related Costs (specify)_________________________________________",{"$nulls":6},25]
{"$rows_empty":9}
["FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4105)"]
[]
["Rev. 1",{"$nulls":7},"41-309"]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S-3V","index":6,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["DRAFT",null,"FORM CMS-2540-10",{"$nulls":4},"4190 (Cont.)"]
[null,null,"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET "]
[null,"SNF  REPORTING OF",null,null,"FROM ________",null," S-3"]
["","DIRECT CARE EXPENDITURES","________________",null,"TO ___________",null,"PART V"]
[{"$nulls":4},"Adjusted","Paid Hours","Average"]
[{"$nulls":4},"Salaries","Related","Hourly Wage"]
[null,null,"Amount","Fringe","(col. 1 +","to Salary","(col. 3 ÷"]
[null,null,"Reported","Benefits","col. 2)","in col. 3","col. 4)"]
["Occupational Category",null,"1",2,"3","4","5"]
[null,"Direct Salaries"]
[null,"Nursing Occupations"]
[1,"Registered Nurses (RNs)",{"$nulls":5},1]
[2,"Licensed Practical Nurses (LPNs)",{"$nulls":5},2]
[3,"Nursing Assistants/Aides",{"$nulls":5},3]
[null,"Total Nursing"]
[4,"Physical Therapists ",{"$nulls":5},4]
[5,"Physical Therapy Assistants ",{"$nulls":5},5]
[6,"Physical Therapy Aides ",{"$nulls":5},6]
[7,"Occupational Therapists ",{"$nulls":5},7]
[8,"Occupational Therapy Assistants ",{"$nulls":5},8]
[9,"Occupational Therapy Aides ",{"$nulls":5},9]
[10,"Speech Therapists ",{"$nulls":5},10]
[11,"Respiratory Therapists",{"$nulls":5},11]
[12,"Other Medical Staff",{"$nulls":5},12]
[null,"Contract Labor"]
[null,"Nursing Occupations"]
[13,"Registered Nurses (RNs)",{"$nulls":5},13]
[14,"Licensed Practical Nurses (LPNs)",{"$nulls":5},14]
[15,"Nursing Assistants/Aides",{"$nulls":5},15]
[null,"Total Nursing"]
[16,"Physical Therapists ",{"$nulls":5},16]
[17,"Physical Therapy Assistants ",{"$nulls":5},17]
[18,"Physical Therapy Aides ",{"$nulls":5},18]
[19,"Occupational Therapists ",{"$nulls":5},19]
[20,"Occupational Therapy Assistants ",{"$nulls":5},20]
[21,"Occupational Therapy Aides ",{"$nulls":5},21]
[22,"Speech Therapists ",{"$nulls":5},22]
[23,"Respiratory Therapists",{"$nulls":5},23]
[24,"Other Medical Staff",{"$nulls":5},24]
{"$rows_empty":12}
["FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4105)"]
[]
["41-308",{"$nulls":6},"Rev. ___"]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S4","index":7,"n_rows":257,"n_cols":26,"rows_kept":257,"cut":false,"hidden":false,"merged":[[38,6,38,7]],"flags":["formulas_cached_only"]}
["4190 (Cont.)",{"$nulls":4},"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[{"$nulls":4},"  PROVIDER NO.:",null,"  PERIOD:",{"$nulls":18},"{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1"]
["S.N.F. -BASED HOME HEALTH AGENCY",{"$nulls":5},"  FROM ____________",null,null,"WORKSHEET S-4"]
["STATISTICAL DATA",null,null,null,"  HHA NO.:",null,"  TO _______________"]
[]
["    HOME HEALTH AGENCY STATISTICAL DATA"]
[1,"County",{"$nulls":9},1]
[{"$nulls":6},"Title","Title","Title"]
[null,"     DESCRIPTION",{"$nulls":4},"V","XVIII","XIX","Other","Total"]
[{"$nulls":6},"1","2","3","4","5"]
[2," Home Health Aide Hours",{"$nulls":9},2]
[3," Unduplicated Census Count (see instructions)",{"$nulls":9},3]
["    HOME HEALTH AGENCY - NUMBER OF EMPLOYEES"]
[null,"          (FULL TIME EQUIVALENT)",{"$nulls":6},"Staff","Contract","Total"]
[{"$nulls":8},"1","2","3"]
[4,"Enter the number of hours in your normal work week ",{"$nulls":9},4]
[5," Administrator and Assistant Administrator(s)",{"$nulls":9},5]
[6," Directors and Assistant Director(s)",{"$nulls":9},6]
[7," Other Administrative Personnel",{"$nulls":9},7]
[8," Direct Nursing Service",{"$nulls":9},8]
[9," Nursing Supervisor",{"$nulls":9},9]
[10," Physical Therapy Service",{"$nulls":9},10]
[11," Physical Therapy Supervisor",{"$nulls":9},11]
[12," Occupational Therapy Service",{"$nulls":9},12]
[13," Occupational Therapy Supervisor",{"$nulls":9},13]
[14," Speech Pathology Service",{"$nulls":9},14]
[15," Speech Pathology Supervisor",{"$nulls":9},15]
[16," Medical Social Service",{"$nulls":9},16]
[17," Medical Social Service Supervisor",{"$nulls":9},17]
[18," Home Health Aide",{"$nulls":9},18]
[19," Home Health Aide Supervisor",{"$nulls":9},19]
[20," Other (specify)",{"$nulls":9},20]
["HOME HEALTH AGENCY CBSA CODES"]
[21," Enter the number of hours in your normal work week",{"$nulls":9},21]
[22," How many CBSAs in column 1 did you provide services to during this cost reporting period.",{"$nulls":9},22]
[23," List those CBSA code(s) in column 1 serviced during this cost reporting period (line 20 contains the first code).",{"$nulls":9},23]
[]
["PPS ACTIVITY DATA - Applicable for Medicare Services Rendered on or after October 1, 2000"]
[{"$nulls":6},"Full Episodes",null,"LUPA","PEP","TOTAL"]
[{"$nulls":6},"Without","With",null," only"]
[{"$nulls":6},"Outliers","Outliers","Episodes","Episodes","(cols. 1-4)"]
[{"$nulls":6},1,2,3,4,5]
[24,"Skilled Nursing Visits",{"$nulls":9},24]
[25,"Skilled Nursing Visit Charges",{"$nulls":9},25]
[26,"Physical Therapy Visits",{"$nulls":9},26]
[27,"Physical Therapy Visit Charges",{"$nulls":9},27]
[28,"Occupational Therapy Visits",{"$nulls":9},28]
[29,"Occupational Therapy Visit Charges",{"$nulls":9},29]
[30,"Speech Pathology Visits",{"$nulls":9},30]
[31,"Speech Pathology Visit Charges",{"$nulls":9},31]
[32,"Medical Social Service Visits",{"$nulls":9},32]
[33,"Medical Social Service Visit Charges",{"$nulls":9},33]
[34,"Home Health Aide Visits",{"$nulls":9},34]
[35,"Home Health Aide Visit Charges",{"$nulls":9},35]
[36,"Total visits (sum of lines  24, 25, 28, 29, 31 and 34)",{"$nulls":9},36]
[37,"Other Charges",{"$nulls":9},37]
[38,"Total Charges (sum of lines  25, 27, 29, 31, 33, 35 and 37)",{"$nulls":9},38]
[39,"Total Number of Episodes (standard/non outlier)",{"$nulls":9},39]
[40,"Total Number of Outlier Episodes",{"$nulls":9},40]
[" ","Total Non-Routine Medical Supply Charges",{"$nulls":9},41]
[]
["FORM CMS-2540-10 (12.10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4106)"]
["41-310",{"$nulls":9},"Rev. 1"]
{"$rows_empty":193}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S5","index":8,"n_rows":257,"n_cols":18,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",{"$nulls":6},"FORM CMS-2540-10",{"$nulls":9},"2011-02-11"]
["SNF - BASED  RURAL  HEALTH  CLINIC",{"$nulls":5},"PROVIDER NO:",null,null,null,"PERIOD:"]
["FEDERALLY  QUALIFIED  HEALTH",{"$nulls":5},"_______________________________",null,null,null,"FROM____________________",{"$nulls":4},"WORKSHEET"]
["CENTER  STATISTICAL  DATA",{"$nulls":5},"COMPONENT NO:",null,null,null,"TO_______________________",{"$nulls":4},"S - 5"]
[{"$nulls":6},"  ________________________"]
["Check applicable box:",{"$nulls":4},"[     ]  RHC",null,"[     ]  FQHC"]
["PART  I  -  STATISTICAL  DATA"]
[1,"Street:",{"$nulls":11},"County:",null,null,null,1]
[2,"City:",{"$nulls":7},"State:",null,null,null,"Zip Code:",null,null,null,2]
[3,"Designation (for FQHC's only) - Enter \"R\" for rural or \"U\" for urban",{"$nulls":15},3]
["Source of Federal funds:",{"$nulls":12},"Grant Award",null,"Date"]
[4,"Community Health Center (Section 330(d), PHS Act)",{"$nulls":15},4]
[5,"Migrant Health Center (Section 329(d), PHS Act)",{"$nulls":15},5]
[6,"Health Services for the Homeless (Section 340(d), PHS Act)",{"$nulls":15},6]
[7,"Appalachian Regional Commission",{"$nulls":15},7]
[8,"Look - Alikes",{"$nulls":15},8]
[9,"Other (specify)",{"$nulls":15},9]
[10,"Does the facility operate as other than an RHC or FQHC?  If yes, indicate the number of other operations in column 2.",{"$nulls":13},"1","2"]
[null,"(Enter in subscripts of line 10 the type of other operation(s) and the operating hours.)",{"$nulls":15},10]
[null,"NOTE: Line 11 (Clinic) is to be completed regardless of the response to line 10."]
[null,"Facility hours of operations  (1)"]
[null,null,null,"Sunday",null,"Monday",null,"Tuesday",null,"Wednesday",null,"Thursday",null,"Friday",null,"Saturday"]
[null,null,null,"from","to","from","to","from","to","from","to","from","to","from","to","from","to"]
[null,0,null,"1","2","3","4","5","6","7","8","9","10","11","12","13","14"]
[11,"Clinic",{"$nulls":15},11]
[null,"(1)  List hours of operation based on a 24 hour clock.  For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400. "]
[12," Have you received an approval for an exception to the productivity standard?",{"$nulls":15},12]
[13," Is this a consolidated cost report in accordance with CMS Pub 27, section 508D. If yes, enter in column 2 the number of",{"$nulls":15},13]
[null," providers included in this report.  List the names of all providers and numbers on subscripted lines below."]
[14," Provider Name",{"$nulls":9},"NPI Number",{"$nulls":5},14]
[15," Have you provided all or substantially all GME cost.   If yes, enter in column 2 the number of program visits performed as ",{"$nulls":15},15]
[null," Nursing and Allied Health Education Activities."]
[]
[]
[]
["FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS  PUB  15-II,  SECTION  4107)",{"$nulls":16}," "]
["41-311",{"$nulls":16},"Rev. 1"]
[null," "," ",{"$nulls":14}," "]
[null," "," ",{"$nulls":10}," "," ",null,null," "]
[{"$nulls":10}," ",null," "," ",null," ",null," "]
{"$rows_empty":19}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S6","index":9,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11",{"$nulls":4},"FORM CMS-2540-10",null,null,null,"4190 (Cont.)"]
[{"$nulls":8},"  PROVIDER NO.:","  PERIOD:"]
["SKILLED   NURSING   FACILITY   BASED",{"$nulls":8},"  FROM ____________","  WORKSHEET S-6"]
["C.M.H.C.   STATISTICAL  DATA",{"$nulls":7},"  C.M.H.C.  NO.: _______________","  TO _______________"]
[]
[null,"      NUMBER  OF  EMPLOYEES  (FULL TIME EQUIVALENT)"]
[null,"Employment Category:  Enter the number of hours ",{"$nulls":6},"Staff","Contract","Total"]
[null,"         in your normal work week (           ).",{"$nulls":6},"1","2","3"]
[1,"Administrator and Assistant Administrators",{"$nulls":9},1]
[2,"Directors and Assistant Directors",{"$nulls":9},2]
[3,"Other Administrative Personnel",{"$nulls":9},3]
[4,"Directing Nursing Service",{"$nulls":9},4]
[5,"Nursing Supervisor",{"$nulls":9},5]
[6,"Physical Therapy Service",{"$nulls":9},6]
[7,"Physical Therapy Supervisor",{"$nulls":9},7]
[8,"Occupational Therapy Service",{"$nulls":9},8]
[9,"Occupational Therapy Supervisor",{"$nulls":9},9]
[10,"Speech Pathology Service",{"$nulls":9},10]
[11,"Speech Pathology Supervisor",{"$nulls":9},11]
[12,"Medical Social Service",{"$nulls":9},12]
[13,"Medical Social Service Supervisor ",{"$nulls":9},13]
[14,"Respiratory Therapy Service",{"$nulls":9},14]
[15,"Respiratory Therapy Supervisor",{"$nulls":9},15]
[16,"Psychological Service",{"$nulls":9},16]
[17,"Psychological Service Supervisor",{"$nulls":9},17]
[18,{"$nulls":10},18]
[19,{"$nulls":10},19]
{"$rows_empty":8}
["FORM  CMS - 2540-10  ( 12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4108 )"]
["Rev. 1",{"$nulls":10},"41-312"]
{"$rows_empty":22}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S7a","index":10,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[0,3,0,5],[60,3,60,5]],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
["PROSPECTIVE PAYMENT",null,null," PROVIDER  NO.:",null,"PERIOD:",null," WORKSHEET  S-7"]
["FOR SNF",{"$nulls":4},"FROM:  "]
["STATISTICAL DATA",{"$nulls":4},"TO:  "]
[null,"GROUP ",{"$nulls":6},"Days"]
[null,"1",{"$nulls":6},2]
[1,"RUX",{"$nulls":7},1]
[2,"RUL",{"$nulls":7},2]
[3,"RVX",{"$nulls":7},3]
[4,"RVL",{"$nulls":7},4]
[5,"RHX",{"$nulls":7},5]
[6,"RHL",{"$nulls":7},6]
[7,"RMX",{"$nulls":7},7]
[8,"RML",{"$nulls":7},8]
[9,"RLX",{"$nulls":7},9]
[10,"RUC",{"$nulls":7},10]
[11,"RUB",{"$nulls":7},11]
[12,"RUA",{"$nulls":7},12]
[13,"RVC",{"$nulls":7},13]
[14,"RVB",{"$nulls":7},14]
[15,"RVA",{"$nulls":7},15]
[16,"RHC",{"$nulls":7},16]
[17,"RHB",{"$nulls":7},17]
[18,"RHA",{"$nulls":7},18]
[19,"RMC",{"$nulls":7},19]
[20,"RMB",{"$nulls":7},20]
[21,"RMA",{"$nulls":7},21]
[22,"RLB",{"$nulls":7},22]
[23,"RLA",{"$nulls":7},23]
[24,"ES3",{"$nulls":7},24]
[25,"ES2",{"$nulls":7},25]
[26,"ES1",{"$nulls":7},26]
[27,"HE2",{"$nulls":7},27]
[28,"HE1",{"$nulls":7},28]
[29,"HD2",{"$nulls":7},29]
[30,"HD1",{"$nulls":7},30]
[31,"HC2",{"$nulls":7},31]
[32,"HC1",{"$nulls":7},32]
[33,"HB2",{"$nulls":7},33]
[34,"HB1",{"$nulls":7},34]
[35,"LE2",{"$nulls":7},35]
[36,"LE1",{"$nulls":7},36]
[37,"LD2",{"$nulls":7},37]
[38,"LD1",{"$nulls":7},38]
[39,"LC2",{"$nulls":7},39]
[40,"LC1",{"$nulls":7},40]
[41,"LB2",{"$nulls":7},41]
[42,"LB1",{"$nulls":7},42]
[43,"CE2",{"$nulls":7},43]
[44,"CE1",{"$nulls":7},44]
[45,"CD2",{"$nulls":7},45]
[46,"CD1",{"$nulls":7},46]
[47,"CC2",{"$nulls":7},47]
[48,"CC1",{"$nulls":7},48]
[49,"CB2",{"$nulls":7},49]
[50,"CB1",{"$nulls":7},50]
[]
["FORM CMS-2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
[" CMS PUB. 15-II, SECTION 4109)"]
[" ",{"$nulls":8},"Rev.1"]
["02/11",null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
["PROSPECTIVE PAYMENT FOR SNF",null,null,null," PROVIDER  NO.:",null,"PERIOD:",null," WORKSHEET"]
["STATISTICAL DATA",{"$nulls":5},"FROM:  ",null,"S-7"]
[{"$nulls":6},"TO:  "]
[null,"GROUP ",{"$nulls":6},"Days"]
[null,"1",{"$nulls":6},2]
[51,"CA2",{"$nulls":7},51]
[52,"CA1",{"$nulls":7},52]
[53,"SE3",{"$nulls":7},53]
[54,"SE2",{"$nulls":7},54]
[55,"SE1",{"$nulls":7},55]
[56,"SSC",{"$nulls":7},56]
[57,"SSB",{"$nulls":7},57]
[58,"SSA",{"$nulls":7},58]
[59,"IB2",{"$nulls":7},59]
[60,"IB1",{"$nulls":7},60]
[61,"IA2",{"$nulls":7},61]
[62,"IA1",{"$nulls":7},62]
[63,"BB2",{"$nulls":7},63]
[64,"BB1",{"$nulls":7},64]
[65,"BA2",{"$nulls":7},65]
[66,"BA1",{"$nulls":7},66]
[67,"PE2",{"$nulls":7},67]
[68,"PE1",{"$nulls":7},68]
[69,"PD2",{"$nulls":7},69]
[70,"PD1",{"$nulls":7},70]
[71,"PC2",{"$nulls":7},71]
[72,"PC1",{"$nulls":7},72]
[73,"PB2",{"$nulls":7},73]
[74,"PB1",{"$nulls":7},74]
[75,"PA2",{"$nulls":7},75]
[76,"PA1",{"$nulls":7},76]
[99,"AAA",{"$nulls":7},99]
[100,"Total",{"$nulls":7},100]
[]
[null," Enter in column 1 the expense for each category. Enter in column 2 the percentage of total expense for each"]
[null," category to total SNF revenue from Worksheet G-2, Part I, line 6, column 3. Indicate in column 3 \"Y\" for yes or \"N\""]
[null," for no if the spending reflects increases associated with direct patient care and related expenses for each category."]
[null," (See instructions)"]
[{"$nulls":6},"Expenses","Percentage","Y/N"]
[{"$nulls":6},1,2,3]
[101," Staffing",{"$nulls":7},101]
[102," Recruitment",{"$nulls":7},102]
[103," Retention of employees",{"$nulls":7},103]
[104," Training",{"$nulls":7},104]
[105," Other  (Specify)",{"$nulls":7},105]
{"$rows_empty":9}
["FORM CMS-2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
[" CMS PUB. 15-II, SECTION 4109)"]
["Rev. 1",{"$nulls":8},"41-314"]
{"$rows_empty":138}
[{"$nulls":11},"Rev. 1"]

{"sheet":"S8","index":11,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,null,"PROVIDER NO.:",null,"PERIOD:"]
["HOSPICE  IDENTIFICATION  DATA ",null,null,null,"FROM _____________",null,"WORKSHEET  S - 8"]
[null,null,"HOSPICE NO.:"]
[null,null,"_____________",null,"TO ________________"]
[]
["PART I   Enrollment Days Based on Level of Care"]
[null,null,"Title XVIII","Title XIX","Title XVIII","Title XIX"]
[{"$nulls":4},"Unduplicated","Unduplicated","Other","Total"]
[null,null,"Unduplicated","Unduplicated"," Skilled Nursing","Nursing","Unduplicated","Unduplicated"]
[null,"Enrollment Days","Medicare  Days","Medicaid  Days","Facility Days","Facility Days","Days"," Days"]
[null,null,1,2,3,4,5,6]
["1","Continuous Home Care",{"$nulls":6},"1"]
["2","Routine Home Care",{"$nulls":6},"2"]
["3","Inpatient Respite Care ",{"$nulls":6},"3"]
["4","General Inpatient Care",{"$nulls":6},"4"]
["5","Total Hospice Days",{"$nulls":6},"5"]
[]
["PART II  Census Data"]
[{"$nulls":4},"Title XVIII","Title XIX"]
[{"$nulls":4},"Skilled"]
[null,null,"Title XVIII","Title XIX"," Nursing facility","Nursing Facility","Other","Total"]
[null,null,1,2,3,4,5,6]
["6","Number of Patients Receiving Hospice Care",{"$nulls":6},"6"]
[7,"Total Number of Unduplicated Continuous"]
[null," Care Hours Billable to Medicare",{"$nulls":6},"7"]
["8","Average Length of Stay",{"$nulls":6},"8"]
["9","Unduplicated Census Count",{"$nulls":6},"9"]
[]
[]
[]
[]
["FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,  SECTION 4110 )"]
[]
["41-315",{"$nulls":7},"Rev. 1"]
{"$rows_empty":24}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"A","index":12,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[54,0,54,2],[55,0,55,2]],"flags":["formulas_cached_only"]}
["02/11",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:",{"$nulls":4},"."]
[" RECLASSIFICATION  AND  ADJUSTMENT ",{"$nulls":5},"       FROM ________________",null,"          WORKSHEET  A"]
[" OF  TRIAL  BALANCE  OF  EXPENSES",null,null,null,"     _________________",null,"       TO   ________________"]
[{"$nulls":6},"RECLASSI-","RECLASSIFIED","ADJUSTMENTS","NET  EXPENSES"]
[{"$nulls":6},"FICATIONS","TRIAL"," TO  EXPENSES","FOR  COST"]
[null,null,"COST  CENTER","SALARIES","OTHER","TOTAL","Increase/Decrease  ","BALANCE","Increase/Decrease","ALLOCATION"]
[null,null,"   (Omit  Cents)",null,null,"( Col 1 + Col 2 )","( Fr Wkst A-6 )","( Col 3 +/- Col 4 )","( Fr Wkst A-8 )","( Col 5 +/- Col 6 )"]
["A","B","D","1","2","3","4","5","6","7","A"]
["GENERAL  SERVICE  COST  CENTERS"]
["1","00100"," Capital-Related Costs - Building  &  Fixture",{"$nulls":7},"1"]
["2","00200"," Capital-Related Costs - Moveable Equipment",{"$nulls":7},"2"]
["3","00300"," Employee Benefits",{"$nulls":7},"3"]
["4","00400"," Administrative and General",{"$nulls":7},"4"]
["5","00500"," Plant Operation, Maintenance and Repairs",{"$nulls":7},"5"]
["6","00600"," Laundry and Linen Service",{"$nulls":7},"6"]
["7","00700"," Housekeeping",{"$nulls":7},"7"]
["8","00800"," Dietary",{"$nulls":7},"8"]
["9","00900"," Nursing Administration",{"$nulls":7},"9"]
["10","01000"," Central Services and Supply",{"$nulls":7},"10"]
["11","01100"," Pharmacy",{"$nulls":7},"11"]
["12","01200"," Medical Records and Library",{"$nulls":7},"12"]
["13","01300"," Social Service",{"$nulls":7},"13"]
["14","01400"," Nursing and Allied Health Education Activities",{"$nulls":7},"14"]
["15",null," Other General Service Cost ",{"$nulls":7},"15"]
[" DIRECT CARE EXPENDITURES",null,null,"LINES 16 THROUGH 29 ARE RESERVED FOR FUTURE USE"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30,"03000"," Skilled Nursing Facility",{"$nulls":7},30]
[31,"03100"," Nursing Facility ",{"$nulls":7},31]
[32,"03200"," Intermediate Care Facility - Mentally Challenged",{"$nulls":7},32]
[33,null," Other Long Term Care",{"$nulls":7},33]
["ANCILLARY SERVICE COST CENTERS"]
[40,"04000"," Radiology",{"$nulls":7},40]
[41,"04100"," Laboratory",{"$nulls":7},41]
[42,"04200"," Intravenous Therapy",{"$nulls":7},42]
[43,"04300"," Oxygen (Inhalation) Therapy",{"$nulls":7},43]
[44,"04400"," Physical Therapy",{"$nulls":7},44]
[45,"04500"," Occupational Therapy",{"$nulls":7},45]
[46,"04600"," Speech Pathology",{"$nulls":7},46]
[47,"04700"," Electro cardiology",{"$nulls":7},47]
{"$rows_empty":8}
["FORM  CMS-2540-10  ( 12/10  )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4113 )        "]
["Rev. 1",{"$nulls":9},"41-316"]
[]
[]
["4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"02/11"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:",{"$nulls":4},"."]
[" RECLASSIFICATION  AND  ADJUSTMENT ",{"$nulls":5},"       FROM ________________",null,"          WORKSHEET  A"]
[" OF  TRIAL  BALANCE  OF  EXPENSES",null,null,null,"     _________________",null,"       TO   ________________"]
[null,null,"COST  CENTER",null,null,null,"RECLASSI-","RECLASSIFIED","ADJUSTMENTS","NET  EXPENSES"]
[null,null,null,"SALARIES","OTHER","TOTAL","FICATIONS","TRIAL"," TO  EXPENSES","FOR  COST"]
[null,null,"   (Omit  Cents)",null,null,null,"Increase/Decrease ","BALANCE","Increase /Decrease","ALLOCATION"]
[" ",{"$nulls":4},"( Col 1 + Col 2 )","( Fr Wkst A-6 )","( Col 3 +/- Col 4 )","( Fr Wkst A-8 )","( Col 5 +/- Col 6 )"]
["A","B","D","1","2","3","4","5","6","7"]
[48,"04800"," Medical Supplies Charged to Patients",{"$nulls":7},48]
[49,"04900"," Drugs Charged to Patients",{"$nulls":7},49]
[50,"05000"," Dental Care - Title XIX only",{"$nulls":7},50]
[51,"05100"," Support Surfaces",{"$nulls":7},51]
[52,null,"Other Ancillary Service Cost Center",{"$nulls":7},52]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60,"06000"," Clinic",{"$nulls":7},60]
[61,"06100"," Rural Health Clinic (RHC)",{"$nulls":7},61]
[62,6200," FQHC",{"$nulls":7},62]
[63,6300," Other Outpatient Service Cost",{"$nulls":7},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70,"07000"," Home Health Agency Cost",{"$nulls":7},70]
[71,"07100"," Ambulance",{"$nulls":7},71]
[72,"07200"," Nursing and Allied Health Education Activities",{"$nulls":7},72]
[73,"07300"," C.M.H.C.",{"$nulls":7},73]
[74,"07400"," Other Reimbursable Cost",{"$nulls":7},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[80,"08000"," Malpractice Premiums & Paid Losses",{"$nulls":6},"-0-",80]
[81,"08100"," Interest Expense",{"$nulls":6},"- 0 -",81]
[82,"08200"," Utilization Review -- SNF",{"$nulls":6},"- 0 -",82]
[83,"08300"," Hospice",{"$nulls":7},83]
[84,null," Other Special Purpose Cost",{"$nulls":7},84]
["NON REIMBURSABLE  COST  CENTERS"]
[90,"09000"," Gift, Flower, Coffee Shops and Canteen",{"$nulls":7},90]
[91,"09100"," Barber and Beauty Shop",{"$nulls":7},91]
[92,"09200"," Physicians' Private Offices",{"$nulls":7},92]
[93,"09300"," Nonpaid Workers",{"$nulls":7},93]
[94,"09400"," Patients Laundry",{"$nulls":7},94]
[95,null," Other Non Reimbursable Cost ",{"$nulls":7},95]
[100,null," TOTAL",{"$nulls":7},100]
{"$rows_empty":7}
["FORM  CMS-2540-10  ( 12/10  )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4113 )        "]
["41-317",{"$nulls":9},"Rev. 1"]
{"$rows_empty":156}
[{"$nulls":11},"Rev. 1"]

{"sheet":"A6","index":13,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",{"$nulls":4},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":5},"PROVIDER  NO:",null,"PERIOD:"]
[null,"RECLASSIFICATIONS",{"$nulls":5},"FROM _________________________",null,"   WORKSHEET  A-6"]
[{"$nulls":5}," __________________________________",null,"TO __________________"]
[null,"EXPLANATION  OF  ","CODE",null,"I N C R E A S E",null,null,null,"D E C R E A S E"]
[null," RECLASSIFICATION  ENTRY  ","(1)","COST CENTER","LN NO.","SALARY","NON SALARY","COST CENTER","LN NO.","SALARY","NON SALARY"]
[null,null,"1","2","3","4","5","6","7","8","9"]
["  1",{"$nulls":10},"  1"]
["  2",{"$nulls":10},"  2"]
["  3",{"$nulls":10},"  3"]
["  4",{"$nulls":10},"  4"]
["  5",{"$nulls":10},"  5"]
["  6",{"$nulls":10},"  6"]
["  7",{"$nulls":10},"  7"]
["  8",{"$nulls":10},"  8"]
["  9",{"$nulls":10},"  9"]
[" 10",{"$nulls":10}," 10"]
[" 11",{"$nulls":10}," 11"]
[" 12",{"$nulls":10}," 12"]
[" 13",{"$nulls":10}," 13"]
[" 14",{"$nulls":10}," 14"]
[" 15",{"$nulls":10}," 15"]
[" 16",{"$nulls":10}," 16"]
[" 17",{"$nulls":10}," 17"]
[" 18",{"$nulls":10}," 18"]
[" 19",{"$nulls":10}," 19"]
[" 20",{"$nulls":10}," 20"]
[" 21",{"$nulls":10}," 21"]
[" 22",{"$nulls":10}," 22"]
[" 23",{"$nulls":10}," 23"]
[" 24",{"$nulls":10}," 24"]
[" 25",{"$nulls":10}," 25"]
[" 26",{"$nulls":10}," 26"]
[" 27",{"$nulls":10}," 27"]
[" 28",{"$nulls":10}," 28"]
[" 29",{"$nulls":10}," 29"]
[" 30",{"$nulls":10}," 30"]
[" 31",{"$nulls":10}," 31"]
[" 32",{"$nulls":10}," 32"]
[" 33",{"$nulls":10}," 33"]
[" 34",{"$nulls":10}," 34"]
[" 35",{"$nulls":10}," 35"]
[36,"TOTAL  RECLASSIFICATIONS  (Sum of column 4 and 5 must ",{"$nulls":9},36]
[null,"              equal total line - sum of column 8 and 9",null,null,"(2)"]
["   (1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.",{"$nulls":5},"   (2) Transfer to Worksheet A, column 4, line as appropriate."]
["FORM CMS-2540-10 ( 10/12  )   (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4114 )      "]
["Rev. 1",{"$nulls":10},"41-318"]
{"$rows_empty":12}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"A7","index":14,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":5},"PROVIDER NO.:",null,"PERIOD:"]
[null,"RECONCILIATION OF CAPITAL COSTS CENTERS",{"$nulls":5},"FROM _________",null,"WORKSHEET A-7"]
[{"$nulls":5}," _____________",null,"TO __________"]
[" ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES"]
[{"$nulls":5},"Acquisitions",null,"Disposals",null,"Fully"]
[null,null,null,"Beginning",null,null,null,"and","Ending","Depreciated"]
[null,"Description",null,"Balances","Purchases","Donation","Total","Retirements","Balance","Assets"]
[null,null,null,"1","2","3","4","5","6","7"]
[1,"Land",{"$nulls":8},1]
[2,"Land Improvements",{"$nulls":8},2]
[3,"Buildings and Fixtures",{"$nulls":8},3]
[4,"Building Improvements",{"$nulls":8},4]
[5,"Fixed Equipment",{"$nulls":8},5]
[6,"Movable Equipment",{"$nulls":8},6]
[7,"Subtotal (sum of lines 1-6)",{"$nulls":8},7]
[8,"Reconciling Items",{"$nulls":8},8]
[9,"Total (line 6 minus line 8)",{"$nulls":8},9]
{"$rows_empty":25}
["FORM CMS-2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4015)"]
["41-319",{"$nulls":9},"Rev. 1"]
{"$rows_empty":14}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"A8","index":15,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11","FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[null,null," PROVIDER  NO.",null," PERIOD:"]
[null,"ADJUSTMENTS  TO  EXPENSES",null,null,"  FROM ____________",null,"     WORKSHEET  A-8"]
[null,null,"________________",null,"  TO _____________"]
[null,null,"(2)",null,"       EXPENSE  CLASSIFICATION  ON"]
[null,"                     (1)","BASIS  FOR",null,"      WORKSHEET  A,  TO / FROM  WHICH"]
[null,"DESCRIPTION","ADJUST-","AMOUNT","      THE AMOUNT IS TO BE ADJUSTED\\"]
[null,null,"MENT",null,null,"COST  CENTER",null,"LINE  NO."]
[null,1,2,3,null,4,null,5]
["  1"," Investment income on restricted funds",{"$nulls":6},"  1"]
[null," (Chapter 2)"]
["  2"," Trade, quantity and time discounts",{"$nulls":6},"  2"]
[null," on purchases  (Chapter 8)"]
["  3"," Refunds and rebates of expenses ",{"$nulls":6},"  3"]
[null," Chapter 8)"]
["  4"," Rental of provider space by suppliers",{"$nulls":6},"  4"]
[null," Chapter 8)"]
["  5"," Telephone services (pay stations",{"$nulls":6},"  5"]
[null," excluded)  (Chapter 21)"]
["  6"," Television and radio service ",{"$nulls":6},"  6"]
[null," (Chapter 21)"]
["  7"," Parking lot  (chapter 21)",{"$nulls":6},"  7"]
[]
["  8"," Remuneration applicable to provider-","Worksheet",{"$nulls":5},"  8"]
[null," based physician adjustment","A-8-2"]
["  9"," Home office costs  (chapter 21)",{"$nulls":6},"  9"]
[]
[" 10"," Sale of scrap, waste, etc.",{"$nulls":6}," 10"]
[null," (Chapter23)"]
[" 11"," Nonallowable costs related to certain",{"$nulls":6}," 11"]
[null," Capital expenditures  (chapter 24)"]
[" 12"," Adjustment resulting from transactions","Worksheet",{"$nulls":5}," 12"]
[null," with related organizations  (chapter 10)","A-8-1"]
[" 13"," Laundry and Linen service ",{"$nulls":6}," 13"]
[]
[" 14"," Revenue - Employee meals",{"$nulls":6}," 14"]
[]
[" 15"," Cost of meals - Guests ",{"$nulls":6}," 15"]
[]
[" 16"," Sale of medical supplies to other than patients",{"$nulls":6}," 16"]
[]
[" 17"," Sale of drugs to other than patients",{"$nulls":6}," 17"]
[]
[" 18"," Sale of medical records and abstracts",{"$nulls":6}," 18"]
[]
[" 19"," Vending machines",{"$nulls":6}," 19"]
[]
[" 20"," Income from imposition of interest,",{"$nulls":6}," 20"]
[" "," finance or penalty charges  (chapter 21)",{"$nulls":6}," "]
[" 21"," Interest expense on Medicare overpayments",{"$nulls":6}," 21"]
[null," and borrowings to repay Medicare overpayments"]
[22," Depreciation--buildings and fixtures",null,null,null,"Capital Related Cost- Building",null,1,22]
[]
[23," Depreciation--movable equipment",null,null,null,"Capital Related Cost-Movable",null,null,23]
[{"$nulls":5},"Equipment",null,"2"]
[24," Other Adjustment",{"$nulls":6},24]
[]
[100," TOTAL (Sum of lines 1 through 24)",{"$nulls":6},100]
[null," (Transfer to Worksheet A, col. 6, line 100)"]
[" "]
["     (2)  Basis for adjustment",null,"A.  Costs--if costs, including applicable overhead, can be determined."]
[null,null,"B.  Amount Received--if cost cannot be determined."]
["FORM CMS-2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,"]
[" SECTION 4116 )"]
["Rev. 1",{"$nulls":7},"41-320"]
{"$rows_empty":191}
[{"$nulls":11},"Rev. 1"]

{"sheet":"A81","index":16,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
["  STATEMENT  OF  COSTS",null,null,null," PROVIDER NO:",null," PERIOD:"]
[" OF  SERVICES  FROM",{"$nulls":5},"  FROM _____________",null,"  WORKSHEET A-8-1"]
["RELATED  ORGANIZATIONS",null,null,null,"___________________",null,"  TO ___________"]
[" Part I Costs incurred and adjustments required as a result of transactions with related"]
[null,null,"organizations.  Location and amount included on Worksheet A, Column 5",{"$nulls":4},"     Amount",null,"Adjustments"]
[{"$nulls":7},"   Allowable",null,"(Col 4 minus"]
[null,"Line No.","Cost Center","Expense Items",null,null,"Amount","     In  Cost",null,"Col 5)"]
[null," 1","2",3,null,null,"4",5,null,"6"]
[1,{"$nulls":9},1]
[2,{"$nulls":9},2]
[3,{"$nulls":9},3]
[4,{"$nulls":9},4]
[5,{"$nulls":9},5]
[6,{"$nulls":9},6]
[7,{"$nulls":9},7]
[8,{"$nulls":9},8]
[9,{"$nulls":9},9]
[100," TOTALS (Sum of lines 1-9) ",{"$nulls":8},100]
[null," Transfer column  6, line 100 to Worksheet A-8, column  3, line 12)"]
["Part II Interrelationship to related organization(s):"]
[]
[null,"  The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act,  requires that you"]
[null,"  furnish the information requested under Part II of this worksheet."]
[]
[null,"   This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable"]
[null,"   to services, facilities and supplies furnished by organizations related to you by common ownership or control, represent reasonable"]
[null,"   costs as determined under section 1861 of the Social Security Act.  If you do not provide all or any part of the requested information,"]
[null,"   the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII."]
[{"$nulls":5},"Related Organization(s)"]
["(1)",null,null,"Percentage",null,null,null,"   Percentage"]
["   Symbol",null,"Name","of",null,"Name",null,"        of",null,"Type  of"]
[null,null,null,"Ownership",null,null,null,"    Ownership",null,"Business"]
[null,"1","2","         3",null,null,"4","          5",null,"6"]
["1",{"$nulls":9},"1"]
["2",{"$nulls":9},"2"]
["3",{"$nulls":9},"3"]
["4",{"$nulls":9},"4"]
["5",{"$nulls":9},"5"]
["6",{"$nulls":9},"6"]
["7",{"$nulls":9},"7"]
["8",{"$nulls":9},"8"]
["9",{"$nulls":9},"9"]
["10",{"$nulls":9},"10"]
["(1) Use the following symbols to indicate interrelationship to related organizations:"]
[null,"A. Individual has financial interest (stockholder, partner, etc.)",null,null,null,"     E. Individual is director, officer, administrator or key person of provider"]
[null,"     in both related organization and in provider.",null,null,null,"          and related organization."]
[null,"B. Corporation, partnership or other organization has financial",null,null,null,"     F. Director, officer, administrator or key person of related organization"]
[null,"      interest in provider.",null,null,null,"           or relative of such person has financial interest in provider."]
[null,"C. Provider has financial interest in corporation, partnership,",null,null,null,"     G. Other (financial or non-financial) specify ______________________"]
[null,"       or other organization.",null,null,null,"            _____________________________________________________"]
[null,"D. Director, officer, administrator or key person of provider or"]
[null,"     relative of such person has financial interest in related"]
[null,"      organization."]
["FORM CMS - 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15-II SECTION 4117 )"]
[]
["41-321",{"$nulls":9},"Rev. 1"]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"A82","index":17,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11",null,null,"FORM CMS-2540-10",{"$nulls":4},"4139 (CONT.)"]
[{"$nulls":4},"    PROVIDER NO:",null,"    PERIOD:"]
["PROVIDER-BASED  PHYSICIANS  ADJUSTMENTS",{"$nulls":5},"    FROM ______________________",null,"    WORKSHEET  A-8-2"]
[{"$nulls":4},"________________________",null,"    TO _________________"]
[null,null,"Cost  Center /",{"$nulls":4},"Physician /",null,"5  Percent  of"]
[null,"Wkst  A","Physician","Total","Professional","Provider","R C E","Provider","Unadjusted","Unadjusted"]
[null,"Line No.","Identifier","Remuneration","Component","Component","Amount","Component","R C E   Limit","R C E   Limit"]
[{"$nulls":7},"Hours"]
[null,"1","2","3","4","5","6","7","8","9"]
[1,{"$nulls":9},1]
[2,{"$nulls":9},2]
[3,{"$nulls":9},3]
[4,{"$nulls":9},4]
[5,{"$nulls":9},5]
[6,{"$nulls":9},6]
[7,{"$nulls":9},7]
[8,{"$nulls":9},8]
[9,{"$nulls":9},9]
[10,{"$nulls":9},10]
[11,{"$nulls":9},11]
[100,null,"TOTAL",{"$nulls":7},100]
[]
[null,null,null,"Cost  of","Provider","Physician","Provider"]
[null,null,"Cost  Center /","Memberships","Component","Cost  of","Component","Adjusted","R C E"]
[null,"Wkst  A","Physician","&  Continuing","Share of","Malpractice","Share  of","R C E   Limit","Disallowance","Adjustment"]
[null,"Line No.","Identifier","Education","Col 12","Insurance","Column  14"]
[null,"10","11","12","13","14","15","16","17","18"]
[1,{"$nulls":9},1]
[2,{"$nulls":9},2]
[3,{"$nulls":9},3]
[4,{"$nulls":9},4]
[5,{"$nulls":9},5]
[6,{"$nulls":9},6]
[7,{"$nulls":9},7]
[8,{"$nulls":9},8]
[9,{"$nulls":9},9]
[10,{"$nulls":9},10]
[11,{"$nulls":9},11]
[100,null,"TOTAL",{"$nulls":7},100]
["FORM CMS-2540-10 ( 12/10  )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4118 )"]
[]
["Rev. 1",{"$nulls":9},"41-322"]
{"$rows_empty":17}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"B","index":18,"n_rows":360,"n_cols":13,"rows_kept":360,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null,"               PART  I"]
[{"$nulls":6},"NET   EXPENSES"," CAP.  REL. "," CAP.  REL. ","EMPLOYEE",null,"ADMINIS-"]
[{"$nulls":6},"FOR   COST","BUILDINGS","MOVABLE","BENEFITS","SUBTOTAL","TRATIVE"]
[null,null,"COST  CENTER",null,null,null,"ALLOCATION","&  FIXTURES","EQUIPMENT",null,"( Sum of ","&  GENERAL"]
[null,null,"   (Omit  Cents)",null,null,null,"Fr. Wkst A,  Col 7",null,null,null," Columns  0 - 3 )"]
[{"$nulls":6},"0","1","2","3","3 A","4"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Capital-Related Costs - Building  &  Fixture",{"$nulls":10},"1"]
["2"," Capital-Related Costs - Moveable Equipment",{"$nulls":10},"2"]
["3"," Employee Benefits",{"$nulls":10},"3"]
["4"," Administrative and General",{"$nulls":10},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":10},"5"]
["6"," Laundry and Linen Service",{"$nulls":10},"6"]
["7"," Housekeeping",{"$nulls":10},"7"]
["8"," Dietary",{"$nulls":10},"8"]
["9"," Nursing Administration",{"$nulls":10},"9"]
["10"," Central Services and Supply",{"$nulls":10},"10"]
["11"," Pharmacy",{"$nulls":10},"11"]
["12"," Medical Records and Library",{"$nulls":10},"12"]
["13"," Social Service",{"$nulls":10},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":10},"14"]
["15"," Other General Service Cost ",{"$nulls":10},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":10},30]
[31," Nursing Facility ",{"$nulls":10},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":10},32]
[33," Other Long Term Care",{"$nulls":10},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":10},40]
[41," Laboratory",{"$nulls":10},41]
[42," Intravenous Therapy",{"$nulls":10},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":10},43]
[44," Physical Therapy",{"$nulls":10},44]
[45," Occupational Therapy",{"$nulls":10},45]
[46," Speech Pathology",{"$nulls":10},46]
[47," Electro cardiology",{"$nulls":10},47]
[48," Medical Supplies Charged to Patients",{"$nulls":10},48]
[49," Drugs Charged to Patients",{"$nulls":10},49]
[50," Dental Care - Title XIX only",{"$nulls":10},50]
[51," Support Surfaces",{"$nulls":10},51]
[52," Other Ancillary Service Cost Center",{"$nulls":10},52]
[]
[]
[]
[]
[]
[" FORM  CMS-2540-10  ( 12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120 )          "]
[]
["41-323",{"$nulls":11},"Rev. 1"]
["2011-02-11",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null,"               PART  I"]
[{"$nulls":6},"NET   EXPENSES"," CAP.  REL. "," CAP.  REL. ","EMPLOYEE",null,"ADMINIS-"]
[{"$nulls":6},"FOR   COST","BUILDINGS","MOVABLE","BENEFITS","SUBTOTAL","TRATIVE"]
[null,null,"COST  CENTER",null,null,null,"ALLOCATION","&  FIXTURES","EQUIPMENT",null,"( Sum of ","&  GENERAL"]
[" ",null,"   (Omit  Cents)",null,null,null,"Fr. Wkst A,  Col 7",null,null,null," Columns  0 - 3 )"]
[{"$nulls":6},"0","1","2","3","3 A","4"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":10},60]
[61," Rural Health Clinic (RHC)",{"$nulls":10},61]
[62," FQHC",{"$nulls":10},62]
[63," Other Outpatient Service Cost",{"$nulls":10},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":10},70]
[71," Ambulance",{"$nulls":10},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":10},72]
[73," C.M.H.C.",{"$nulls":10},73]
[74," Other Reimbursable Cost",{"$nulls":10},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":10},83]
[84," Other Special Purpose Cost",{"$nulls":10},84]
[89," Subtotals",{"$nulls":10},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":10},90]
[91," Barber and Beauty Shop",{"$nulls":10},91]
[92," Physicians' Private Offices",{"$nulls":10},92]
[93," Nonpaid Workers",{"$nulls":10},93]
[94," Patients Laundry",{"$nulls":10},94]
[95," Other Non Reimbursable Cost ",{"$nulls":10},95]
[98," Cross Foot Adjustments",{"$nulls":10},98]
[99," Negative Cost Center",{"$nulls":10},99]
[100," Total",{"$nulls":10},100]
{"$rows_empty":11}
[" FORM  CMS-2540-10  ( 12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120 )          "]
[]
["Rev. 1",{"$nulls":11},"41-324"]
[]
[]
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"          WORKSHEET   B"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null,"               PART  I"]
[{"$nulls":5},"PLANT  OPER.","LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY"]
[{"$nulls":5},"MAINTENANCE","&  LINEN","KEEPING",null,"ADMINIS-","SERVICES"]
[null,null,"COST  CENTER",null,null,"&  REPAIRS","SERVICE",null,null,"TRATION","& SUPPLY"]
[null,null,"   (Omit  Cents)"]
[{"$nulls":5},"5","6","7","8","9","10","11"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Capital-Related Costs - Building  &  Fixture",{"$nulls":10},"1"]
["2"," Capital-Related Costs - Moveable Equipment",{"$nulls":10},"2"]
["3"," Employee Benefits",{"$nulls":10},"3"]
["4"," Administrative and General",{"$nulls":10},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":10},"5"]
["6"," Laundry and Linen Service",{"$nulls":10},"6"]
["7"," Housekeeping",{"$nulls":10},"7"]
["8"," Dietary",{"$nulls":10},"8"]
["9"," Nursing Administration",{"$nulls":10},"9"]
["10"," Central Services and Supply",{"$nulls":10},"10"]
["11"," Pharmacy",{"$nulls":10},"11"]
["12"," Medical Records and Library",{"$nulls":10},"12"]
["13"," Social Service",{"$nulls":10},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":10},"14"]
["15"," Other General Service Cost ",{"$nulls":10},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":10},30]
[31," Nursing Facility ",{"$nulls":10},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":10},32]
[33," Other Long Term Care",{"$nulls":10},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":10},40]
[41," Laboratory",{"$nulls":10},41]
[42," Intravenous Therapy",{"$nulls":10},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":10},43]
[44," Physical Therapy",{"$nulls":10},44]
[45," Occupational Therapy",{"$nulls":10},45]
[46," Speech Pathology",{"$nulls":10},46]
[47," Electro cardiology",{"$nulls":10},47]
[48," Medical Supplies Charged to Patients",{"$nulls":10},48]
[49," Drugs Charged to Patients",{"$nulls":10},49]
[50," Dental Care - Title XIX only",{"$nulls":10},50]
[51," Support Surfaces",{"$nulls":10},51]
[52," Other Ancillary Service Cost Center",{"$nulls":10},52]
[]
[]
[]
[]
[]
[" FORM  CMS-2540-10  ( 12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120 )          "]
[]
[]
["41-325",{"$nulls":11},"Rev. 1"]
[]
["2011-02-11",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null,"               PART  I"]
[{"$nulls":5},"PLANT  OPER.","LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY"]
[{"$nulls":5},"MAINTENANCE","&  LINEN","KEEPING",null,"ADMINIS-","SERVICES"]
[null,null,"COST  CENTER",null,null,"&  REPAIRS","SERVICE",null,null,"TRATION","& SUPPLY"]
[null,null,"   (Omit  Cents)"]
[{"$nulls":5},"5","6","7","8","9","10","11"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":10},60]
[61," Rural Health Clinic (RHC)",{"$nulls":10},61]
[62," FQHC",{"$nulls":10},62]
[63," Other Outpatient Service Cost",{"$nulls":10},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":10},70]
[71," Ambulance",{"$nulls":10},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":10},72]
[73," C.M.H.C.",{"$nulls":10},73]
[74," Other Reimbursable Cost",{"$nulls":10},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":10},83]
[84," Other Special Purpose Cost",{"$nulls":10},84]
[89," Subtotals",{"$nulls":10},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":10},90]
[91," Barber and Beauty Shop",{"$nulls":10},91]
[92," Physicians' Private Offices",{"$nulls":10},92]
[93," Nonpaid Workers",{"$nulls":10},93]
[94," Patients Laundry",{"$nulls":10},94]
[95," Other Non Reimbursable Cost ",{"$nulls":10},95]
[98," Cross Foot Adjustments",{"$nulls":10},98]
[99," Negative Cost Center",{"$nulls":10},99]
[100," Total",{"$nulls":10},100]
{"$rows_empty":11}
[" FORM  CMS-2540-10  ( 12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120 )          "]
[]
["Rev. 1",{"$nulls":11},"41-326"]
[]
[]
[]
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null,"               PART  I"]
[{"$nulls":5},"MEDICAL","SOCIAL","NURSING &","OTHER",null,"POST"]
[null,null,"COST  CENTER",null,null,"RECORDS","SERVICE","ALLIED","GENERAL","SUBTOTAL","STEP-DOWN","TOTAL"]
[null,null,"   (Omit  Cents)",null,null,"&  LIBRARY",null,"HEALTH","SERVICE ",null,"ADJUSTMENTS"]
[{"$nulls":7},"EDUCATION","COST"]
[{"$nulls":5},"12","13","14","15","16","17","18"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Capital-Related Costs - Building  &  Fixture",{"$nulls":10},"1"]
["2"," Capital-Related Costs - Moveable Equipment",{"$nulls":10},"2"]
["3"," Employee Benefits",{"$nulls":10},"3"]
["4"," Administrative and General",{"$nulls":10},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":10},"5"]
["6"," Laundry and Linen Service",{"$nulls":10},"6"]
["7"," Housekeeping",{"$nulls":10},"7"]
["8"," Dietary",{"$nulls":10},"8"]
["9"," Nursing Administration",{"$nulls":10},"9"]
["10"," Central Services and Supply",{"$nulls":10},"10"]
["11"," Pharmacy",{"$nulls":10},"11"]
["12"," Medical Records and Library",{"$nulls":10},"12"]
["13"," Social Service",{"$nulls":10},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":10},"14"]
["15"," Other General Service Cost ",{"$nulls":10},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":10},30]
[31," Nursing Facility ",{"$nulls":10},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":10},32]
[33," Other Long Term Care",{"$nulls":10},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":10},40]
[41," Laboratory",{"$nulls":10},41]
[42," Intravenous Therapy",{"$nulls":10},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":10},43]
[44," Physical Therapy",{"$nulls":10},44]
[45," Occupational Therapy",{"$nulls":10},45]
[46," Speech Pathology",{"$nulls":10},46]
[47," Electro cardiology",{"$nulls":10},47]
[48," Medical Supplies Charged to Patients",{"$nulls":10},48]
[49," Drugs Charged to Patients",{"$nulls":10},49]
[50," Dental Care - Title XIX only",{"$nulls":10},50]
[51," Support Surfaces",{"$nulls":10},51]
[52," Other Ancillary Service Cost Center",{"$nulls":10},52]
[]
[]
[]
[" FORM  CMS-2540-10  ( 12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120 )          "]
[]
["41-327",{"$nulls":10},"Rev. 1"]
[]
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null,"               PART  I"]
[{"$nulls":5},"MEDICAL","SOCIAL","NURSING &","OTHER",null,"POST"]
[{"$nulls":5},"RECORDS","SERVICE","ALLIED","GENERAL","SUBTOTAL","STEP-DOWN","TOTAL"]
[null,null,"COST  CENTER",null,null,"&  LIBRARY",null,"HEALTH","SERVICE ",null,"ADJUSTMENTS"]
[null,null,"   (Omit  Cents)",{"$nulls":4},"EDUCATION","COST"]
[{"$nulls":5},"12","13","14","15","16","17","18"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":10},60]
[61," Rural Health Clinic (RHC)",{"$nulls":10},61]
[62,"FQHC",{"$nulls":10},62]
[63," Other Outpatient Service Cost",{"$nulls":10},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":10},70]
[71," Ambulance",{"$nulls":10},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":10},72]
[73," C.M.H.C.",{"$nulls":10},73]
[74," Other Reimbursable Cost",{"$nulls":10},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":10},83]
[84," Other Special Purpose Cost",{"$nulls":10},84]
[89," Subtotals",{"$nulls":10},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":10},90]
[91," Barber and Beauty Shop",{"$nulls":10},91]
[92," Physicians' Private Offices",{"$nulls":10},92]
[93," Nonpaid Workers",{"$nulls":10},93]
[94," Patients Laundry",{"$nulls":10},94]
[95," Other Non Reimbursable Cost ",{"$nulls":10},95]
[98," Cross Foot Adjustments",{"$nulls":10},98]
[99," Negative Cost Center",{"$nulls":10},99]
[100," Total",{"$nulls":10},100]
[]
[" FORM  CMS-2540-10  ( 12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120 )          "]
[]
["Rev. 1",{"$nulls":11},"41-328"]
{"$rows_empty":63}
[" "]

{"sheet":"B-1","index":19,"n_rows":370,"n_cols":13,"rows_kept":370,"cut":false,"hidden":false,"merged":[[264,10,264,11],[108,10,108,11],[161,10,161,11],[162,10,162,11],[213,10,213,11],[3,10,3,11],[55,10,55,11],[56,10,56,11],[107,10,107,11],[214,10,214,11],[263,10,263,11]],"flags":["formulas_cached_only"]}
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"WORKSHEET  B - 1"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null," "]
[{"$nulls":7}," CAP.  REL. "," CAP.  REL. ","EMPLOYEE","RECONCIL-","ADMINIS-"]
[{"$nulls":7},"BUILDINGS","MOVABLE","BENEFITS","IATION","TRATIVE"]
[null,null,"COST  CENTER",{"$nulls":4},"&  FIXTURES","EQUIPMENT",null,null,"&  GENERAL"]
[null,null,"   (Omit  Cents)",{"$nulls":4},"( Square","( Square","(Gross",null,"(Accumulated"]
[{"$nulls":7},"Feet)","Feet)","Salaries)",null,"Cost)"]
[{"$nulls":6},"0","1","2","3","4 A","4"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Capital-Related Costs - Building  &  Fixture",{"$nulls":10},"1"]
["2"," Capital-Related Costs - Moveable Equipment",{"$nulls":10},"2"]
["3"," Employee Benefits",{"$nulls":10},"3"]
["4"," Administrative and General",{"$nulls":10},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":10},"5"]
["6"," Laundry and Linen Service",{"$nulls":10},"6"]
["7"," Housekeeping",{"$nulls":10},"7"]
["8"," Dietary",{"$nulls":10},"8"]
["9"," Nursing Administration",{"$nulls":10},"9"]
["10"," Central Services and Supply",{"$nulls":10},"10"]
["11"," Pharmacy",{"$nulls":10},"11"]
["12"," Medical Records and Library",{"$nulls":10},"12"]
["13"," Social Service",{"$nulls":10},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":10},"14"]
["15"," Other General Service Cost ",{"$nulls":10},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":10},30]
[31," Nursing Facility",{"$nulls":10},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":10},32]
[33," Other Long Term care",{"$nulls":10},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":10},40]
[41," Laboratory",{"$nulls":10},41]
[42," Intravenous Therapy",{"$nulls":10},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":10},43]
[44," Physical Therapy",{"$nulls":10},44]
[45," Occupational Therapy",{"$nulls":10},45]
[46," Speech Pathology",{"$nulls":10},46]
[47," Electro cardiology",{"$nulls":10},47]
[48," Medical Supplies Charged to Patients",{"$nulls":10},48]
[49," Drugs Charged to Patients",{"$nulls":10},49]
[50," Dental Care - Title XIX only",{"$nulls":10},50]
[51," Support Surfaces",{"$nulls":10},51]
[52," Other Ancillary Service Cost Center",{"$nulls":10},52]
[]
[]
[]
[]
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120)          "]
["41-329",{"$nulls":11},"Rev. 1"]
[]
[]
["2011-02-11",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"WORKSHEET  B - 1"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null," "]
[{"$nulls":7}," CAP.  REL. "," CAP.  REL. ","EMPLOYEE",null,"ADMINIS-"]
[{"$nulls":7},"BUILDINGS","MOVABLE","BENEFITS","RECONCIL-","TRATIVE"]
[" ",null,"COST  CENTER",{"$nulls":4},"&  FIXTURES","EQUIPMENT",null,"IATION","&  GENERAL"]
[null,null,"   (Omit  Cents)",{"$nulls":4},"( Square","( Square","(Gross",null,"(Accumulated"]
[{"$nulls":7},"Feet)","Feet)","Salaries)",null,"Cost)"]
[{"$nulls":6},"0","1","2","3","4 A","4"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":10},60]
[61," Rural Health Clinic (RHC)",{"$nulls":10},61]
[62," FQHC",{"$nulls":10},62]
[63," Other Outpatient Service Cost",{"$nulls":10},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":10},70]
[71," Ambulance",{"$nulls":10},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":10},72]
[73," C.M.H.C.",{"$nulls":10},73]
[74," Other Reimbursable Cost",{"$nulls":10},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":10},83]
[84," Other Special Purpose Cost",{"$nulls":10},84]
[89," Subtotals",{"$nulls":10},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":10},90]
[91," Barber and Beauty Shop",{"$nulls":10},91]
[92," Physicians' Private Offices",{"$nulls":10},92]
[93," Nonpaid Workers",{"$nulls":10},93]
[94," Patients Laundry",{"$nulls":10},94]
[95," Other Non Reimbursable Cost ",{"$nulls":10},95]
[98," Cross Foot Adjustment",{"$nulls":10},98]
[99," Negative Cost Center",{"$nulls":10},99]
[102," Cost to Be Allocated (Per Worksheet B, Part I) ",{"$nulls":10},102]
[103," Unit Cost Multiplier (Worksheet B, Part I)",{"$nulls":10},103]
[104," Cost to Be Allocated (Per Worksheet B, Part II) ",{"$nulls":10},104]
[105," Unit Cost Multiplier (Worksheet B, Part II)",{"$nulls":10},105]
{"$rows_empty":8}
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120)          "]
["Rev. 1",{"$nulls":11},"41-330"]
[]
[]
[]
[]
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"WORKSHEET  B - 1"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null," "]
[{"$nulls":5},"PLANT  OPER.","LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY"]
[{"$nulls":5},"MAINTENANCE","&  LINEN","KEEPING",null,"ADMINIS-","SERVICES"]
[null,null,"COST  CENTER",null,null,"&  REPAIRS","SERVICE",null,null,"TRATION","& SUPPLY"]
[null,null,"   (Omit  Cents)",null,null,"(Square","(Pounds of","(Hours of","(Meals","(Direct","(Costed","(Costed"]
[{"$nulls":5},"Feet)","Laundry)","Service)","Served)","Nrsing  Hrs.)","Requisitions)","Requisitions)"]
[{"$nulls":5},"5","6","7","8","9","10","11"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Captial-Related Costs - Building  &  Fixture",{"$nulls":10},"1"]
["2"," Capital-Related Costs - Moveable Equipment",{"$nulls":10},"2"]
["3"," Employee Benefits",{"$nulls":10},"3"]
["4"," Administrative and General",{"$nulls":10},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":10},"5"]
["6"," Laundry and Linen Service",{"$nulls":10},"6"]
["7"," Housekeeping",{"$nulls":10},"7"]
["8"," Dietary",{"$nulls":10},"8"]
["9"," Nursing Administration",{"$nulls":10},"9"]
["10"," Central Services and Supply",{"$nulls":10},"10"]
["11"," Pharmacy",{"$nulls":10},"11"]
["12"," Medical Records and Library",{"$nulls":10},"12"]
["13"," Social Service",{"$nulls":10},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":10},"14"]
["15"," Other General Service Cost ",{"$nulls":10},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":10},30]
[31," Nursing Facility",{"$nulls":10},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":10},32]
[33," Other Long Term care",{"$nulls":10},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":10},40]
[41," Laboratory",{"$nulls":10},41]
[42," Intravenous Therapy",{"$nulls":10},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":10},43]
[44," Physical Therapy",{"$nulls":10},44]
[45," Occupational Therapy",{"$nulls":10},45]
[46," Speech Pathology",{"$nulls":10},46]
[47," Electro cardiology",{"$nulls":10},47]
[48," Medical Supplies Charged to Patients",{"$nulls":10},48]
[49," Drugs Charged to Patients",{"$nulls":10},49]
[50," Dental Care - Title XIX only",{"$nulls":10},50]
[51," Support Surfaces",{"$nulls":10},51]
[52," Other Ancillary Service Cost Center",{"$nulls":10},52]
[]
[]
[]
[]
[]
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120)          "]
["41-331",{"$nulls":11},"Rev. 1"]
[]
[]
["2011-02-11",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"WORKSHEET  B - 1"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null," "]
[{"$nulls":5},"PLANT  OPER.","LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY"]
[{"$nulls":5},"MAINTENANCE","&  LINEN","KEEPING",null,"ADMINIS-","SERVICES"]
[null,null,"COST  CENTER",null,null,"&  REPAIRS","SERVICE",null,null,"TRATION","& SUPPLY"]
[null,null,"   (Omit  Cents)",null,null,"(Square","(Pounds of","(Hours of","(Meals","(Direct","(Costed","(Costed"]
[{"$nulls":5},"Feet)","Laundry)","Service)","Served)","Nrsing  Hrs.)","Requisitions)","Requisitions)"]
[{"$nulls":5},"5","6","7","8","9","10","11"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":10},60]
[61," Rural Health Clinic (RHC)",{"$nulls":10},61]
[62," FQHC",{"$nulls":10},62]
[63," Other Outpatient Service Cost",{"$nulls":10},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":10},70]
[71," Ambulance",{"$nulls":10},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":10},72]
[73," C.M.H.C.",{"$nulls":10},73]
[74," Other Reimbursable Cost",{"$nulls":10},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":10},83]
[84," Other Special Purpose Cost",{"$nulls":10},84]
[89," Subtotals",{"$nulls":10},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":10},90]
[91," Barber and Beauty Shop",{"$nulls":10},91]
[92," Physicians' Private Offices",{"$nulls":10},92]
[93," Nonpaid Workers",{"$nulls":10},93]
[94," Patients Laundry",{"$nulls":10},94]
[95," Other Non Reimbursable Cost ",{"$nulls":10},95]
[98," Cross Foot Adjustment",{"$nulls":10},98]
[99," Negative Cost Center",{"$nulls":10},99]
[102," Cost to Be Allocated (Per Worksheet B, Part I) ",{"$nulls":10},102]
[103," Unit Cost Multiplier (Worksheet B, Part I)",{"$nulls":10},103]
[104," Cost to Be Allocated (Per Worksheet B, Part II) ",{"$nulls":10},104]
[105," Unit Cost Multiplier (Worksheet B, Part II)",{"$nulls":10},105]
{"$rows_empty":8}
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120)          "]
["Rev. 1",{"$nulls":11},"41-332"]
[]
[]
[]
[]
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"WORKSHEET  B - 1"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null," "]
[{"$nulls":5},"MEDICAL","SOCIAL","NURSING &","OTHER",null,"POST"]
[null,null,"COST  CENTER",null,null,"RECORDS","SERVICE","ALLIED","GENERAL","SUBTOTAL","STEP-DOWN","TOTAL"]
[null,null,"   (Omit  Cents)",null,null,"&  LIBRARY",null,"HEALTH EDUCATION","SERVICE ",null,"ADJUSTMENTS"]
[{"$nulls":5},"(Time","(Time","(Assigned","COST"]
[{"$nulls":5},"Spent)","Spent)","Time)"]
[{"$nulls":5},"12","13","14","15","16","17","18"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Captial-Related Costs - Building  &  Fixture",{"$nulls":10},"1"]
["2"," Capital-Related Costs - Moveable Equipment",{"$nulls":10},"2"]
["3"," Employee Benefits",{"$nulls":10},"3"]
["4"," Administrative and General",{"$nulls":10},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":10},"5"]
["6"," Laundry and Linen Service",{"$nulls":10},"6"]
["7"," Housekeeping",{"$nulls":10},"7"]
["8"," Dietary",{"$nulls":10},"8"]
["9"," Nursing Administration",{"$nulls":10},"9"]
["10"," Central Services and Supply",{"$nulls":10},"10"]
["11"," Pharmacy",{"$nulls":10},"11"]
["12"," Medical Records and Library",{"$nulls":10},"12"]
["13"," Social Service",{"$nulls":10},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":10},"14"]
["15"," Other General Service Cost ",{"$nulls":10},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":10},30]
[31," Nursing Facility",{"$nulls":10},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":10},32]
[33," Other Long Term care",{"$nulls":10},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":10},40]
[41," Laboratory",{"$nulls":10},41]
[42," Intravenous Therapy",{"$nulls":10},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":10},43]
[44," Physical Therapy",{"$nulls":10},44]
[45," Occupational Therapy",{"$nulls":10},45]
[46," Speech Pathology",{"$nulls":10},46]
[47," Electro cardiology",{"$nulls":10},47]
[48," Medical Supplies Charged to Patients",{"$nulls":10},48]
[50," Dental Care - Title XIX only",{"$nulls":10},50]
[52," Other Ancillary Service Cost Center",{"$nulls":10},52]
[]
[]
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120)          ",{"$nulls":10},"Rev. 1"]
[]
["41-333",{"$nulls":11},"Rev. 1"]
[]
[]
["2011-02-11",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":6},"     PROVIDER  NO.:",null,"     PERIOD:"]
["COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":7},"       FROM ________________",null,"WORKSHEET  B - 1"]
[{"$nulls":6},"     _________________",null,"       TO   ________________",null," "]
[{"$nulls":5},"MEDICAL","SOCIAL","NURSING &","OTHER",null,"POST"]
[{"$nulls":5},"RECORDS","SERVICE","ALLIED","GENERAL","SUBTOTAL","STEP-DOWN","TOTAL"]
[null,null,"COST  CENTER",null,null,"&  LIBRARY",null,"HEALTH EDU","SERVICE ",null,"ADJUSTMENTS"]
[null,null,"   (Omit  Cents)",null,null,"(Time","(Time","(Assigned","COST"]
[{"$nulls":5},"Spent)","Spent)","Time)"]
[{"$nulls":5},"12","13","14","15","16","17","18"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":10},60]
[61," Rural Health Clinic (RHC)",{"$nulls":10},61]
[62,"FQHC",{"$nulls":10},62]
[63," Other Outpatient Service Cost",{"$nulls":10},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":10},70]
[71," Ambulance",{"$nulls":10},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":10},72]
[73," C.M.H.C.",{"$nulls":10},73]
[74," Other Reimbursable Cost",{"$nulls":10},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":10},83]
[84," Other Special Purpose Cost",{"$nulls":10},84]
[89," Subtotals",{"$nulls":10},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":10},90]
[91," Barber and Beauty Shop",{"$nulls":10},91]
[92," Physicians' Private Offices",{"$nulls":10},92]
[93," Nonpaid Workers",{"$nulls":10},93]
[94," Patients Laundry",{"$nulls":10},94]
[95," Other Non Reimbursable Cost ",{"$nulls":10},95]
[98," Cross Foot Adjustment",{"$nulls":10},98]
[99," Negative Cost Center",{"$nulls":10},99]
[102," Cost to Be Allocated (Per Worksheet B, Part I) ",{"$nulls":10},102]
[103," Unit Cost Multiplier (Worksheet B, Part I)",{"$nulls":10},103]
[104," Cost to Be Allocated (Per Worksheet B, Part II) ",{"$nulls":10},104]
[105," Unit Cost Multiplier (Worksheet B, Part II)",{"$nulls":10},105]
[]
[]
[]
[]
[]
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4120)          "]
["Rev. 1",{"$nulls":11},"41-334"]
{"$rows_empty":63}
[" "]

{"sheet":"B-II","index":20,"n_rows":300,"n_cols":12,"rows_kept":300,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:",{"$nulls":4},"."]
[null,"ALLOCATION  OF  CAPITAL  -  RELATED  COSTS",{"$nulls":4},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":4},"     _________________",null,"       TO   ________________",null,"               PART  II"]
[null,null,null,"DIRECTLY"," CAP.  REL. "," CAP.  REL. ",null,"EMPLOYEE","ADMINIS-","PLANT  OPER."]
[null,null,null,"ASSIGNED","BUILDINGS","MOVABLE","SUBTOTAL","BENEFITS","TRATIVE","MAINTENANCE"]
[null,"COST  CENTER",null,"CAPITAL","&  FIXTURES","EQUIPMENT",null,null,"&  GENERAL","&  REPAIRS"]
[null,"   (Omit  Cents)",null,"RELATED  COSTS"]
[null,null,null,"0","1","2","2 A","3","4","5"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Capital-Related Costs - Building  &  Fixture",{"$nulls":8},"1"]
["2"," Capital-Related Costs - Moveable Equipment",{"$nulls":8},"2"]
["3"," Employee Benefits",{"$nulls":8},"3"]
["4"," Administrative and General",{"$nulls":8},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":8},"5"]
["6"," Laundry and Linen Service",{"$nulls":8},"6"]
["7"," Housekeeping",{"$nulls":8},"7"]
["8"," Dietary",{"$nulls":8},"8"]
["9"," Nursing Administration",{"$nulls":8},"9"]
["10"," Central Services and Supply",{"$nulls":8},"10"]
["11"," Pharmacy",{"$nulls":8},"11"]
["12"," Medical Records and Library",{"$nulls":8},"12"]
["13"," Social Service",{"$nulls":8},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":8},"14"]
["15"," Other General Service Cost ",{"$nulls":8},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":8},30]
[31," Nursing Facility",{"$nulls":8},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":8},32]
[33," Other Long Term care",{"$nulls":8},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":8},40]
[41," Laboratory",{"$nulls":8},41]
[42," Intravenous Therapy",{"$nulls":8},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":8},43]
[44," Physical Therapy",{"$nulls":8},44]
[45," Occupational Therapy",{"$nulls":8},45]
[46," Speech Pathology",{"$nulls":8},46]
[47," Electro cardiology",{"$nulls":8},47]
[48," Medical Supplies Charged to Patients",{"$nulls":8},48]
[49," Drugs Charged to Patients",{"$nulls":8},49]
[50," Dental Care - Title XIX only",{"$nulls":8},50]
[51," Support Surfaces",{"$nulls":8},51]
[52," Other Ancillary Service Cost Center",{"$nulls":8},52]
[]
[]
[]
[]
[]
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4121 )        "]
[]
["41-335",{"$nulls":9},"Rev. 1"]
[]
["2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:",{"$nulls":4},"."]
[null,"ALLOCATION  OF  CAPITAL  -  RELATED  COSTS",{"$nulls":4},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":4},"     _________________",null,"       TO   ________________",null,"               PART  II"]
[null,null,null,"DIRECTLY"," CAP.  REL. "," CAP.  REL. ",null,"EMPLOYEE","ADMINIS-","PLANT  OPER."]
[null,null,null,"ASSIGNED","BUILDINGS","MOVABLE","SUBTOTAL","BENEFITS","TRATIVE","MAINTENANCE"]
[" ","COST  CENTER",null,"CAPITAL","&  FIXTURES","EQUIPMENT",null,null,"&  GENERAL","&  REPAIRS"]
[null,"   (Omit  Cents)",null,"RELATED  COSTS"]
[null,null,null,"0","1","2","2 A","3","4","5"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":8},60]
[61," Rural Health Clinic (RHC)",{"$nulls":8},61]
[62," FQHC",{"$nulls":8},62]
[63," Other Outpatient Service Cost",{"$nulls":8},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":8},70]
[71," Ambulance",{"$nulls":8},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":8},72]
[73," C.M.H.C.",{"$nulls":8},73]
[74," Other Reimbursable Cost",{"$nulls":8},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":8},83]
[84," Other Special Purpose Cost",{"$nulls":8},84]
[89," Subtotals",{"$nulls":8},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":8},90]
[91," Barber and Beauty Shop",{"$nulls":8},91]
[92," Physicians' Private Offices",{"$nulls":8},92]
[93," Nonpaid Workers",{"$nulls":8},93]
[94," Patients Laundry",{"$nulls":8},94]
[95," Other Non Reimbursable Cost ",{"$nulls":8},95]
[98," Cross Foot Adjustments",{"$nulls":8},98]
[99," Negative Cost Center",{"$nulls":8},99]
[100," Total",{"$nulls":8},100]
{"$rows_empty":12}
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4121 )        "]
[]
["Rev. 1",{"$nulls":9},"41-336"]
[]
[]
["4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:",{"$nulls":4},"."]
[null,"ALLOCATION  OF  CAPITAL  -  RELATED  COSTS",{"$nulls":4},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":4},"     _________________",null,"       TO   ________________",null,"               PART  II"]
[{"$nulls":4},"LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY"]
[{"$nulls":4},"&  LINEN","KEEPING",null,"ADMINIS-","SERVICES"]
[null,"COST  CENTER",null,null,"SERVICE",null,null,"TRATION","& SUPPLY"]
[null,"   (Omit  Cents)"]
[{"$nulls":4},"6","7","8","9","10","11"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Capital-Related Costs - Building  &  Fixture",{"$nulls":8},"1"]
["2"," Capital-Related Costs - Movable Equipment",{"$nulls":8},"2"]
["3"," Employee Benefits",{"$nulls":8},"3"]
["4"," Administrative and General",{"$nulls":8},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":8},"5"]
["6"," Laundry and Linen Service",{"$nulls":8},"6"]
["7"," Housekeeping",{"$nulls":8},"7"]
["8"," Dietary",{"$nulls":8},"8"]
["9"," Nursing Administration",{"$nulls":8},"9"]
["10"," Central Services and Supply",{"$nulls":8},"10"]
["11"," Pharmacy",{"$nulls":8},"11"]
["12"," Medical Records and Library",{"$nulls":8},"12"]
["13"," Social Service",{"$nulls":8},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":8},"14"]
["15"," Other General Service Cost ",{"$nulls":8},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":8},30]
[31," Nursing Facility",{"$nulls":8},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":8},32]
[33," Other Long Term care",{"$nulls":8},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":8},40]
[41," Laboratory",{"$nulls":8},41]
[42," Intravenous Therapy",{"$nulls":8},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":8},43]
[44," Physical Therapy",{"$nulls":8},44]
[45," Occupational Therapy",{"$nulls":8},45]
[46," Speech Pathology",{"$nulls":8},46]
[47," Electro cardiology",{"$nulls":8},47]
[48," Medical Supplies Charged to Patients",{"$nulls":8},48]
[49," Drugs Charged to Patients",{"$nulls":8},49]
[50," Dental Care - Title XIX only",{"$nulls":8},50]
[51," Support Surfaces",{"$nulls":8},51]
[52," Other Ancillary Service Cost Center",{"$nulls":8},52]
[]
[]
[]
[]
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4121 )        "]
[]
["41-337",{"$nulls":9},"Rev. 1"]
[]
["2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:"]
[null,"ALLOCATION  OF  CAPITAL  -  RELATED  COSTS",{"$nulls":4},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":4},"     _________________",null,"       TO   ________________",null,"               PART  II"]
[{"$nulls":4},"LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY"]
[{"$nulls":4},"&  LINEN","KEEPING",null,"ADMINIS-","SERVICES"]
[null,"COST  CENTER",null,null,"SERVICE",null,null,"TRATION","& SUPPLY"]
[null,"   (Omit  Cents)"]
[{"$nulls":4},"6","7","8","9","10","11"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":8},60]
[61," Rural Health Clinic (RHC)",{"$nulls":8},61]
[62," FQHC",{"$nulls":8},62]
[63," Other Outpatient Service Cost",{"$nulls":8},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":8},70]
[71," Ambulance",{"$nulls":8},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":8},72]
[73," C.M.H.C.",{"$nulls":8},73]
[74," Other Reimbursable Cost",{"$nulls":8},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":8},83]
[84," Other Special Purpose Cost",{"$nulls":8},84]
[89," Subtotals",{"$nulls":8},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":8},90]
[91," Barber and Beauty Shop",{"$nulls":8},91]
[92," Physicians' Private Offices",{"$nulls":8},92]
[93," Nonpaid Workers",{"$nulls":8},93]
[94," Patients Laundry",{"$nulls":8},94]
[95," Other Non Reimbursable Cost ",{"$nulls":8},95]
[98," Cross Foot Adjustments",{"$nulls":8},98]
[99," Negative Cost Center",{"$nulls":8},99]
[100," Total",{"$nulls":8},100]
{"$rows_empty":12}
["FORM  CMS-2540-10  ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II,  SECTION 4121 )        "]
[]
["Rev. 1",{"$nulls":9},"41-338"]
[]
[]
["2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:"]
[null,"ALLOCATION  OF  CAPITAL  -  RELATED  COSTS",{"$nulls":4},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":4},"     _________________",null,"       TO   ________________",null,"               PART  II"]
[null,null,null,"MEDICAL","SOCIAL","NURSING &","OTHER",null,"POST"]
[null,"COST  CENTER",null,"RECORDS","SERVICE","ALLIED","GENERAL","SUBTOTAL","STEP-DOWN","TOTAL"]
[null,"   (Omit  Cents)",null,"&  LIBRARY",null,"HEALTH","SERVICE ",null,"ADJUSTMENTS"]
[{"$nulls":5},"EDUCATION","COST"]
[null,null,null,"12","13","14","15","16","17","18"]
["GENERAL  SERVICE  COST  CENTERS"]
["1"," Capital-Related Costs - Building  &  Fixture",{"$nulls":8},"1"]
["2"," Capital-Related Costs - Movable Equipment",{"$nulls":8},"2"]
["3"," Employee Benefits",{"$nulls":8},"3"]
["4"," Administrative and General",{"$nulls":8},"4"]
["5"," Plant Operation, Maintenance and Repairs",{"$nulls":8},"5"]
["6"," Laundry and Linen Service",{"$nulls":8},"6"]
["7"," Housekeeping",{"$nulls":8},"7"]
["8"," Dietary",{"$nulls":8},"8"]
["9"," Nursing Administration",{"$nulls":8},"9"]
["10"," Central Services and Supply",{"$nulls":8},"10"]
["11"," Pharmacy",{"$nulls":8},"11"]
["12"," Medical Records and Library",{"$nulls":8},"12"]
["13"," Social Service",{"$nulls":8},"13"]
["14"," Nursing and Allied Health Education Activities",{"$nulls":8},"14"]
["15"," Other General Service Cost ",{"$nulls":8},"15"]
["INPATIENT  ROUTINE  SERVICE  COST  CENTERS"]
[30," Skilled Nursing Facility",{"$nulls":8},30]
[31," Nursing Facility",{"$nulls":8},31]
[32," Intermediate Care Facility - Mentally Retarded",{"$nulls":8},32]
[33," Other Long Term care",{"$nulls":8},33]
["ANCILLARY  SERVICE COST  CENTERS"]
[40," Radiology",{"$nulls":8},40]
[41," Laboratory",{"$nulls":8},41]
[42," Intravenous Therapy",{"$nulls":8},42]
[43," Oxygen (Inhalation) Therapy",{"$nulls":8},43]
[44," Physical Therapy",{"$nulls":8},44]
[45," Occupational Therapy",{"$nulls":8},45]
[46," Speech Pathology",{"$nulls":8},46]
[47," Electro cardiology",{"$nulls":8},47]
[48," Medical Supplies Charged to Patients",{"$nulls":8},48]
[49," Drugs Charged to Patients",{"$nulls":8},49]
[50," Dental Care - Title XIX only",{"$nulls":8},50]
[51," Support Surfaces",{"$nulls":8},51]
[52," Other Ancillary Service Cost Center",{"$nulls":8},52]
[]
[]
[]
[]
["41-339",{"$nulls":9},"Rev. 1"]
[]
[]
["2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[{"$nulls":4},"     PROVIDER  NO.:",null,"     PERIOD:"]
[null,"ALLOCATION  OF  CAPITAL  -  RELATED  COSTS",{"$nulls":4},"       FROM ________________",null,"          WORKSHEET  B"]
[{"$nulls":4},"     _________________",null,"       TO   ________________",null,"               PART  II"]
[null,null,null,"MEDICAL","SOCIAL","NURSING &","OTHER",null,"POST"]
[null,null,null,"RECORDS","SERVICE","ALLIED","GENERAL","SUBTOTAL","STEP-DOWN","TOTAL"]
[null,"COST  CENTER",null,"&  LIBRARY",null,"HEALTH","SERVICE ",null,"ADJUSTMENTS"]
[null,"   (Omit  Cents)",null,null,null,"EDUCATION","COST"]
[null,null,null,"12","13","14","15","16","17","18"]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60," Clinic",{"$nulls":8},60]
[61," Rural Health Clinic (RHC)",{"$nulls":8},61]
[62," FQHC",{"$nulls":8},62]
[63," Other Outpatient Service Cost",{"$nulls":8},63]
["OTHER  REIMBURSABLE  COST  CENTERS"]
[70," Home Health Agency Cost",{"$nulls":8},70]
[71," Ambulance",{"$nulls":8},71]
[72," Nursing and Allied Health Education Activities",{"$nulls":8},72]
[73," C.M.H.C.",{"$nulls":8},73]
[74," Other Reimbursable Cost",{"$nulls":8},74]
["SPECIAL  PURPOSE  COST  CENTERS"]
[83," Hospice",{"$nulls":8},83]
[84," Other Special Purpose Cost",{"$nulls":8},84]
[89," Subtotals",{"$nulls":8},89]
["NON REIMBURSABLE  COST  CENTERS"]
[90," Gift, Flower, Coffee Shops and Canteen",{"$nulls":8},90]
[91," Barber and Beauty Shop",{"$nulls":8},91]
[92," Physicians' Private Offices",{"$nulls":8},92]
[93," Nonpaid Workers",{"$nulls":8},93]
[94," Patients Laundry",{"$nulls":8},94]
[95," Other Non Reimbursable Cost ",{"$nulls":8},95]
[98," Cross Foot Adjustments",{"$nulls":8},98]
[99," Negative Cost Center",{"$nulls":8},99]
[100," Total",{"$nulls":8},100]
[]
[]
[]
[]
[]
[{"$error":"#REF!"}]
[]
["Rev. 1",{"$nulls":9},"41-340"]

{"sheet":"B-2","index":21,"n_rows":257,"n_cols":27,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 ( Cont.)",null,"FORM CMS-2540-10",null,null,null,"2011-02-11"]
[null,null," PROVIDER NO.:"," PERIOD",{"$nulls":22},"  ."]
["POST  STEP  DOWN  ADJUSTMENTS",null,null,"  FROM_______________",null,"  WORKSHEET   B-2"]
[null,null,"____________________","  TO____________"]
[null,null,null,"WORKSHEET   B -"]
[null,"DESCRIPTION",null,"PART  NO.","LINE  NO.","AMOUNT"]
[null,"1",null,"2","3","4"]
["1",{"$nulls":5},"1"]
["2",{"$nulls":5},"2"]
["3",{"$nulls":5},"3"]
["4",{"$nulls":5},"4"]
["5",{"$nulls":5},"5"]
["6",{"$nulls":5},"6"]
["7",{"$nulls":5},"7"]
["8",{"$nulls":5},"8"]
["9",{"$nulls":5},"9"]
["10",{"$nulls":5},"10"]
["11",{"$nulls":5},"11"]
["12",{"$nulls":5},"12"]
["13",{"$nulls":5},"13"]
["14",{"$nulls":5},"14"]
["15",{"$nulls":5},"15"]
["16",{"$nulls":5},"16"]
["17",{"$nulls":5},"17"]
["18",{"$nulls":5},"18"]
["19",{"$nulls":5},"19"]
["20",{"$nulls":5},"20"]
["21",{"$nulls":5},"21"]
["22",{"$nulls":5},"22"]
["23",{"$nulls":5},"23"]
["24",{"$nulls":5},"24"]
["25",{"$nulls":5},"25"]
["26",{"$nulls":5},"26"]
["27",{"$nulls":5},"27"]
["28",{"$nulls":5},"28"]
["29",{"$nulls":5},"29"]
["30",{"$nulls":5},"30"]
["31",{"$nulls":5},"31"]
["32",{"$nulls":5},"32"]
["33",{"$nulls":5},"33"]
["34",{"$nulls":5},"34"]
["35",{"$nulls":5},"35"]
["36",{"$nulls":5},"36"]
["37",{"$nulls":5},"37"]
["38",{"$nulls":5},"38"]
["39",{"$nulls":5},"39"]
["40",{"$nulls":5},"40"]
["41",{"$nulls":5},"41"]
["42",{"$nulls":5},"42"]
["43",{"$nulls":5},"43"]
["44",{"$nulls":5},"44"]
["45",{"$nulls":5},"45"]
["46",{"$nulls":5},"46"]
["47",{"$nulls":5},"47"]
["48",{"$nulls":5},"48"]
["49",{"$nulls":5},"49"]
["50",{"$nulls":5},"50"]
["FORM CMS 2540-10 ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15-II SECTION 4122 )"]
[" "]
[]
[]
["41-341",{"$nulls":5},"Rev. 1"]
{"$rows_empty":193}
[{"$nulls":11},"Rev. 1"]

{"sheet":"C","index":22,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,"FORM CMS-2540-10",null,null,"4190 ( Cont.)"]
["RATIO  OF  COST  TO CHARGES",null," PROVIDER  NO.  :"," PERIOD :"]
["FOR  ANCILLARY  AND  OUTPATIENT ",null,null,"  FROM  _________________","      WORKSHEET   C"]
["COST  CENTERS",null,"  ______________________","  TO   ___________"]
[]
[]
[]
[]
[null,null,"TOTAL","Total","Ratio"]
[null,"Cost  Center","(From  Wkst B,","Charges","(col. 1 divided"]
[null,null,"Pt. I,  Col.  18)",null,"by col. 2)"]
[null,null,"1","2","3"]
["ANCILLARY  SERVICE  COST  CENTERS"]
[40,"  Radiology",null,null,null,40]
[41,"  Laboratory",null,null,null,41]
[42,"  Intravenous  Therapy",null,null,null,42]
[43,"  Oxygen  ( Inhalation )  Therapy",null,null,null,43]
[44,"  Physical  Therapy",null,null,null,44]
[45,"  Occupational  Therapy",null,null,null,45]
[46,"  Speech  Pathology",null,null,null,46]
[47,"  Electro cardiology",null,null,null,47]
[48,"  Medical  Supplies  Charged",null,null,null,48]
[49,"  Drugs  Charged  to  Patients",null,null,null,49]
[50,"  Dental  Care  -  Title  XIX  only",null,null,null,50]
[51,"  Support Surfaces",null,null,null,51]
[52,"  Other Ancillary Service Cost",null,null,null,52]
["OUTPATIENT  SERVICE  COST  CENTERS"]
[60,"  Clinic",null,null,null,60]
[61,"  R H C",null,null,null,61]
[62," FQHC",null,null,null,62]
[63,"  Other Outpatient Service Cost",null,null,null,63]
[71," Ambulance",null,null,null,71]
[100,"  Total",null,null,null,100]
{"$rows_empty":19}
["FORM  CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15 II, SECTION 4123 )"]
[]
["Rev. 1",{"$nulls":4},"41-342"]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"D","index":23,"n_rows":257,"n_cols":13,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",{"$nulls":5},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
["APPORTIONMENT  OF  ANCILLARY  AND",{"$nulls":5}," PROVIDER  NO.  :",null," PERIOD :",null,"WORKSHEET   D"]
["OUTPATIENT  COST ",{"$nulls":7},"  FROM  ______________",null,"PART  I"]
[{"$nulls":6},"  ______________________",null,"  TO   ________________"]
["PART  I  -  CALCULATION OF ANCILLARY AND OUTPATIENT COST"]
["Check ",null,"[    ]  Title  V ","( 1 )","Check   One:"," [     ]   SNF","[    ]    NF","[    ]    ICF/MR",null,"[     ]  Other    __________________"]
["  One:",null,"[    ]  Title  XVIII",null,null," [     ]   PPS  - Must also complete Part II"]
[null,null,"[    ]  Title  XIX","( 1 )"]
[null,null,null,"RATIO   OF","HEALTH  CARE",null,null,null,"HEALTH CARE"]
[null,null,null,"COST   TO","PROGRAM  CHARGES",null,null,null,"PROGRAM  COST"]
["     Cost  Center",null,null,"CHARGES"]
[null,null,null,"( Fr.  Wkst.  C","Part  A",null,"Part   B",null,"Part  A",null,"Part   B"]
[null,null,null,"Column  3 )",{"$nulls":4},"(Col. 1 X Col. 2)",null,"(Col. 1 X Col. 3)"]
[null,null,null,"1","2",null,3,null,4,null,5]
["ANCILLARY  SERVICE COST CENTERS"]
[40,"  Radiology",{"$nulls":10},40]
[41,"  Laboratory",{"$nulls":10},41]
[42,"  Intravenous  Therapy",{"$nulls":10},42]
[43,"  Oxygen  ( Inhalation )",{"$nulls":10},43]
[null,"  Therapy"]
[44,"  Physical  Therapy",{"$nulls":10},44]
[45,"  Occupational  Therapy",{"$nulls":10},45]
[46,"  Speech  Pathology",{"$nulls":10},46]
[47,"  Electro cardiology",{"$nulls":10},47]
[48,"  Medical  Supplies",{"$nulls":10},48]
[null,"  Charged To  Patients"]
[49,"  Drugs Charged to Patients",{"$nulls":10},49]
[50,"  Dental  Care  - Title XIX",{"$nulls":10},50]
[51,"  Support Surfaces",{"$nulls":10},51]
[52,"  Other Ancillary Services",{"$nulls":10},52]
["OUTPATIENT  COST  CENTERS"]
[60,"  Clinic",{"$nulls":10},60]
[61,"  R  H  C",{"$nulls":10},61]
[62," FQHC",{"$nulls":10},62]
[63,"  Other Outpatient Services",{"$nulls":10},63]
[71," Ambulance   (2)",{"$nulls":10},71]
[100," Total (Sum of  lines 40 - 71)",{"$nulls":10},100]
[" ( 1 )   For  titles  V  and  XIX  use  columns  1,  2  and  4  only.  "]
[" ( 2 )  Line 71 columns 2 and 4  are for titles V and XIX.  No amounts should be entered here for title XVIII."]
["FORM CMS- 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II  SECTION 4124)"]
[]
["41-343",{"$nulls":11},"Rev. 1"]
{"$rows_empty":17}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"DII","index":24,"n_rows":257,"n_cols":14,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":6},"4190 (Cont.)"]
["APPORTIONMENT OF ANCILLARY AND ",null,null,null," PROVIDER  NO.  :",null," PERIOD :",null,null,"WORKSHEET   D"]
["OUTPATIENT COST  ",{"$nulls":5},"  FROM  ______________",null,null,"PARTS  II & III"]
[{"$nulls":4},"  ______________________",null,"  TO   ________________"]
["Check One:",null,"[      ]","SNF","[      ]","NF","[      ]","ICF/MR"]
[]
["PART   II  -   APPORTIONMENT   OF  VACCINE  COST "]
[]
[1,"Drugs charged to patients - ratio of cost to charges ( From  Worksheet C,  column 3,  line 49)",{"$nulls":9},1]
[2,"Program vaccine charges ( From your records,  or the P S & R.)",{"$nulls":9},2]
[3,"Program costs  ( Line 1  X  line 2)  ( Title XVIII, PPS providers,",{"$nulls":9},3]
[null," transfer this amount to Worksheet E,  Part  I,  line 24)"]
[]
["PART III - CALCULATION OF PASS THROUGH COSTS FOR NURSING & ALLIED HEALTH"]
[]
[{"$nulls":4},"Total Cost","Nursing &","Ratio of Nursing","Program","Part A","Program","Part B"]
[{"$nulls":4},"(From","Allied Health","& Allied Health","Part A Cost","Nursing & Allied","Part B Cost","Nursing & Allied"]
[null,"Cost  Centers",null,null,"Worksheet B,","(From Wkst. B,","Costs  To Total","(From Wkst. D.","Health Costs for","(From Wkst. D.","Health Costs for"]
[{"$nulls":4},"Part I, Col 18)","Part I, Column 14)","Costs - Part  A","Part 1, Col. 4)","Pass Through","Part 1, Col. 5)","Pass Through"]
[{"$nulls":6},"(Col. 2  /  Col.. 1)",null,"(Col. 3 X Col. 4)",null,"(Col. 3 X Col. 6)"]
[{"$nulls":4},"1","2","3","4","5","6","7"]
["ANCILLARY SERVICE COST CENTERS"]
[40,"  Radiology",{"$nulls":9},40]
[41,"  Laboratory",{"$nulls":9},41]
[42,"  Intravenous  Therapy",{"$nulls":9},42]
[43,"  Oxygen  ( Inhalation ) Therapy",{"$nulls":9},43]
[44,"  Physical  Therapy",{"$nulls":9},44]
[45,"  Occupational  Therapy",{"$nulls":9},45]
[46,"  Speech  Pathology",{"$nulls":9},46]
[47,"  Electro cardiology",{"$nulls":9},47]
[48,"  Medical  Supplies",{"$nulls":9},48]
[49,"  Drugs  Charged  to Patients",{"$nulls":9},49]
[50,"  Dental  Care  -  Title XIX only",{"$nulls":9},50]
[51,"  Support Surfaces",{"$nulls":9},51]
[52,"  Other Ancillary Service Costs",{"$nulls":9},52]
[100,"  Total ( Sum of lines 40 - 52)",{"$nulls":9},100]
[]
[]
[]
[]
[]
["FORM CMS- 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II  SECTION 4124)"]
["Rev. 1",{"$nulls":10},"41-344"]
{"$rows_empty":16}
[" "]
{"$rows_empty":196}
[{"$nulls":13},"Rev. 1"]

{"sheet":"D-1","index":25,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,null,null," PROVIDER  NO.  :"," PERIOD :"]
["  COMPUTATION  OF  INPATIENT",null,null,null,"  FROM  ______________",null," WORKSHEET  D-1"]
["          ROUTINE  COSTS",null,null,"  ______________________","  TO   ____________",null,"PARTS   I  &  II"]
["     Check  One:",null,"[    ]   Title  V ","[    ]   Title  XVIII ","[    ]   Title  XIX "]
["     Check  One:",null,"[    ]   SNF","[    ]   NF ","[    ]   ICF/MR"]
["PART  I   CALCULATION  OF  INPATIENT  ROUTINE  COSTS"]
[]
[null,"INPATIENT  DAYS"]
[1," Inpatient days including private room days",{"$nulls":6},1]
[2," Private room days",{"$nulls":6},2]
[3," Inpatient days including private room days applicable to the Program",{"$nulls":6},3]
[4," Medically necessary private room days applicable to the Program",{"$nulls":6},4]
[5," Total general inpatient routine service cost",{"$nulls":6},5]
[null,"PRIVATE  ROOM  DIFFERENTIAL  ADJUSTMENT"]
[6," General inpatient routine service charges",{"$nulls":6},6]
[7," General inpatient routine service cost/charge ratio  (Line 5 divided by line 6)",{"$nulls":6},7]
[8," Enter private room charges from your records",{"$nulls":6},8]
[9," Average private room per diem charge (Private room charges",{"$nulls":6},9]
[null,"   line 8 divided by private room days, line 2)"]
[10," Enter semi-private room charges from your records",{"$nulls":6},10]
[11," Average semi-private room per diem charge  (Semi-private room charges",{"$nulls":6},11]
[null,"  line 10, divided by semi-private room days) "]
[12," Average per diem private room charge differential ( Line 9 minus line 11 )",{"$nulls":6},12]
[13," Average per diem private room cost differential ( Line 7 times line 12 )",{"$nulls":6},13]
[14," Private room cost differential adjustment ( Line 2 times line 13 )",{"$nulls":6},14]
[15," General inpatient routine service cost net of private room cost differential ",{"$nulls":6},15]
[null," ( Line 5  minus line 14 )"]
[null,"PROGRAM  INPATIENT  ROUTINE  SERVICE  COSTS"]
[16," Adjusted general inpatient service cost per diem",{"$nulls":6},16]
[null,"  ( Line 15  divided by line 1 )"]
[17," Program routine service cost  ( Line 3 times line 16 )",{"$nulls":6},17]
[18," Medically necessary private room cost applicable to program  ( line 4 times line 13 )",{"$nulls":6},18]
[19," Total program general inpatient routine service cost  ( Line 17 plus line 18 )",{"$nulls":6},19]
[20," Capital related cost allocated to inpatient routine service costs  ( From Wkst.  B,",{"$nulls":6},20]
[null,"  Part  II  column  18, - line 30 for SNF;  line 31 for NF,or line 32 for ICF/MR )"]
[21," Per diem capital related costs  ( Line 20 divided by line 1 )",{"$nulls":6},21]
[22," Program capital related cost  ( Line 3 times line 21 )",{"$nulls":6},22]
[23," Inpatient routine service cost  ( Line 19 minus line 22 )",{"$nulls":6},23]
[24," Aggregate charges to beneficiaries for excess costs  ( From provider records )",{"$nulls":6},24]
[25," Total program routine service costs for comparison to the cost limitation",{"$nulls":6},25]
[null,"  ( Line 23 minus line 24 )"]
[26," Enter the per diem limitation (1)",{"$nulls":6},26]
[27," Inpatientroutine service cost limitation (Line 3 times the per diem limitation line 26) (1)",{"$nulls":6},27]
[28," Reimbursable inpatient routine service costs  ( Line 22 plus  the lesser of line 25 or line 27  )",{"$nulls":6},28]
[null," ( Transfer to  Worksheet  E,  Part II,  line 4) ( See instructions )"]
[null,"(1) Lines 26 and 27 are not applicable for title XVIII, but may be used for title V and or title XIX"]
[]
["PART  II   CALCULATION OF INPATIENT NURSING & ALLIED HEALTH COSTS FOR  PPS  PASS-THROUGH"]
["1","Total inpatient days",{"$nulls":6},"1"]
["2","Program inpatient days. ( From Worksheet S-3,  Part I, cols. 3,  or 5,  line 1 as applicable)",{"$nulls":6},"2"]
[3,"Total Nursing & Allied Health costs. ( From Worksheet B, Part I, column 14, line 14)",{"$nulls":6},"3"]
[4,"Nursing & Allied Health ratio.  ( Line 2 divided by line 1)",{"$nulls":6},"4"]
["5","Program Nursing & Allied Health costs for pass-through.  (Line 3 times line 4)",{"$nulls":6},"5"]
["FORM  CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15-II, SECTION 4125 )"]
[]
["41-345",{"$nulls":7},"Rev. 1"]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"E-I","index":26,"n_rows":248,"n_cols":46,"rows_kept":248,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,null,"FORM CMS-2540-10",null,null,"4190 ( Cont.)"]
[null,"          CALCULATION  OF  ",null,"PROVIDER NO.:","PERIOD:",{"$nulls":8},".",{"$nulls":31},"."]
[null,"REIMBURSEMENT  SETTLEMENT",null,null,"FROM _____________","  WORKSHEET  E"]
[null,"               TITLE XVIII",null,"_________________","TO  ______________","PART  I"]
[]
["PART  A  -  INPATIENT  SERVICE  PPS  PROVIDER  COMPUTATION  OF  REIMBURSEMENT LESSER OF COST OR CHARGES"]
[1,"Inpatient ancillary services  - Part  A - ( See Instructions )",{"$nulls":4},1]
[2," Nursing and Allied Health Education Activities",{"$nulls":4},2]
[3,"Total cost ( Sum of lines 1 and 2)",{"$nulls":4},3]
[4,"Inpatient  PPS amount (see instructions)",{"$nulls":4},4]
[5,"Primary payor amounts",{"$nulls":4},5]
[6,"Coinsurance",{"$nulls":4},6]
[7,"Reimbursable bad debts (From your records)",{"$nulls":4},7]
[8,"Reimbursable bad debts for dual eligible beneficiaries (See instructions)",{"$nulls":4},8]
[9,"Adjusted reimbursable bad debts for periods ending on and after 10/01/2005  (See instructions) ",{"$nulls":4},9]
[10,"Recovery of bad debts - for statistical records only",{"$nulls":4},10]
[11,"Utilization review",{"$nulls":4},11]
[12,"Subtotal  (See instructions)",{"$nulls":4},12]
[13,"Interim payments (See instructions)",{"$nulls":4},13]
[14,"Tentative adjustment",{"$nulls":4},14]
[15,"OTHER adjustment (See instructions)",{"$nulls":4},15]
[16,"Balance due provider/program  (Line 12 minus line 13 and 14, plus or minus line 15)",{"$nulls":4},16]
[null,"(Indicate overpayment in brackets) (See Instructions)"]
[17,"Protested amounts (Nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2)",{"$nulls":4},17]
[]
["   PART  B - ANCILLARY  SERVICES  COMPUTATION  OF  REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY"]
[18,"Ancillary services Part B",{"$nulls":4},18]
[19,"Vaccine cost (From Wkst D, Part II, line 3)",{"$nulls":4},19]
[20,"Nursing & Allied Health Education Activities (from Wkst D, part III, col. 7, line 100)",{"$nulls":4},20]
[21,"Total reasonable costs (Sum of lines 18, 19, and 20)",{"$nulls":4},21]
[22,"Medicare Part B ancillary charges (See instructions)",{"$nulls":4},22]
[23,"Cost of covered services (Lesser of line 21 or line 22)",{"$nulls":4},23]
[24,"Primary payor amounts",{"$nulls":4},24]
[25,"Coinsurance and deductibles",{"$nulls":4},25]
[26,"Reimbursable bad debts (From your records)",{"$nulls":4},26]
[27,"Other Adjustments  (See instructions) Specify",{"$nulls":4},27]
[28,"Subtotal (Sum of lines 23 and 26, minus lines 24 and 25, plus or minus line 27)",{"$nulls":4},28]
[29,"Interim payments (See instructions)",{"$nulls":4},29]
[30,"Tentative adjustment",{"$nulls":4},30]
[31,"OTHER  adjustments (See instructions)",{"$nulls":4},31]
[32,"Balance due provider/program (Line 28 minus  line 29, 30 and line 31)",{"$nulls":4},32]
[null,"(Indicate overpayments in brackets) (See Instructions)"]
[33,"Protested amounts (Nonallowable cost report items) in accordance with CMS Pub.15-II, section 115.2",{"$nulls":4},33]
["FORM  CMS  2540-10  (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II SECTION 4130)"]
[]
[]
[]
["Rev. 1",{"$nulls":5},"41-346"]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"E-II","index":27,"n_rows":257,"n_cols":48,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",null,null,"2011-02-11"]
[null,"        CALCULATION  OF",null,"PROVIDER NO.:","PERIOD:",{"$nulls":10}," ",{"$nulls":31},"."]
[null,"REIMBURSEMENT  SETTLEMENT",null,null,"FROM __________","  WORKSHEET  E"]
[null,"FOR TITLE V  and TITLE XIX ONLY",null,"_________________","TO  ______________","PART  II"]
["Check one:",null,null,"[     ]   Title  V ","[     ]   Title  XIX "]
["Check one:",null,"[     ]   SNF","[     ]   NF","[     ]   ICF/MR"]
[null,"COMPUTATION  OF  NET  COST  OF  COVERED  SERVICES"]
[1,"Inpatient ancillary services (See Instructions)",{"$nulls":4},1]
[2,"Intern and Resident Cost (From  Worksheet D-2)",{"$nulls":4},2]
[3,"Outpatient services",{"$nulls":4},3]
[4,"Inpatient routine services (See instructions)",{"$nulls":4},4,{"$nulls":18},"Total reasonable costs (sum of lines 1, 2 and 3)"]
[5,"Utilization review--physicians' compensation (From provider records)",{"$nulls":4},5,{"$nulls":18},"Cost of covered services (lesser of lines 4 or 5)"]
[6,"Cost of covered services (Sum of lines 1 - 5)",{"$nulls":4},6,{"$nulls":18},"Inpatient routine PPS amount (see instructions)"]
[7,"Differential in charges between semiprivate accommodations and less",{"$nulls":4},7]
[null,"than semiprivate accommodations"]
[8,"SUBTOTAL (Line 6 minus line 7)",{"$nulls":4},8,{"$nulls":18},"Reimbursable bad debts"]
[9,"Primary payor amounts",{"$nulls":4},9,{"$nulls":18},"Utilization review"]
[10,"Total Reasonable Cost (Line 8 minus line 9)",{"$nulls":4},10,{"$nulls":18},"Recovery of unreimbursed cost under the lesser of reasonable cost or customary charges"]
[null,"REASONABLE  CHARGES"]
[11,"Inpatient ancillary service charges",{"$nulls":4},11,{"$nulls":18},"Subtotal  (Sum of lines 6 through 14)"]
[12,"Intern and Resident Charges (From Provider Records)",{"$nulls":4},12,{"$nulls":18},"Sequestration adjustment"]
[13,"Outpatient service charges",{"$nulls":4},13,{"$nulls":18},"Interim payments (See instructions)"]
[14,"Inpatient routine service charges",{"$nulls":4},14,{"$nulls":18},"Balance due provider/program  (Line 15 minus the sum of lines 16 and 17)"]
[15,"Differential in charges between semiprivate accommodations and less",{"$nulls":4},15,{"$nulls":18},"(Indicate overpayments in brackets)"]
[null,"than semiprivate accommodations",{"$nulls":23},"Protested amounts (Nonallowable cost report items in accordance with"]
[16,"Total reasonable charges",{"$nulls":4},16,{"$nulls":18},"CMS Pub.  15-II, section 115.2)"]
[null,"CUSTOMARY  CHARGES",{"$nulls":23},"Balance due provider/program (Line 18 plus or minus line 19)"]
[17,"Aggregate amount actually collected from patients liable for payment for",{"$nulls":4},17]
[null,"services on a charge basis"]
[18,"Amounts that would have been realized from patients liable for payment for services",{"$nulls":4},18]
[null,"on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)"]
[19,"Ratio of line 17 to line 18 (not to exceed 1.000000)",{"$nulls":4},19]
[20,"Total customary charges (See instructions)",{"$nulls":4},20]
[null,"COMPUTATION  OF  REIMBURSEMENT  SETTLEMENT "]
[21,"Cost of covered services (See Instructions)",{"$nulls":4},21]
[22,"Deductibles  ",{"$nulls":4},22]
[23,"Subtotal (Line 21 minus line 22)",{"$nulls":4},23]
[24,"Coinsurance",{"$nulls":4},24]
[25,"Subtotal (Line 23 minus line 24)",{"$nulls":4},25]
[26,"Reimbursable bad debts ( From your records)",{"$nulls":4},26]
[27,"Subtotal (Sum of lines 25 and 26)",{"$nulls":4},27]
[28,"Unrefunded charges to beneficiaries for excess costs erroneously collected",{"$nulls":4},28]
[null,"based on correction of cost limit"]
[29,"Recovery of excess depreciation resulting from provider termination or a decrease  ",{"$nulls":4},29]
[null,"in program utilization"]
[30,"Other Adjustments (See instructions)  Specify",{"$nulls":4},30]
[31,"Amounts applicable to prior cost reporting periods resulting from disposition of",{"$nulls":4},31]
[null,"depreciable assets ( If minus, enter amount in brackets)"]
[32,"Subtotal (Line 27  plus or minus lines 30, and 31, minus lines 28 and 29)",{"$nulls":4},32]
[33,"Interim payments ",{"$nulls":4},33]
[34,"Balance due provider/program (Line 32 minus line 33)",{"$nulls":4},34]
[null,"(Indicate overpayments in brackets) (See Instructions)"]
[]
["FORM  CMS  2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,"]
["SECTIONS 4130.2 ) "]
[]
["41-347",{"$nulls":5},"Rev. 1"]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"E1","index":28,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,null,"FORM CMS-2540-10",{"$nulls":4},"4190 ( Cont.)"]
["ANALYSIS  OF  PAYMENTS  TO  PROVIDERS",null,null,"  PROVIDER NO.:  ",null," PERIOD: "]
[" FOR  SERVICES  RENDERED ",{"$nulls":4},"  FROM ________________",null,"   WORKSHEET  E - 1"]
[null,null,null,"________________",null,"  TO   ________________"]
[{"$nulls":4},"                           Inpatient   Part  A",null,"                                     Part  B"]
[{"$nulls":4},"mm/dd/yyyy","Amount","mm/dd/yyyy","Amount"]
[null,"Description",null,null,"1","2","3","4"]
[1," Total interim payments paid to provider",{"$nulls":6},"1"]
[2," Interim payments payable on individual bills,  either submitted",{"$nulls":6},"2"]
[null," or to be submitted to the intermediary/contractor for services"]
[null," rendered in the cost reporting period.  If none,  enter zero"]
[3," List separately each retroactive lump sum ",null," .01",{"$nulls":4},3.01]
[null," adjustment amount based on subsequent revision of",null," .02",{"$nulls":4},3.02]
[null," the interim rate for the cost reporting period","Program to "," .03",{"$nulls":4},3.03]
[null," Also show date of each payment.","Provider"," .04",{"$nulls":4},3.04]
[null,null,null," .05",{"$nulls":4},3.05]
[null," If none, write \"NONE,\" or enter a zero  (1)",null," .50",{"$nulls":4},"3.50"]
[null,null,null," .51",{"$nulls":4},3.51]
[null,null,"Provider to "," .52",{"$nulls":4},3.52]
[null,null,"Program"," .53",{"$nulls":4},3.53]
[null,null,null," .54",{"$nulls":4},3.54]
[null,"SUBTOTAL (Sum of lines 3.01 - 3.05 minus sum of lines 3.50 - 3.54)",null," .99",{"$nulls":4},3.99]
[4,"TOTAL  INTERIM  PAYMENTS  (Sum of lines 1, 2 & 3.99) Transfer to Wkst E, Part I",{"$nulls":6},"4"]
[null,"line 18 for Part A, and line 35 for Part B. or Transfer to Wkst E, Part II, line 33)"]
[null,"TO  BE  COMPLETED   BY   INTERMEDIARY/CONTRACTOR"]
[5,"List separately each tentative settlement","Program to"," .01",{"$nulls":4},5.01]
[null,"payment after desk review. Also show","Provider"," .02",{"$nulls":4},"5.02"]
[null,"date of each payment.",null," .03",{"$nulls":4},"5.03"]
[null,"If none, write \"NONE,\" or enter a zero.(1)",null," .50",{"$nulls":4},"5.50"]
[null,null,"Provider to "," .51",{"$nulls":4},"5.51"]
[null,null,"Program"," .52",{"$nulls":4},"5.52"]
[null,"SUBTOTAL (Sum of lines 5.01 - 5.03 minus sum of lines 5.50 - 5.52)",null," .99",{"$nulls":4},"5.99"]
[6,"Determined net settlement amount (balance","Program to provider"," .01",{"$nulls":4},"6.01"]
[null,"due) based on the cost report. (1)","Provider to program"," .50",{"$nulls":4},"6.50"]
[7,"TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)",{"$nulls":6},"7"]
[8,"Name of Intermediary/Contractor",null,null,"Intermediary/Contractor Number",null,null,null,8]
[]
[9,"    Signature of Authorized Person",null,null,"    Date:  (mm/dd/yyyy)",null,null,null,9]
[]
[" (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-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4131 )"]
["Rev. 1",{"$nulls":7},"41-348"]
{"$rows_empty":17}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"G","index":29,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 ( Cont.)",null,null,"FORM CMS-2540-10",null,null,"2011-02-11"]
[null,null,null,"PROVIDER NO.:","PERIOD:"]
[null,"BALANCE   SHEET",null,null,"FROM ________"," WORKSHEET  G"]
["   (If you are nonproprietary and do not maintain fund-type",null,null,null,"TO ___________"]
["accounting records,  complete the \"General Fund\" column only)"]
[null,null,null,"Specific"]
[null,"Assets","General","Purpose","Endowment","Plant"]
[null,"(Omit cents)","Fund","Fund","Fund","Fund"]
[null,null,"1","2","3","4"]
[null,"CURRENT  ASSETS"]
[1,"Cash on hand and in banks",{"$nulls":4},1]
[2,"Temporary investments",{"$nulls":4},2]
[3,"Notes receivable",{"$nulls":4},3]
[4,"Accounts receivable",{"$nulls":4},4]
[5,"Other receivables",{"$nulls":4},5]
[6,"Less: allowances for uncollectible notes","  (                   )","  (                   )","  (                   )","  (                   )",6]
[null,"and accounts receivable"]
[7,"Inventory",{"$nulls":4},7]
[8,"Prepaid expenses",{"$nulls":4},8]
[9,"Other current assets",{"$nulls":4},9]
[10,"Due from other funds",{"$nulls":4},10]
[11,"TOTAL  CURRENT  ASSETS",{"$nulls":4},11]
[null,"(Sum of lines 1 - 10)"]
[null,"FIXED  ASSETS"]
[12,"Land",{"$nulls":4},12]
[13,"Land improvements",{"$nulls":4},13]
[14,"Less: Accumulated depreciation","  (                   )","  (                   )","  (                   )","  (                   )",14]
[15,"Buildings",{"$nulls":4},15]
[16,"Less Accumulated depreciation","  (                   )","  (                   )","  (                   )","  (                   )",16]
[17,"Leasehold improvements",{"$nulls":4},17]
[18,"Less: Accumulated Amortization","  (                   )","  (                   )","  (                   )","  (                   )",18]
[19,"Fixed equipment",{"$nulls":4},19]
[20,"Less: Accumulated depreciation","  (                   )","  (                   )","  (                   )","  (                   )",20]
[21,"Automobiles and trucks",{"$nulls":4},21]
[22,"Less: Accumulated depreciation","  (                   )","  (                   )","  (                   )","  (                   )",22]
[23,"Major movable equipment",{"$nulls":4},23]
[24,"Less: Accumulated depreciation","  (                   )","  (                   )","  (                   )","  (                   )",24]
[25,"Minor equipment - Depreeciable",{"$nulls":4},25]
[26,"Minor equipment nondepreciable",{"$nulls":4},26]
[27,"Other fixed assets",{"$nulls":4},27]
[28,"TOTAL  FIXED  ASSETS",{"$nulls":4},28]
[null,"(Sum of lines 12 - 27)"]
[null,"OTHER  ASSETS"]
[29,"Investments",{"$nulls":4},29]
[30,"Deposits on leases",{"$nulls":4},30]
[31,"Due from owners/officers",{"$nulls":4},31]
[32,"Other assets",{"$nulls":4},32]
[33,"TOTAL  OTHER  ASSETS",{"$nulls":4},33]
[null,"(Sum of lines 29 - 34)"]
[34,"TOTAL  ASSETS",{"$nulls":4},34]
[null,"(Sum of lines 11, 28 and 33)"]
[null,"(         ) = contra amount"]
[]
["FORM CMS 2540 10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15-II, SECTION 4140 )"]
[]
["41-349",{"$nulls":5},"Rev. 1"]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"GII","index":30,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,null,"FORM CMS-2540-10",null,null,"4190 ( Cont.)"]
[null,null,null,"PROVIDER NO.:","PERIOD:"]
["BALANCE  SHEET",null,null,null,"FROM ________"," WORKSHEET  G"]
["(If you are nonproprietary and do not maintain fund-type",null,null,null,"TO ___________","   (Cont.)"]
["accounting records,  complete the \"General Fund\" column only)"]
[null,"Liabilities and Fund",null,"Specific"]
[null,"Balances","General","Purpose","Endowment","Plant"]
[null,"(Omit cents)","Fund","Fund","Fund","Fund"]
[null,null,"1","2","3","4"]
[null,"CURRENT  LIABILITIES"]
[35,"Accounts payable",{"$nulls":4},35]
[36,"Salaries, wages & fees payable",{"$nulls":4},36]
[37,"Payroll taxes payable",{"$nulls":4},37]
[38,"Notes & loans payable (Short term)",{"$nulls":4},38]
[39,"Deferred income",{"$nulls":4},39]
[40,"Accelerated payments",{"$nulls":4},40]
[41,"Due to other funds",{"$nulls":4},41]
[42,"Other current liabilities",{"$nulls":4},42]
[43,"TOTAL  CURRENT  LIABILITIES",{"$nulls":4},43]
[null,"(Sum of lines 35 - 42)"]
[null,"LONG  TERM  LIABILITIES"]
[44,"Mortgage payable",{"$nulls":4},44]
[45,"Notes payable",{"$nulls":4},45]
[46,"Unsecured loans",{"$nulls":4},46]
[47,"Loans from owners:  ",{"$nulls":4},47]
[48,"Other long term liabilities",{"$nulls":4},48]
[49,{"$nulls":5},49]
[50,"TOTAL  LONG  TERM  LIABILITIES",{"$nulls":4},50]
[null,"(Sum of lines 44 - 49)"]
[51,"TOTAL  LIABILITIES",{"$nulls":4},51]
[null,"(Sum of lines 43 and 50)"]
[null,"CAPITAL  ACCOUNTS"]
[52,"General fund balance",{"$nulls":4},52]
[53,"Specific purpose fund",{"$nulls":4},53]
[54,"Donor created - endowment fund",{"$nulls":4},54]
[null,"balance - restricted"]
[55,"Donor created - endowment fund",{"$nulls":4},55]
[null,"balance - unrestricted"]
[56,"Governing body created - endowment",{"$nulls":4},56]
[null,"fund balance"]
[57,"Plant fund balance - invested in plant",{"$nulls":4},57]
[58,"Plant fund balance - reserve for",{"$nulls":4},58]
[null,"plant improvement, replacement and"]
[null,"expansion"]
[59,"TOTAL  FUND  BALANCES",{"$nulls":4},59]
[null,"(Sum of lines 50 thru 56)"]
[60,"TOTAL  LIABILITIES  AND",{"$nulls":4},60]
[null,"FUND  BALANCES"]
[null,"(Sum of lines 51 and 59)"]
[null,"(         ) = contra amount"]
[]
[]
["FORM CMS-2540-10  ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15-II, SECTION 4140 )"]
[]
["Rev. 1",{"$nulls":5},"41-350"]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"G-1","index":31,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[{"$nulls":4}," PROVIDER  NO:",null," PERIOD:"]
[null,"STATEMENT  OF  CHANGES  IN  FUND  BALANCES",{"$nulls":4},"  FROM ___________________",null,"          WORKSHEET  G - 1"]
[{"$nulls":4},"________________________",null,"  TO ________________"]
[]
[]
[]
[null,null,"GENERAL  FUND",null,"SPECIFIC  PURPOSE  FUND",null,"ENDOWMENT  FUND",null,"PLANT  FUND"]
[null,null,1,2,3,4,5,6,7,8]
[1,"Fund balances at beginning of ",{"$nulls":8},1]
[null,"period"]
[2,"Net income (loss) ",{"$nulls":8},2]
[null,"(From Wkst. G-3, line 32)"]
[3,"Total (Sum of line 1 and line 2)",{"$nulls":8},3]
[4,"Additions (Credit adjustments) ",{"$nulls":8},4]
[5,{"$nulls":9},5]
[6,{"$nulls":9},6]
[7,{"$nulls":9},7]
[8,{"$nulls":9},8]
[9,{"$nulls":9},9]
[10,"Total additions (Sum of lines 4 - 9)",{"$nulls":8},10]
[11,"Subtotal (Line 3 plus line 10)",{"$nulls":8},11]
[12,"Deductions (Debit adjustments)",{"$nulls":8},12]
[13,{"$nulls":9},13]
[14,{"$nulls":9},14]
[15,{"$nulls":9},15]
[16,{"$nulls":9},16]
[17,{"$nulls":9},17]
[18,"Total deductions ",{"$nulls":8},18]
[null," (Sum of lines 12 - 17)"]
[19,"Fund balance at end of period per",{"$nulls":8},19]
[null,"balance sheet (Line 11 - line 18)"]
{"$rows_empty":8}
["FORM CMS 2540-10  ( 12/10  ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4140)"]
["41-351",{"$nulls":9},"Rev. 1"]
{"$rows_empty":17}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"G-2","index":32,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,"FORM CMS-2540-10",null,null,"4190 ( Cont.)"]
[null,null,"PROVIDER NO:","PERIOD:"]
[null,"STATEMENT  OF  PATIENT  REVENUES","______________","FROM _________"," WORKSHEET  G - 2"]
[null,"AND  OPERATING  EXPENSES",null,"TO ___________","  PARTS  I  &  II"]
[null,"PART I - PATIENT REVENUES"]
[null,"Revenue  Center","INPATIENT","OUTPATIENT"," TOTAL"]
[null,null,"1","2","3"]
[null,"GENERAL  INPATIENT  ROUTINE  CARE  SERVICES"]
[1," Skilled Nursing Facility",null,null,null,1]
[2," Nursing facility",null,null,null,2]
[3," ICF/MR",null,null,null,3]
[4," Other long term care",null,null,null,4]
[5,"Total general inpatient care services ",null,null,null,5]
[null,"(Sum of lines 1 - 4)"]
[null," All Other Care Service"]
[6," Ancillary services",null,null,null,6]
[7," Clinic",null,null,null,7]
[8," Home Health Agency",null,null,null,8]
[9," Ambulance",null,null,null,9]
[10," RHC",null,null,null,10]
[11," FQHC & CMHC",null,null,null,11]
[12," SNF Based Hospice",null,null,null,12]
[13," Total Patient Revenues  ( Sum of lines 5 - 12 )",null,null,null,13]
[null," ( Transfer column 3 to Worksheet G-3, Line 1 )"]
[null,"PART II - OPERATING EXPENSES"]
[1," Operating Expenses  ( Per Worksheet A, Col. 3, Line 100 )",null,null,null,1]
[]
[2," Add  ( Specify )",null,null,null,2]
[]
[3,{"$nulls":4},3]
[]
[4,{"$nulls":4},4]
[]
[5,{"$nulls":4},5]
[]
[6,{"$nulls":4},6]
[]
[7,{"$nulls":4},7]
[]
[8," Total Additions  ( Sum of lines 2 - 7 ) ",null,null,null,8]
[]
[9," Deduct  ( Specify )",null,null,null,9]
[]
[10,{"$nulls":4},10]
[]
[11,{"$nulls":4},11]
[]
[12,{"$nulls":4},12]
[]
[13,{"$nulls":4},13]
[]
[14," Total Deductions  ( Sum of lines 9 - 13 )",null,null,null,14]
[]
[15," Total Operating Expenses  ( Sum of lines 1 and 8,  minus line 14 )",null,null,null,15]
[null," ( Transfer to  Worksheet G-3, Line 4 )"]
["FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15-II, SECTION  4140 )"]
[]
["Rev. 1",{"$nulls":4},"41-352"]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"G-3","index":33,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 ( Cont.)",null,"FORM CMS-2540-10",null,"2011-02-11"]
[null,"STATEMENT  OF  REVENUES      "," PROVIDER NO:"," PERIOD:"]
[null,"AND  EXPENSES      ","______________","  FROM _________","  WORKSHEET  G - 3"]
[null,null,null,"  TO ___________"]
[]
[1," Total patient revenues (From Wkst. G - 2,  Part I, col. 3, line 13)",null,null,null,1]
[2," Less: contractual allowances and discounts  on patients accounts",null,null,null,2]
[3," Net patient revenues (Line 1 minus line 2)",null,null,null,3]
[4," Less: total operating expenses (From Worksheet G-2, Part II, line 15)",null,null,null,4]
[5," Net income from service to patients (Line 3 minus 4)",null,null,null,5]
[6," Other income:",null,null,null,6]
[7,"     Contributions, donations, bequests, etc",null,null,null,7]
[8,"     Income from investments",null,null,null,8]
[9,"     Revenues from communications ( Telephone and Internet service)",null,null,null,9]
[10,"     Revenue from television and radio service",null,null,null,10]
[11,"     Purchase discounts",null,null,null,11]
[12,"     Rebates and refunds of expenses",null,null,null,12]
[13,"     Parking lot receipts",null,null,null,13]
[14,"     Revenue from laundry and linen service",null,null,null,14]
[15,"     Revenue from meals sold to employees and guests",null,null,null,15]
[16,"     Revenue from rental of living quarters",null,null,null,16]
[17,"     Revenue from sale of medical and surgical supplies to other than patients",null,null,null,17]
[18,"     Revenue from sale of drugs to other than patients",null,null,null,18]
[19,"     Revenue from sale of medical records and abstracts",null,null,null,19]
[20,"     Tuition (fees, sale of textbooks, uniforms, etc.)",null,null,null,20]
[21,"     Revenue from gifts, flower, coffee shops, canteen",null,null,null,21]
[22,"     Rental of vending machines",null,null,null,22]
[23,"     Rental of skilled nursing space",null,null,null,23]
[24,"     Governmental appropriations",null,null,null,24]
[25,"     Other (specify)",null,null,null,25]
[26," Total other income (Sum of lines 7 - 25)",null,null,null,26]
[27," Total (Line 5 plus line 26)",null,null,null,27]
[28," Other expenses (specify)",null,null,null,28]
[29,"",null,null,null,29]
[30,"",null,null,null,30]
[31," Total other expenses (Sum of lines 28 - 30)",null,null,null,31]
[32," Net income (or loss) for the period (Line 27 minus  line 31)",null,null,null,32]
{"$rows_empty":16}
["FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB. 15-II, SECTION 4140)"]
["41-353",{"$nulls":4},"Rev. 1"]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H","index":34,"n_rows":257,"n_cols":13,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11",null,null,null,"      FORM CMS-2540-10",{"$nulls":6}," 4190 (Cont.)"]
["ANALYSIS OF PROVIDER-BASED",{"$nulls":6},"PROVIDER NO.:  __________",null,"PERIOD:",null,"WORKSHEET"]
["HOME HEALTH AGENCY COSTS",{"$nulls":8},"FROM  __________",null,"H"]
[{"$nulls":7},"HHA NO.:  ________________",null,"TO  _____________"]
[{"$nulls":4},"TRANSPOR-","CONTRACTED/","OTHER","TOTAL","RECLASSIFI-","RECLASSIFIED","ADJUST-","NET"]
[null,null,"SALARIES","EMPLOYEE","TATION","PURCHASED ","COSTS","(sum of cols.","CATIONS","TRIAL BALANCE","MENTS","EXPENSES FOR"]
[null,"COST CENTER DESCRIPTIONS",null,"BENEFITS ","(see","SERVICES",null,"1 thru 5)",null,"(col. 6 + col. 7)",null,"ALLOCATION"]
[null,"(omit cents)",null,null,"instructions)",{"$nulls":6},"(col. 8 + col. 9)"]
[null,null,"1","2","3","4","5","6","7","8","9","10"]
["GENERAL SERVICE COST CENTERS"]
[1,"Capital Related-Bldgs. and Fixtures",{"$nulls":10},1]
[2,"Capital Related-Movable Equipment",{"$nulls":10},2]
[3,"Plant Operation & Maintenance",{"$nulls":10},3]
[4,"Transportation (see instructions)",{"$nulls":10},4]
[5,"Administrative and General",{"$nulls":10},5]
["HHA REIMBURSABLE SERVICES",{"$nulls":11}," "]
[6,"Skilled Nursing Care",{"$nulls":10},6]
[7,"Physical Therapy",{"$nulls":10},7]
[8,"Occupational Therapy",{"$nulls":10},8]
[9,"Speech Pathology",{"$nulls":10},9]
[10,"Medical Social Services",{"$nulls":10},10]
[11,"Home Health Aide",{"$nulls":10},11]
[12,"Supplies (see instructions)",{"$nulls":10},12]
[13,"Drugs",{"$nulls":10},13]
[14,"DME",{"$nulls":10},14]
[15,"Telemedicine",{"$nulls":10},15]
["HHA NONREIMBURSABLE SERVICES",{"$nulls":11}," "]
[16,"Home Dialysis Aide Service",{"$nulls":10},16]
[17,"Respiratory Therapy",{"$nulls":10},17]
[18,"Private Duty Nursing",{"$nulls":10},18]
[19,"Clinic",{"$nulls":10},19]
[20,"Health Promotion Activities",{"$nulls":10},20]
[21,"Day Care Program",{"$nulls":10},21]
[22,"Home Delivered Meals Program",{"$nulls":10},22]
[23,"Homemaker Service",{"$nulls":10},23]
[24,"All Others",{"$nulls":10},24]
[25,"Total (sum of lines 1-24)",{"$nulls":10},25]
["Column, 6 line 25 should agree with the Worksheet A, column 3, line 70, or subscript as applicable. "]
{"$rows_empty":7}
["FORM CMS-2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 4141)"]
[]
[]
["Rev. 1",{"$nulls":11},"       41-354"]
{"$rows_empty":10}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H1-1","index":35,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["   4190 (Cont.)",null,null,"      FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":5},"PROVIDER NO.:  ___________",null,"  PERIOD:",null,"WORKSHEET H-1"]
["COST ALLOCATION - HHA GENERAL SERVICE COST",{"$nulls":6},"  FROM  ________________",null,"PART I"]
[{"$nulls":5},"HHA NO.:  ________________",null,"  TO   ___________________"]
[null,null,"NET EXPENSES","CAPITAL"]
[null,null,"FOR COST","RELATED COSTS"]
[null,null,"ALLOCATION",null,null,"PLANT",null,null,"ADMINIS-"]
[null,null,"(from Wkst.","BLDGS. &","MOVABLE","OPERATION &","TRANS-","SUBTOTAL","TRATIVE","TOTAL"]
[null,null,"H, col. 10)","FIXTURES","EQUIPMENT","MAINTENANCE","PORTATION","(cols. 0-4)","& GENERAL","(cols. 4a + 5)"]
[null,null,"0","1","2","3","4","4a","5","6"]
["GENERAL SERVICE COST CENTERS"]
[1,"Capital Related-Bldgs. and Fixtures",{"$nulls":8},1]
[2,"Capital Related-Movable Equipment",{"$nulls":8},2]
[3,"Plant Operation & Maintenance",{"$nulls":8},3]
[4,"Transportation (see instructions)",{"$nulls":8},4]
[5,"Administrative and General",{"$nulls":8},5]
["HHA REIMBURSABLE SERVICES"]
[6,"Skilled Nursing Care",{"$nulls":8},6]
[7,"Physical Therapy",{"$nulls":8},7]
[8,"Occupational Therapy",{"$nulls":8},8]
[9,"Speech Pathology",{"$nulls":8},9]
[10,"Medical Social Services",{"$nulls":8},10]
[11,"Home Health Aide",{"$nulls":8},11]
[12,"Supplies (see instructions)",{"$nulls":8},12]
[13,"Drugs",{"$nulls":8},13]
[14,"DME",{"$nulls":8},14]
[15,"Telemedicine",{"$nulls":8},15]
["HHA NONREIMBURSABLE SERVICES"]
[16,"Home Dialysis Aide Services",{"$nulls":8},16]
[17,"Respiratory Therapy",{"$nulls":8},17]
[18,"Private Duty Nursing",{"$nulls":8},18]
[19,"Clinic",{"$nulls":8},19]
[20,"Health Promotion Activities",{"$nulls":8},20]
[21,"Day Care Program",{"$nulls":8},21]
[22,"Home Delivered Meals Program",{"$nulls":8},22]
[23,"Homemaker Service",{"$nulls":8},23]
[24,"All Others",{"$nulls":8},24]
[25,"Totals (sum of lines 1-24)",{"$nulls":8},25]
[]
[]
[]
[]
[]
["FORM CMS-2540-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4142)"]
[]
["          41-355",{"$nulls":8},"Rev. 1"]
{"$rows_empty":13}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H1-II","index":36,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11","      FORM CMS-2540-10",{"$nulls":6},"    4190 (Cont.)"]
[{"$nulls":4},"PROVIDER NO.:  __________",null,"  PERIOD:",null,"WORKSHEET H-1,"]
["COST ALLOCATION - HHA STATISTICAL BASIS",{"$nulls":5},"  FROM _________________",null,"PART II"]
[{"$nulls":4},"HHA NO.:  ________________",null,"  TO ___________________"]
[null,null,null,"CAPITAL"]
[null,null,null,"RELATED COSTS",null,"PLANT",null,null,"ADMINIS-"]
[null,null,null,"BLDGS. &","MOVABLE","OPERATION &",null,null,"TRATIVE"]
[null,null,null,"FIXTURES","EQUIPMENT","MAINTENANCE","TRANS-",null,"& GENERAL"]
[null,null,null,"(SQUARE","(DOLLAR","(SQUARE","PORTATION","RECONCIL-","(ACCUM."]
[null,null,null,"FEET)","VALUE)","FEET)","(MILEAGE)","IATION","COST)"]
[null,null,null,"1","2","3","4","5a","5"]
["GENERAL SERVICE COST CENTERS"]
[1,"Capital Related-Bldgs. and Fixtures",{"$nulls":7},1]
[2,"Capital Related-Movable Equipment",{"$nulls":7},2]
[3,"Plant Operation & Maintenance",{"$nulls":7},3]
[4,"Transportation (see instructions)",{"$nulls":7},4]
[5,"Administrative and General",{"$nulls":7},5]
["HHA REIMBURSABLE SERVICES"]
[6,"Skilled Nursing Care",{"$nulls":7},6]
[7,"Physical Therapy",{"$nulls":7},7]
[8,"Occupational Therapy",{"$nulls":7},8]
[9,"Speech Pathology",{"$nulls":7},9]
[10,"Medical Social Services",{"$nulls":7},10]
[11,"Home Health Aide",{"$nulls":7},11]
[12,"Supplies (see instructions)",{"$nulls":7},12]
[13,"Drugs",{"$nulls":7},13]
[14,"DME",{"$nulls":7},14]
[15,"Telemedicine",{"$nulls":7},15]
["HHA NONREIMBURSABLE SERVICES"]
[16,"Home Dialysis Aide Services",{"$nulls":7},16]
[17,"Respiratory Therapy",{"$nulls":7},17]
[18,"Private Duty Nursing",{"$nulls":7},18]
[19,"Clinic",{"$nulls":7},19]
[20,"Health Promotion Activities",{"$nulls":7},20]
[21,"Day Care Program",{"$nulls":7},21]
[22,"Home Delivered Meals Program",{"$nulls":7},22]
[23,"Homemaker Service",{"$nulls":7},23]
[24,"All Others",{"$nulls":7},24]
[25,"Total (sum of lines 1-24)",{"$nulls":7},25]
[26,"Cost To Be Allocated ",{"$nulls":7},26]
[27,"Unit Cost Multiplier",{"$nulls":7},27]
[]
["FORM CMS-2540-10 (DRAFT)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4142)"]
[]
["Rev. 1",{"$nulls":8},"            41-356"]
{"$rows_empty":14}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H2-1","index":37,"n_rows":257,"n_cols":34,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["         4190 (Cont.)",null,null,null,"      FORM CMS-2540-10",{"$nulls":5},"2011-02-11",null,null,"2011-02-11",null,null,"      FORM CMS-2540-10",{"$nulls":4},"         4190 (Cont.)",null,null,"4190 (Cont.)",null,"      FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":4},"PROVIDER NO.: ______________",null,null,"PERIOD:",null,"WORKSHEET H-2,",null,"ALLOCATION OF GENERAL SERVICE",null,null,"PROVIDER NO.: ______________",null,null,"PERIOD:",null,"WORKSHEET H-2,",null,null,"ALLOCATION OF GENERAL SERVICE",null,null,"PROVIDER NO.: ______________",null,null,"PERIOD:",null,"WORKSHEET H-2,"]
["COSTS TO HHA COST CENTERS",{"$nulls":4},"HHA NO.: _____________",null,null,"FROM__________________",null,"PART I",null,"COSTS TO HHA COST CENTERS",null,null,"HHA NO.: _____________",null,null,"FROM__________________",null,"PART I (CONT.)",null,null,"COSTS TO HHA COST CENTERS",null,null,"HHA NO.: _____________",null,null,"FROM ______________",null,"PART I (CONT.)"]
[{"$nulls":8},"TO ___________________",{"$nulls":9},"TO ___________________",{"$nulls":10},"TO _________________"]
[null,null,"From",null,"NEW CAPITAL",null," ",null," ",{"$nulls":8}," "," ",{"$nulls":6}," "," ",null,null,"INTERN &"]
[null,null,"Wkst","HHA","RELATED COSTS",{"$nulls":24},"RESIDENT",null,"ALLOCATED"]
[null,"HHA COST CENTER"," H-1","TRIAL"," "," ",null,null,"ADMINIS-",null,"LAUNDRY",null,null,"CORF COST CENTER",null,null,"NURSING","CENTRAL",null,"MEDICAL",{"$nulls":4},"HHA COST CENTER","INTERNS & RESIDENTS",null,"OTHER","SUBTOTAL","COST & POST",null,"HHA"]
[null,"(omit cents)","Part I,","BALANCE","BLDGS. &","MOVABLE","EMPLOYEE","SUBTOTAL","TRATIVE &","OPERATION","& LINEN",null,null,"(omit cents)","HOUSE"," ","ADMINIS-","SERVICES &",null,"RECORDS &","SOCIAL",null,null,null,"(omit cents)","SALARY AND","PROGRAM","GENERAL","(sum of cols.","STEPDOWN","SUBTOTAL","A&G (see","TOTAL"]
[null,null,"col. 6,","(1)","FIXTURES","EQUIPMENT","BENEFITS","(cols. 0-3)","GENERAL","OF PLANT","SERVICE",null,null,null,"KEEPING","DIETARY","TRATION","SUPPLY","PHARMACY","LIBRARY","SERVICE",{"$nulls":4},"FRINGES","COSTS","SERVICE","3a-16)","ADJUSTMENTS","(cols. 17 ± 18)","Part II)","HHA COSTS"]
[null,null,"line","0",1,2,3,"3A",4,5,6,null,null,null,7,8,9,10,11,12,13,{"$nulls":4},14,15,16,17,18,19,20,21]
[1,"Administrative and General","5",{"$nulls":8},1,1,"Administrative and General",{"$nulls":7},1,null,1,"Administrative and General",{"$nulls":8},1]
[2,"Skilled Nursing Care","6",{"$nulls":8},2,2,"Skilled Nursing Care",{"$nulls":7},2,null,2,"Skilled Nursing Care",{"$nulls":8},2]
[3,"Physical Therapy","7",{"$nulls":8},3,3,"Physical Therapy",{"$nulls":7},3,null,3,"Physical Therapy",{"$nulls":8},3]
[4,"Occupational Therapy","8",{"$nulls":8},4,4,"Occupational Therapy",{"$nulls":7},4,null,4,"Occupational Therapy",{"$nulls":8},4]
[5,"Speech Pathology","9",{"$nulls":8},5,5,"Speech Pathology",{"$nulls":7},5,null,5,"Speech Pathology",{"$nulls":8},5]
[6,"Medical Social Services","10",{"$nulls":8},6,6,"Medical Social Services",{"$nulls":7},6,null,6,"Medical Social Services",{"$nulls":8},6]
[7,"Home Health Aide","11",{"$nulls":8},7,7,"Home Health Aide",{"$nulls":7},7,null,7,"Home Health Aide",{"$nulls":8},7]
[8,"Supplies","12",{"$nulls":8},8,8,"Supplies",{"$nulls":7},8,null,8,"Supplies",{"$nulls":8},8]
[9,"Drugs","13",{"$nulls":8},9,9,"Drugs",{"$nulls":7},9,null,9,"Drugs",{"$nulls":8},9]
[10,"DME","14",{"$nulls":8},10,10,"DME",{"$nulls":7},10,null,10,"DME",{"$nulls":8},10]
[11,"Telemedicine","15",{"$nulls":8},11,11,"Telemedicine",{"$nulls":7},11,null,11,"Telemedicine",{"$nulls":8},11]
[12,"Home Dialysis Aide Services","16",{"$nulls":8},12,12,"Home Dialysis Aide Services",{"$nulls":7},12,null,12,"Home Dialysis Aide Services",{"$nulls":8},12]
[13,"Respiratory Therapy","17",{"$nulls":8},13,13,"Respiratory Therapy",{"$nulls":7},13,null,13,"Respiratory Therapy",{"$nulls":8},13]
[14,"Private Duty Nursing","18",{"$nulls":8},14,14,"Private Duty Nursing",{"$nulls":7},14,null,14,"Private Duty Nursing",{"$nulls":8},14]
[15,"Clinic","19",{"$nulls":8},15,15,"Clinic",{"$nulls":7},15,null,15,"Clinic",{"$nulls":8},15]
[16,"Health Promotion Activities","20",{"$nulls":8},16,16,"Health Promotion Activities",{"$nulls":7},16,null,16,"Health Promotion Activities",{"$nulls":8},16]
[17,"Day Care Program","21",{"$nulls":8},17,17,"Day Care Program",{"$nulls":7},17,null,17,"Day Care Program",{"$nulls":8},17]
[18,"Home Delivered Meals Program","22",{"$nulls":8},18,18,"Home Delivered Meals Program",{"$nulls":7},18,null,18,"Home Delivered Meals Program",{"$nulls":8},18]
[19,"Homemaker Service","23",{"$nulls":8},19,19,"Homemaker Service",{"$nulls":7},19,null,19,"Homemaker Service",{"$nulls":8},19]
[20,"All Others",24,{"$nulls":8},20,20,"All Others",{"$nulls":7},20,null,20,"All Others",{"$nulls":8},20]
[21,"Totals (sum of lines 1-20) (2)",{"$nulls":9},21,21,"Totals (sum of lines 1-20) (2)",{"$nulls":7},21,null,21,"Totals (sum of lines 1-20) (2)",{"$nulls":8},21]
[22,"Unit Cost Multiplier: column 19, line 1 ",{"$nulls":9},22,22,"Unit Cost Multiplier: column 19, line 1 ",{"$nulls":7},22,null,22,"Unit Cost Multiplier: column 19, line 1 ",{"$nulls":8},22]
[null,"divided by the sum of column 19,",{"$nulls":11},"divided by the sum of column 19,",{"$nulls":10},"divided by the sum of column 19,"]
[null,"line 21, minus column 19, line 1,",{"$nulls":11},"line 21, minus column 19, line 1,",{"$nulls":10},"line 21, minus column 19, line 1,"]
[null,"rounded to 6 decimal places.",{"$nulls":11},"rounded to 6 decimal places.",{"$nulls":10},"rounded to 6 decimal places."]
[]
["(1) Column 0, line 21 must agree with Wkst. A, column 7, line 70.",{"$nulls":11},"(2) Columns 0 through 20 line 21 must agree with the corresponding columns of Wkst. B, Part I, line 70.",{"$nulls":10},"(2) Columns 0 through 20, line 21 must agree with the corresponding columns of Wkst. B, Part I, line 70."]
["(2) Columns 0 through 20, line 21 must agree with the corresponding columns of Wkst. B, Part I, line 70."]
[]
[]
[]
[]
["FORM CMS-2540-10 (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)",{"$nulls":11},"FORM CMS-2540-10 (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)",{"$nulls":10},"FORM CMS-2540-10 (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)"]
[]
["     41-357",{"$nulls":10},"Rev. 1","Rev. 1",{"$nulls":8},"       41-358",null,null,"       41-359",{"$nulls":8},"Rev. 1"]
{"$rows_empty":14}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H2-II","index":38,"n_rows":257,"n_cols":29,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["  4190 (Cont.)",null,null,null,"      FORM CMS-2540-10",{"$nulls":4},"2011-02-11",null,null,"2011-02-11",null,null,"      FORM CMS-2540-10",null,null,null,"  4190 (Cont.)","  4190 (Cont.)",null,null,"      FORM CMS-2540-10",null,null,null,"2011-02-11"]
["ALLOCATION OF GENERAL SERVICE",null,"PROVIDER NO.: ___________",null,null,"PERIOD:",null,null,"WORKSHEET H-2,",null,null,"ALLOCATION OF GENERAL SERVICE",null,"PROVIDER NO.: ______________",null,"PERIOD:",null,"WORKSHEET H-2,",null,null,"ALLOCATION OF GENERAL SERVICE",null,"PROVIDER NO.: __________",null,"PERIOD:",null,"WORKSHEET H-2,"]
["COSTS TO HHA COST CENTERS",null,"HHA NO.: _____________",null,null,"FROM__________________",null,null,"PART II",null,null,"COSTS TO HHA COST CENTERS",null,"HHA NO.: _____________",null,"FROM__________________",null,"PART II (CONT.)",null,null,"COSTS TO HHA COST CENTERS",null,"HHA NO.: _____________",null,"FROM__________________",null,"PART II (CONT.)"]
["STATISTICAL BASIS",{"$nulls":4},"TO ___________________",{"$nulls":5},"STATISTICAL BASIS",null,null,null,"TO ___________________",{"$nulls":4},"STATISTICAL BASIS",null,null,null,"TO ___________________"]
[{"$nulls":4},"CAPITAL",null," ",null," ",{"$nulls":8}," "]
[{"$nulls":4},"RELATED COST",null,null,null,"ADMINIS-",{"$nulls":4},"LAUNDRY",null,null,"NURSING","CENTRAL",{"$nulls":5},"MEDICAL",null,"INTERNS & RESIDENTS"]
[{"$nulls":4},"BLDGS. &","MOVABLE","EMPLOYEE",null,"TRATIVE &","OPERATION",null,null,null,"& LINEN","HOUSE-"," ","ADMINIS-","SERVICES &",{"$nulls":5},"RECORDS &","SOCIAL","SALARY &","PROGRAM","OTHER"]
[null,"HHA COST CENTER",null,null,"FIXTURES","EQUIPMENT","BENEFITS",null,"GENERAL","OF PLANT",null,null,"HHA COST CENTER","SERVICE","KEEPING","DIETARY","TRATION","SUPPLY","PHARMACY",null,null,"HHA COST CENTER",null,"LIBRARY","SERVICE","FRINGES","COSTS","GENERAL"]
[{"$nulls":4},"(SQUARE","(DOLLAR","(GROSS","RECONCIL-","(ACCUM.","(SQUARE",null,null,null,"(POUNDS OF","(HOURS OF","(MEALS","(DIRECT","(COSTED","(COSTED",{"$nulls":4},"(TIME","(TIME","(ASSIGNED","(ASSIGNED","SERVICE"]
[{"$nulls":4},"FEET)","VALUE)","SALARIES)","IATION","COST)","FEET)",null,null,null,"LAUNDRY)","SERVICE)","SERVED)","NURS. HRS)","REQUIS.)","REQUIS.)",{"$nulls":4},"SPENT)","SPENT)","TIME)","TIME)","(SPECIFY)"]
[{"$nulls":4},1,2,3,"3A",4,5,null,null,null,6,7,8,9,10,11,{"$nulls":4},12,13,14,15,16]
[1,"Administrative and General",{"$nulls":8},1,1,"Administrative and General",{"$nulls":6},1,1,"Administrative and General",{"$nulls":6},1]
[2,"Skilled Nursing Care",{"$nulls":8},2,2,"Skilled Nursing Care",{"$nulls":6},2,2,"Skilled Nursing Care",{"$nulls":6},2]
[3,"Physical Therapy",{"$nulls":8},3,3,"Physical Therapy",{"$nulls":6},3,3,"Physical Therapy",{"$nulls":6},3]
[4,"Occupational Therapy",{"$nulls":8},4,4,"Occupational Therapy",{"$nulls":6},4,4,"Occupational Therapy",{"$nulls":6},4]
[5,"Speech Pathology",{"$nulls":8},5,5,"Speech Pathology",{"$nulls":6},5,5,"Speech Pathology",{"$nulls":6},5]
[6,"Medical Social Services",{"$nulls":8},6,6,"Medical Social Services",{"$nulls":6},6,6,"Medical Social Services",{"$nulls":6},6]
[7,"Home Health Aide",{"$nulls":8},7,7,"Home Health Aide",{"$nulls":6},7,7,"Home Health Aide",{"$nulls":6},7]
[8,"Supplies",{"$nulls":8},8,8,"Supplies",{"$nulls":6},8,8,"Supplies",{"$nulls":6},8]
[9,"Drugs",{"$nulls":8},9,9,"Drugs",{"$nulls":6},9,9,"Drugs",{"$nulls":6},9]
[10,"DME",{"$nulls":8},10,10,"DME",{"$nulls":6},10,10,"DME",{"$nulls":6},10]
[11,"Telemedicine",{"$nulls":8},11,11,"Telemedicine",{"$nulls":6},11,11,"Telemedicine",{"$nulls":6},11]
[12,"Home Dialysis Aide Services",{"$nulls":8},12,12,"Home Dialysis Aide Services",{"$nulls":6},12,12,"Home Dialysis Aide Services",{"$nulls":6},12]
[13,"Respiratory Therapy",{"$nulls":8},13,13,"Respiratory Therapy",{"$nulls":6},13,13,"Respiratory Therapy",{"$nulls":6},13]
[14,"Private Duty Nursing",{"$nulls":8},14,14,"Private Duty Nursing",{"$nulls":6},14,14,"Private Duty Nursing",{"$nulls":6},14]
[15,"Clinic",{"$nulls":8},15,15,"Clinic",{"$nulls":6},15,15,"Clinic",{"$nulls":6},15]
[16,"Health Promotion Activities",{"$nulls":8},16,16,"Health Promotion Activities",{"$nulls":6},16,16,"Health Promotion Activities",{"$nulls":6},16]
[17,"Day Care Program",{"$nulls":8},17,17,"Day Care Program",{"$nulls":6},17,17,"Day Care Program",{"$nulls":6},17]
[18,"Home Delivered Meals Program",{"$nulls":8},18,18,"Home Delivered Meals Program",{"$nulls":6},18,18,"Home Delivered Meals Program",{"$nulls":6},18]
[19,"Homemaker Service",{"$nulls":8},19,19,"Homemaker Service",{"$nulls":6},19,19,"Homemaker Service",{"$nulls":6},19]
[20,"All Others",{"$nulls":8},20,20,"All Others",{"$nulls":6},20,20,"All Others",{"$nulls":6},20]
[21,"Totals (sum of lines 1-20)",{"$nulls":8},21,21,"Totals (sum of lines 1-20)",{"$nulls":6},21,21,"Totals (sum of lines 1-20)",{"$nulls":6},21]
[22,"Total cost to be allocated",{"$nulls":8},22,22,"Total cost to be allocated",{"$nulls":6},22,22,"Total cost to be allocated",{"$nulls":6},22]
[23,"Unit Cost Multiplier",{"$nulls":8},23,23,"Unit Cost Multiplier",{"$nulls":6},23,23,"Unit Cost Multiplier",{"$nulls":6},23]
[]
[]
["FORM CMS-2540-10  (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)",{"$nulls":10},"FORM CMS-2540-10  (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)",{"$nulls":8},"FORM CMS-2540-10  (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)"]
[]
["          41-360",{"$nulls":9},"Rev. 1","Rev. 1",{"$nulls":7},"          41-361","          41-362",{"$nulls":7},"Rev. 1"]
{"$rows_empty":20}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H3-I","index":39,"n_rows":257,"n_cols":16,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11",{"$nulls":4},"      FORM CMS-2540-10",{"$nulls":8},"             4190 (Cont.)"]
[{"$nulls":7},"PROVIDER NO.:_____________",null,null," PERIOD:",null,null,"   WORKSHEET H-3,"]
["APPORTIONMENT OF PATIENT SERVICE COSTS",{"$nulls":9}," FROM ______________",null,null,"     Parts   I &  II "]
[{"$nulls":7},"HHA NO.:________________",null,null," TO   ________________"]
["Check applicable box",null,null," [ ] Title V     [ ] Title XVIII     [ ] Title XIX"]
["PART I - COMPUTATION OF LESSER OF AGGREGATE PROGRAM COST, AGGREGATE OF THE PROGRAM LIMITATION COST, OR BENEFICIARY COST LIMITATION"]
["Cost Per Visit Computation",null,"From,","Facility","Shared",null,null,"Average",null,"Program Visits",null,null,"Cost of Services"]
[null,null,"Wkst.","Costs","Ancillary",null,null,"Cost",null,"                    Part B",null,null,"                    Part B",null,"Total"]
[null,null,"H-2,","(From","Costs","Total HHA",null,"Per Visit",null,"Not Subject","Subject",null,"Not Subject","Subject","Program Cost"]
[null,"Patient Services","Part I,","Wkst. H-2,","(From","Costs","Total","(col. 3 ",null,"to Deductibles ","to Deductibles ",null,"to Deductibles ","to Deductibles ","(sum of"]
[null,null,"col. 21,","Part I)","Part II)","(cols. 1 + 2)","Visits","÷ col. 4)","Part A","& Coinsurance","& Coinsurance","Part A","& Coinsurance","& Coinsurance","cols. 9-10)"]
[null,null,"line -","1","2","3","4","5","6","7","8","9","10","11","12"]
[1,"Skilled Nursing Care","2",{"$nulls":12},1]
[2,"Physical Therapy","3",{"$nulls":12},2]
[3,"Occupational Therapy","4",{"$nulls":12},3]
[4,"Speech Pathology","5",{"$nulls":12},4]
[5,"Medical Social Services","6",{"$nulls":12},5]
[6,"Home Health Aide","7",{"$nulls":12},6]
[7,"Total (sum of lines 1-6)",{"$nulls":13},7]
[]
["Supplies and Drugs Cost",{"$nulls":8},"       Program Covered Charges",null,null,null,"Cost of Services"]
[" Computations",null,null,"From","Facility","Shared",null,"Total",null,null,"                    Part B",null,null,"                    Part B"]
[null,null,null,"Wkst. H-2,","Costs","Ancillary","Total","Charges",null,null,"Not Subject","Subject",null,"Not Subject","Subject"]
[null,"Other Patient Services",null,"Part I,","(From ","Costs","HHA","(from","Ratio",null,"to","to",null,"to","to"]
[{"$nulls":4},"Wkst. H-2,","(From","Cost","HHA","(col. 3",null,"Deductibles","Deductibles",null,"Deductibles","Deductibles"]
[null,null,null,"col. 21,","Part I)","Part II)","(cols. 1 + 2)","Record)","÷ col. 4)","Part A","& Coinsurance","& Coinsurance","Part A","Coinsurance","Coinsurance"]
[null,null,null,"line -","1","2","3","4","5","6","7","8","9","10","11"]
[8,"Cost of Medical Supplies",null,"8",{"$nulls":11},8]
[9,"Cost of Drugs",null,"9",{"$nulls":11},9]
[]
["PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED SKILLED NURSING FACILITY DEPARTMENTS"]
[{"$nulls":9},"             Total"]
[{"$nulls":9},"         HHA Charge",null,"         HHA Shared",null,"                  Transfer to"]
[{"$nulls":5},"      From Wkst. C,",null,"         Cost to Charge",null,"       (From Provider",null,"                 Ancillary Cost",null,"                   Part I"]
[{"$nulls":5},"             col. 3",null,"             Ratio",null,"            records)",null,"                   (Col.1 X Col 2)",null,"                   as indicated"]
[{"$nulls":5},"               line -",null,1,null,2,null,3,null,4]
[1,"Physical Therapy",null,null,null,44,{"$nulls":7},"          col. 2, line 2",null,1]
[2,"Occupational Therapy",null,null,null,45,{"$nulls":7},"          col. 2, line 3",null,2]
[3,"Speech Pathology",null,null,null,46,{"$nulls":7},"          col. 2, line 4",null,3]
[4,"Cost of Medical Supplies",null,null,null,48,{"$nulls":7},"          col. 2, line 8",null,4]
[5,"Cost of Drugs",null,null,null,49,{"$nulls":7},"          col. 2, line 9",null,5]
[]
[]
["FORM CMS-2540-10 (12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4144"]
[]
["Rev. 1",{"$nulls":14},"        41-363"]
{"$rows_empty":13}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H4","index":40,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["           4190 (Cont.)",null,"      FORM CMS-2540-10",null,null,null,"2011-02-11"]
[null,null,null,"PROVIDER NO.:"," PERIOD:","WORKSHEET H-4,"]
["CALCULATION OF HHA",null,null,"______________"," FROM___________","Parts I & II"]
["REIMBURSEMENT SETTLEMENT",null,null,"HHA NO.:"," TO______________"]
[null,null,null,"______________"]
["Check Applicable Box",null," [ ] Title V","[  ]  Title XVIII","[  ]  Title XIX"]
["PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES"]
[{"$nulls":4},"Part B"]
[{"$nulls":4},"Not Subject to","Subject to"]
[{"$nulls":4},"Deductibles","Deductibles"]
[null,null,null,"Part A","& Coinsurance","& Coinsurance"]
[null,"        Description",null,"1","2","3"]
[null,"Reasonable Cost of Part A & Part B Services"]
[1,"Reasonable cost of services (see instructions)",{"$nulls":4},1]
[2,"Total charges ",{"$nulls":4},2]
[null,"Customary Charges"]
[3,"Amount actually collected from patients liable for payment",{"$nulls":4},3]
[null,"for services on a charge basis (from your records)"]
[4,"Amount that would have been realized from patients liable",{"$nulls":4},4]
[null,"for payment for services on a charge basis had such"]
[null,"payment been made in accordance with 42 CFR 413.13(b)"]
[5,"Ratio of line 3 to line 4 (not to exceed 1.000000)",{"$nulls":4},5]
[6,"Total customary charges (see instructions)",{"$nulls":4},6]
[7,"Excess of total customary charges over total reasonable",{"$nulls":4},7]
[null,"cost (complete only if line 6 exceeds line 1)"]
[8,"Excess of reasonable cost over customary charges ",{"$nulls":4},8]
[null,"(complete only if line 1 exceeds line 6)"]
[9,"Primary payer amounts",{"$nulls":4},9]
["PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT"]
[{"$nulls":4},"Part A Services","Part B Services"]
[null,"        Description",null,null,"1","2"]
[10,"Total reasonable cost (see instructions)",{"$nulls":4},10]
[11,"Total PPS Reimbursement - Full Episodes without Outliers",{"$nulls":4},11]
[12,"Total PPS Reimbursement - Full Episodes with Outliers",{"$nulls":4},12]
[13,"Total PPS Reimbursement - LUPA Episodes",{"$nulls":4},13]
[14,"Total PPS Reimbursement - PEP Episodes",{"$nulls":4},14]
[15,"Total PPS Outlier Reimbursement - Full Episodes with Outliers",{"$nulls":4},15]
[16,"Total PPS Outlier Reimbursement - PEP Episodes",{"$nulls":4},16]
[17,"Total Other Payments",{"$nulls":4},17]
[18,"DME Payments",{"$nulls":4},18]
[19,"Oxygen Payments",{"$nulls":4},19]
[20,"Prosthetic and Orthotic Payments",{"$nulls":4},20]
[21,"Part B deductibles billed to Medicare patients (exclude coinsurance)",{"$nulls":4},21]
[22,"Subtotal (sum of lines 10 thru 20 minus line 21)",{"$nulls":4},22]
[23,"Excess reasonable cost (from line 8)",{"$nulls":4},23]
[24,"Subtotal (line 22 minus line 23)",{"$nulls":4},24]
[25,"Coinsurance billed to program patients (from your records)",{"$nulls":4},25]
[26,"Net cost (line 24 minus line 25)",{"$nulls":4},26]
[27,"Reimbursable bad debts (from your records)",{"$nulls":4},27]
[28,"Reimbursable bad debts for dual eligible beneficiaries (see instructions)",{"$nulls":4},28]
[29,"Total costs - current cost reporting period (line 26 plus line 27)",{"$nulls":4},29]
[30,"Other adjustments (see instructions) (specify)",{"$nulls":4},30]
[31,"Subtotal (line 29 plus/minus line 30)",{"$nulls":4},31]
[32,"Interim payments (see instructions)",{"$nulls":4},32]
[33,"Tentative settlement (for fiscal intermediary use only)",{"$nulls":4},33]
[34,"Balance due provider/program (line 31 minus lines 32 and 33)",{"$nulls":4},34]
[35,"Protested amounts (nonallowable cost report items) in accordance with CMS",{"$nulls":4},35]
[null,"Pub. 15-II, section 115.2"]
[]
[" "]
[]
[]
[]
[]
["FORM CMS-2510-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4145)"]
[]
["             41-364",{"$nulls":5},"Rev. 1"]
{"$rows_empty":189}
[{"$nulls":11},"Rev. 1"]

{"sheet":"H5","index":41,"n_rows":257,"n_cols":30,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",{"$nulls":5},"      FORM CMS-2540-10",{"$nulls":5},"    4190 (Cont.)"]
["ANALYSIS OF PAYMENTS TO PROVIDER-",{"$nulls":5}," PROVIDER NO.:",null,null," PERIOD:",null,"WORKSHEET H-5",{"$nulls":17},"{APP4}IALLWAYS~/lp2~q/PCOPB1~Q/pGQ/1"]
["BASED HHAs FOR SERVICES ",{"$nulls":5}," ______________________",null,null," FROM _____________"]
["RENDERED TO PROGRAM BENEFICIARIES",{"$nulls":5}," HHA NO.:",null,null," TO ________________"]
[{"$nulls":6}," ______________________"]
[]
[null,null,"     Description",{"$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 ",{"$nulls":10},1]
[2," Interim payments payable on individual bills either submitted or to",{"$nulls":10},2]
[null," be submitted to the intermediary/contractor for services rendered"]
[null," in the 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},3.5]
[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"]
[null," of lines 3.50-3.98)                         ",{"$nulls":5},".99",{"$nulls":4},3.99]
[4," Total interim payments (sum of lines 1, 2, and 3.99)",{"$nulls":10},4]
[null," (Transfer to Wkst. H-4, Part II, column as appropriate, line 32)"]
[]
[{"$nulls":4},"TO BE COMPLETED BY INTERMEDIARY/CONTRACTOR"]
[]
[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},5.5]
[{"$nulls":6},"    to   ",".51",{"$nulls":4},5.51]
[{"$nulls":6},"Program",".52",{"$nulls":4},5.52]
[null," Subtotal (sum of lines 5.01-5.49 minus sum  "]
[null," of lines 5.50-5.98)      ",{"$nulls":5},".99",{"$nulls":4},5.99]
[6," Determine net settlement amount (balance due)",{"$nulls":4},"Program"]
[null," based on the cost report (see instructions)",{"$nulls":4},"    to   ",".01"]
[{"$nulls":6},"Provider",{"$nulls":5},6.01]
[{"$nulls":6},"Provider"]
[{"$nulls":6},"    to   ",".02"]
[{"$nulls":6},"Program",{"$nulls":5},6.02]
[7," TOTAL MEDICARE PROGRAM LIABILITY ",{"$nulls":10},7]
[null," (see instructions) "]
[8," Name of Intermediary/Contractor",{"$nulls":7},"    Intermediary Number",null,null,8]
[]
[]
[9," Signature of Authorized Person",{"$nulls":7},"    Date:   (mm/dd/yyyy)",null,null,9]
[]
[]
[" (1)  On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which the provider"]
["      agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
[]
[]
[]
[]
[]
[" "]
[]
["Rev. 1",{"$nulls":11},"           36-365"]
{"$rows_empty":194}
[{"$nulls":11},"Rev. 1"]

{"sheet":"I1","index":42,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["2011-02-11",null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 ( Cont.)"]
["ANALYSIS OF SNF-BASED RURAL HEALTH",null,null,"PROVIDER NO:",null,"PERIOD:"]
["CLINIC/FEDERALLY QUALIFIED",{"$nulls":4},"FROM___________________",null,"WORKSHEET   I-1"]
["HEALTH CENTER COSTS",null,null,"COMPONENT NO:",null,"TO____________________"]
["Check Applicable Box:",null,"[     ]  RHC","[     ]  FQHC"]
[{"$nulls":6},"RECLASSIFIED",null,"NEW EXPENSES"]
[null,null,"COMPEN-","OTHER","TOTAL","RECLASSIFI-","TRIAL","ADJUSTMENTS","FOR"]
[null,null,"SATION","COSTS","(Col. 1 + Col. 2)","CATIONS","BALANCE",null,"ALLOCATION"]
[{"$nulls":6},"(Col. 3 +/- Col. 4)",null,"(Col. 5 +/- Col.6)"]
[null,null,"1","2","3","4","5","6","7"]
["FACILITY HEALTH CARE STAFF COSTS"]
[1,"Physician",{"$nulls":7},1]
[2,"Physician Assistant",{"$nulls":7},2]
[3,"Nurse Practitioner",{"$nulls":7},3]
[4,"Visiting Nurse",{"$nulls":7},4]
[5,"Other Nurse",{"$nulls":7},5]
[6,"Clinical Psychologist",{"$nulls":7},6]
[7,"Clinical Social Worker",{"$nulls":7},7]
[8,"Laboratory Technician",{"$nulls":7},8]
[9,"Other Facility Health Care Staff Costs",{"$nulls":7},9]
[10,"Subtotal (Sum of lines 1 - 9)",{"$nulls":7},10]
["COSTS UNDER AGREEMENT"]
[11,"Physician Services Under Agreement",{"$nulls":7},11]
[12,"Physician Supervision Under Agreement",{"$nulls":7},12]
[13,"Other Costs Under Agreement",{"$nulls":7},13]
[14,"Subtotal (Sum of lines 11 - 13)",{"$nulls":7},14]
["OTHER HEALTH CARE COSTS"]
[15,"Medical Supplies",{"$nulls":7},15]
[16,"Transportation (Health Care Staff) ",{"$nulls":7},16]
[17,"Depreciation - Medical Equipment",{"$nulls":7},17]
[18,"Professional Liability Insurance",{"$nulls":7},18]
[19,"Other Health Care Costs",{"$nulls":7},19]
[20,"Allowable GME Pass-through cost.",{"$nulls":7},20]
[21,"Subtotal (Sum of lines 15 - 19, less line 20)",{"$nulls":7},21]
[22,"Total Cost of Health Care Services",{"$nulls":7},22]
[null,"(Sum of lines 10,  14,  and 21)"]
["COSTS OTHER THAN RHC/FQHC SERVICES"]
[23,"Pharmacy",{"$nulls":7},23]
[24,"Dental",{"$nulls":7},24]
[25,"Optometry",{"$nulls":7},25]
[26,"All other non reimbursable costs",{"$nulls":7},26]
[27,"Nonallowable GME Pass-through cost",{"$nulls":7},27]
[28,"Total nonreimbursable costs (Sum of lines",{"$nulls":7},28]
[null,"23 -  27)"]
["FACILITY OVERHEAD"]
[29,"Facility Costs",{"$nulls":7},29]
[30,"Administrative Costs",{"$nulls":7},30]
[31,"Total Facility Overhead (Sum of lines 29-30)",{"$nulls":7},31]
[32,"Total Facility Costs (Sum of lines 22, 28 and 31)",{"$nulls":7},32]
[null,"* 'The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of  this worksheet."]
["FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II. SECTION 4148)"]
["Rev. 1",{"$nulls":8},"41-366"]
{"$rows_empty":7}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"I2","index":43,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 ( Cont. )",null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,null,"PROVIDER NO:",null,"PERIOD:"]
["ALLOCATION  OF  OVERHEAD",null,null,null,"FROM___________________",null,"WORKSHEET"]
["TO  RHC / FQHC  SERVICES",null,"COMPONENT NO:",null,null,null,"I - 2"]
[{"$nulls":4},"TO____________________"]
["Check Applicable Box:",null,"[     ]  RHC","[     ]  FQHC"]
[]
[null,"PART  I  -  VISITS  AND  PRODUCTIVITY"]
[null,null,"Number ",null,"Productivity","Minimum","Greater of"]
[null,null,"of   FTE","Total","Standard","Visits","Column  2 or"]
[null,null,"Personnel","Visits","(1)","Col. 1 X Col. 3)","Column 4"]
[null,null,"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",{"$nulls":5},7]
[8,"Total Staff Costs (Sum of lines 4 - 7)",{"$nulls":5},8]
[9,"Physician Services Under Agreements ",{"$nulls":5},9]
[]
[null,"PART  II  -  DETERMINATION  OF  TOTAL  ALLOWABLE  COST  APPLICABLE  TO  RHC/FQHC  SERVICES"]
[10,"Total costs of Health Care Services ( From Worksheet  I - 1,  column 7, line 22) ",{"$nulls":5},10]
[11,"Total nonreimbursable costs (From Worksheet  I - 1, column 7, 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)",{"$nulls":5},13]
[14,"Total facility overhead (From Worksheet  I - 1, column 7, line 31)",{"$nulls":5},14]
[15,"GME Overhead (See instructions)",{"$nulls":5},15]
[16,"Net Facility Overhead",{"$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 (Lines 13 X line 18)",{"$nulls":5},19]
[20,"Total allowable cost of RHC / FQHC services ( Sum of lines 10 and 19)",{"$nulls":5},20]
[]
["(1) Productivity standards established by CMS are:  4200 visits for each physician, and 2100 visits for each nonphysician practitioner."]
[]
[]
[]
[]
[]
["FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,"]
[" SECTION 4149)"]
[]
["41-367",{"$nulls":6},"Rev. 1"]
{"$rows_empty":14}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"I3","index":44,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[5,3,5,4]],"flags":["formulas_cached_only"]}
["2011-02-11",null,null,"FORM CMS-2540-10",null,null,null,"4190 (Cont.)"]
["CALCULATION  OF",null,"PROVIDER NO.:",null,"PERIOD:"]
["REIMBURSEMENT",null,"______________________",null,"FROM__________________",null,"WORKSHEET"]
["SETTLEMENT  FOR",null,"COMPONENT NO.:",null,null,null,"I - 3"]
["RHC/FQHC  SERVICES",null,"_______________",null,"TO_____________________"]
["Check one:",null,"[     ]  Title V","[     ]  Title XVIII",null,"[     ]  Title XIX"]
["Check Applicable Box:",null,"[     ]  RHC","[     ]  FQHC"]
[" PART I - DETERMINATION  OF  RATE  FOR  RHC / FQHC  SERVICES"]
[1,"Total Allowable Cost of RHC/FQHC Services (From Worksheet I - 2, Part II, line 20)",{"$nulls":5},1]
[2,"Cost of  vaccines and their administration (From Worksheet I-4, line 15)",{"$nulls":5},2]
[3,"Total Allowable Cost Excluding Vaccine (Line 1 minus line 2)",{"$nulls":5},3]
[4,"Total FTE's and VISITS (From Worksheet  I-2, column 5, line 8)",{"$nulls":5},4]
[5,"Physicians Visits Under Agreement (From Worksheet  I - 2, column 5, line 9)",{"$nulls":5},5]
[6,"Total Adjusted Visits (line 4 plus line 5)",{"$nulls":5},6]
[7,"Adjusted Cost Per Visit (line 3 divided by line 6)",{"$nulls":5},7]
["CALCULATION OF LIMIT",{"$nulls":4},"Prior to","On or after"]
[null,"Lines 8 through 14:  Fiscal year providers use columns 1 and 2.",null,null,null,"January 1","January 1"]
[null,"Lines 8 through 14:  Calendar year providers use column 2 only.",null,null,null,"1","2"]
[8,"Rate per visit limit (From your intermediary/contractor)",{"$nulls":5},8]
[9,"Rate for Medicare Covered Visits (See instructions)",{"$nulls":5},9]
[" PART II - CALCULATION  OF  SETTLEMENT"]
[10,"Medicare Covered Visits Excluding Mental Health Services",{"$nulls":5},10]
[null,"(From intermediary/contractor Records)"]
[11,"Medicare Cost Excluding Costs for Mental Health Services",{"$nulls":5},11]
[null,"(Line 9 x line 10)"]
[12,"Medicare Covered Visits for Mental Health Services",{"$nulls":5},12]
[null,"(From Intermediary/Contractor Records)"]
[13,"Medicare Covered Cost from Mental Health Services",{"$nulls":5},13]
[null,"(Line 9 x line 12)"]
[14,"Limit Adjustment for Mental Health Services",{"$nulls":5},14]
[null,"(See instructions)"]
[15,"Allowable GME Pass-through Cost (See instructions)",{"$nulls":5},15]
[16,"Total Medicare Cost (Sum of line 11 column 1 and 2, plus line 14 columns 1 and 2, plus line 15.",{"$nulls":5},16]
[17,"Primary payer amounts",{"$nulls":5},17]
[18,"Less:  Beneficiary Deductible  for RHC only. (See instructions)(From intermediary/contractor records)",{"$nulls":5},18]
[19,"Net Medicare Cost Excluding Vaccines (Line 16 minus sum of lines  17 and 18)",{"$nulls":5},19]
[20,"Reimbursable Cost of RHC/FQHC Services, Excluding Vaccine (80% of line 19)",{"$nulls":5},20]
[21,"Program cost of vaccines and their administration (From Worksheet I -4 line 16)",{"$nulls":5},21]
[22,"Total Reimbursable Program Cost (Line 20 plus 21)",{"$nulls":5},22]
[23,"Reimbursable Bad Debts",{"$nulls":5},23]
[24,"Reimbursable Bad Debts for dual eligible beneficiaries (See Instructions)",{"$nulls":5},24]
[25,"Other Adjustments",{"$nulls":5},25]
[26,"Net reimbursable amount  (Line 22 plus line 23,  plus or minus line 25 )",{"$nulls":5},26]
[27,"Interim payments (From Worksheet I-5, line 4)",{"$nulls":5},27]
[28,"Tentative settlement (for fiscal intermediary/contractor use only)",{"$nulls":5},28]
[29,"Balance due Component/Program (line 26 minus lines  27 and 28)",{"$nulls":5},29]
[30,"Protested amounts (nonallowable cost report items) in accordance with",{"$nulls":5},30]
[null,"CMS Pub. 15-II, section 115.2"]
["FORM CMS  2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,"]
[" SECTION 4150 )"]
[]
["Rev. 1",{"$nulls":6},"41-368"]
{"$rows_empty":7}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"I4","index":45,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,"FORM CMS-2540-10",null,"2011-02-11"]
[null,null,"PROVIDER NO.:","PERIOD:"]
["COMPUTATION  OF  PNEUMOCOCCAL",null,"_______________","FROM____________","WORKSHEET"]
["AND  INFLUENZA  VACCINE  COST",null,"COMPONENT NO.:",null,"I - 4"]
[null,null,"_______________","TO_______________"]
["Check one:",null,"[     ]  Title V","[     ]  Title XVIII","[     ]  Title XIX"]
["Check Applicable Box:",null,"[     ]  RHC","[     ]  FQHC"]
[null,"CALCULATION OF COST",null,"PNEUMOCOCCAL","INFLUENZA"]
[null,null,null,"1","2"]
[1,"Health care staff cost (from Worksheet I -1, column 7, line 10)",null,null,null,1]
[2,"Ratio of PNEUMOCOCCAL and influenza vaccine staff time to",null,null,null,2]
[null,"total health care staff time "]
[3,"PNEUMOCOCCAL and influenza vaccine health care staff cost",null,null,null,3]
[null,"(Line 1 x line 2)"]
[4,"Medical supplies cost -  PNEUMOCOCCAL and influenza vaccine  ",null,null,null,4]
[null,"(From your records)"]
[5,"Direct cost of PNEUMOCOCCAL and influenza vaccine",null,null,null,5]
[null,"(Sum of lines 3 and 4)"]
[6,"Total direct cost of the facility (From Wkst. I -1, col. 7, line 22)",null,null,null,6]
[7,"Total overhead  (From Worksheet I - 2, line 18)",null,null,null,7]
[8,"Ratio of PNEUMOCOCCAL and influenza vaccine direct cost to",null,null,null,8]
[null,"Total direct cost (Line 5 divided by Line 6)"]
[9,"Overhead cost - PNEUMOCOCCAL and influenza vaccine",null,null,null,9]
[null,"(Line 7 x Line 8)"]
[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",null,null,null,12]
[null,"(Line 10 divided by Line 11)"]
[13,"Number of PNEUMOCOCCAL and influenza vaccine injections ",null,null,null,13]
[null,"Administered to medicare beneficiaries"]
[14,"Medicare cost of PNEUMOCOCCAL and influenza vaccine and ",null,null,null,14]
[null,"its (their) administration (Line 12 x line 13)"]
[15,"Total Cost of PNEUMOCOCCAL and influenza vaccine and its (their) administration",null,null,null,15]
[null,"(Sum of columns 1 and 2, line 10) (Transfer this amount to Worksheet  I-3, line 2)"]
[16,"Total  medicare cost of PNEUMOCOCCAL and influenza vaccine and its (their) administration",null,null,null,16]
[null," (Sum of columns 1 and 2, line 14) (Transfer this amount to Worksheet  I-3, line 21)"]
[]
[]
[]
[]
[]
["FORM CMS  2540-10 ( 12/10  ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II,"]
["  SECTION  4151 )"]
[]
["41-369",{"$nulls":4},"Rev. 1"]
{"$rows_empty":12}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"I-5","index":46,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11",null,"FORM CMS-2540-10",null,null,null,"4190 ( Cont. )"]
["ANALYSIS  OF  PAYMENTS  TO",null," PROVIDER NO.:  ",null," PERIOD: "]
["SNF-BASED RURAL HEALTH",null,"  ___________________",null,"FROM ______________",null,"   WORKSHEET  I - 5"]
["CLINIC AND FEDERALLY",null," COMPONENT NO.:"]
["QUALIFIED HEALTH CENTERS",null,"  ___________________",null,"TO"]
["Check Applicable Box:",null,null,"[     ]  R.H.C.","    [     ]  F.Q.H.C.",null," "]
[{"$nulls":5},"mm/dd/yyyy","Amount"]
[null,"Description",null,null,null,"1","2"]
[1," Total interim payments paid to provider",{"$nulls":5},"1"]
[2," Interim payments payable on individual bills,  either submitted or to",{"$nulls":5},"2"]
[null," be submitted to the intermediary/contractor, for services rendered in "]
[null," the cost reporting period.  If none, write \"none\", or enter zero."]
[3," List separately each retroactive lump sum ",null,null," .01",null,null,"3.01"]
[null,"adjustment amount based on subsequent",null,null," .02",null,null,"3.02"]
[null,"revision of the interim rate for the cost ",null,"Program to "," .03",null,null,"3.03"]
[null," reporting period.",null,"Provider"," .04",null,null,"3.04"]
[{"$nulls":4}," .05",null,null,"3.05"]
[null," Also show date of each payment.",null,null," .50",null,null,"3.50"]
[null," If none, write \"NONE,\" or enter a zero.(1)",null,null," .51",null,null,"3.51"]
[null,null,null,"Provider to "," .52",null,null,"3.52"]
[null,null,null,"Program"," .53",null,null,"3.53"]
[{"$nulls":4}," .54",null,null,"3.54"]
[null,"SUBTOTAL (Sum of lines 3.01 - 3.05",null,null," .99",null,null,"3.99"]
[null,"minus sum of lines 3.50 - 3.55)"]
[4,"TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99) ",{"$nulls":5},4]
[null,"(Transfer to Worksheet I-3:  line 27)"]
[]
[null,"TO  BE  COMPLETED  BY  INTERMEDIARY / CONTRACTOR"]
[5,"List separately each tentative settlement",null,"Program to",".01",null,null,"5.01"]
[null,"payment after desk review.",null,"Provider",".02",null,null,"5.02"]
[{"$nulls":4},".03",null,null,"5.03"]
[null," Also show date of each payment.",null,"Provider to ",".50",null,null,"5.50"]
[null," If none, write \"NONE,\" or enter a zero.(1)",null,"Program",".51",null,null,"5.51"]
[{"$nulls":4},".52",null,null,"5.52"]
[null,"SUBTOTAL (Sum of lines 5.01 - 5.03",null,null,".99",null,null,"5.99"]
[null," minus sum of lines 5.50 - 5.52)"]
[6,"Determined net settlement",null,"Program to",".01",null,null,"6.01"]
[null,"amount  (balance due) based",null,"Provider",".02",null,null,"6.02"]
[null,"on the  cost report. (1)",null,"Provider to",".50",null,null,"6.50"]
[null,null,null,"Program",".51",null,null,6.51]
[7,"TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)",{"$nulls":5},7]
[8,"Name of Intermediary/Contractor",null,null,null,"Intermediary/Contractor Number",null,8]
[]
[]
[9,"Signature of Authorized Person",null,null,null,"Date (mm/dd/yyy)",null,9]
[]
[]
[" (1)   On lines 3, 5, and 6, where an amount is due \"Provider to Program,\" show the amount and date on which the"]
[null," provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
[]
["FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,"]
[null,"SECTION 4152)"]
[]
["Rev. 1",{"$nulls":6},"41-373"]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"J-1-I","index":47,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[6,4,6,5]],"flags":["formulas_cached_only"]}
["4190 ( Cont. )",null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,null,null,"  PROVIDER NO.:",null,"  PERIOD:"]
["ALLOCATION  OF  GENERAL  SERVICE  COSTS",{"$nulls":4},"  FROM ____________",null,"  WORKSHEET  J - 1"]
["TO  COST  CENTERS FOR C.M.H.C.",null,null,"  COMPONENT  NO.: _______________",null,"  TO _______________",null,"    PART  I  "]
[]
[]
[null,null,null,"NET","CAPITAL  RELATED. COST",null,null,null,"ADMINIS-"]
[null,null,null,"EXPENSES",null,null,"EMPLOYEE","SUBTOTAL","TRATIVE"]
[null,"COMPONENT  COST  CENTER",null,"FOR  COST","BUILDS.  &","MOVABLE","BENEFITS",null,"&"]
[null,"(Omit Cents)",null,"ALLOCATION","FIXTURES","EQUIPMENT",null,"(COLS.  0-3)","GENERAL"]
[null,null,null,"0","1","2","3","3a","4"]
[" 1"," Administrative  and  General",{"$nulls":7}," 1"]
[" 2"," Skilled Nursing",{"$nulls":7}," 2"]
[" 3"," Physical Therapy",{"$nulls":7}," 3"]
[" 4"," Occupational Therapy",{"$nulls":7}," 4"]
[" 5"," Speech Pathology",{"$nulls":7}," 5"]
[" 6"," Medical Social Services",{"$nulls":7}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":7}," 7"]
[" 8"," Psychiatric/Psychological Services",{"$nulls":7}," 8"]
[" 9"," Individual Therapy",{"$nulls":7}," 9"]
[" 10"," Group Therapy",{"$nulls":7}," 10"]
[" 11"," Individualized Activity Therapy",{"$nulls":7}," 11"]
[" 12"," Family Counseling",{"$nulls":7}," 12"]
[" 13"," Diagnostic Services",{"$nulls":7}," 13"]
[" 14"," Appr. Patient Training & Education",{"$nulls":7}," 14"]
[" 15"," Prosthetic and Orthotic Devices",{"$nulls":7}," 15"]
[" 16"," Drugs and Biologicals",{"$nulls":7}," 16"]
[" 17"," Medical Supplies",{"$nulls":7}," 17"]
[" 18"," Medical Appliances",{"$nulls":7}," 18"]
[" 19"," Durable Medical Equipment - Rented",{"$nulls":7}," 19"]
[" 20"," Durable Medical Equipment - Sold",{"$nulls":7}," 20"]
[" 21"," Other General Service Cost",{"$nulls":7}," 21"]
[" 22"," Totals  ( Sum of lines 1-21)  ","(1)",{"$nulls":6}," 22"]
[]
[null,"(1)     Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line)."]
[]
[]
[]
[]
[]
["FORM  CMS 2540-10 ( 12/10 )    ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4153)"]
[]
["41-371",{"$nulls":8},"Rev. 1"]
[null,"2011-02-11",null,"FORM CMS-2540-10",{"$nulls":5},"4190 ( Cont. )"]
[null,null,null,"  PROVIDER NO.:",null,"  PERIOD:"]
["ALLOCATION  OF  GENERAL  SERVICE  COSTS",{"$nulls":4},"  FROM ____________",null,"  WORKSHEET  J - 1"]
["TO  COST  CENTERS FOR C.M.H.C.",null,null,"  COMPONENT  NO.: _______________",null,"  TO _______________",null,"    PART  I    (CONT. )"]
[]
[]
[{"$nulls":4},"PLANT"]
[{"$nulls":4},"OPERATION","LAUNDRY","HOUSE -",null,"NURSING"]
[null,"COMPONENT  COST  CENTER",null,null,"MAINTENANCE","& LINEN","KEEPING","DIETARY","ADMINIS-"]
[null,"(Omit Cents)",null,null,"& REPAIRS","SERVICE",null,null,"TRATION"]
[{"$nulls":4},"5","6","7","8","9"]
[" 1"," Administrative  and  General",{"$nulls":7}," 1"]
[" 2"," Skilled Nursing",{"$nulls":7}," 2"]
[" 3"," Physical Therapy",{"$nulls":7}," 3"]
[" 4"," Occupational Therapy",{"$nulls":7}," 4"]
[" 5"," Speech Pathology",{"$nulls":7}," 5"]
[" "," Medical Social Services",{"$nulls":7}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":7}," 7"]
[" 8"," Psychiatric/Psychological Services",{"$nulls":7}," 8"]
[" 9"," Individual Therapy",{"$nulls":7}," 9"]
[" 10"," Group Therapy",{"$nulls":7}," 10"]
[" 11"," Individualized Activity Therapy",{"$nulls":7}," 11"]
[" 12"," Family Counseling",{"$nulls":7}," 12"]
[" 13"," Diagnostic Services",{"$nulls":7}," 13"]
[" 14"," Appr. Patient Training & Education",{"$nulls":7}," 14"]
[" 15"," Prosthetic and Orthotic Devices",{"$nulls":7}," 15"]
[" 16"," Drugs and Biologicals",{"$nulls":7}," 16"]
[" 17"," Medical Supplies",{"$nulls":7}," 17"]
[" 18"," Medical Appliances",{"$nulls":7}," 18"]
[" 19"," Durable Medical Equipment - Rented",{"$nulls":7}," 19"]
[" 20"," Durable Medical Equipment - Sold",{"$nulls":7}," 20"]
[" 21"," Other General Service Cost",{"$nulls":7}," 21"]
[" 22"," Totals  ( Sum of lines 1-21)  ","(1)",{"$nulls":6}," 22"]
[]
[null,"(1)     Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line)."]
[]
[]
[]
[]
[]
[]
["FORM  CMS 2540-10 ( 12/10 )    ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4153)"]
["Rev. 1",{"$nulls":8},"41-372"]
["4190 ( Cont. )",null,null,"FORM CMS 2540-10",{"$nulls":4},"2011-02-11"]
[null,null,null,"  PROVIDER NO.:",null,"  PERIOD:"]
["ALLOCATION  OF  GENERAL  SERVICE  COSTS",{"$nulls":4},"  FROM ____________",null,"  WORKSHEET  J - 1"]
["TO  COST  CENTERS FOR C.M.H.C.",null,null,"  COMPONENT  NO.: _______________",null,"  TO _______________",null,"    PART  I    (CONT. )"]
[]
[]
[]
[null,null,null,"CENTRAL",null,"MEDICAL","SOCIAL ","INTERNS ","OTHER"]
[null,"COMPONENT  COST  CENTER",null,"SERVICES","PHARMACY","RECORDS","SERVICES","& ","GENERAL"]
[null,"(Omit Cents)",null,"& SUPPLY",null,"& LIBRARY",null,"RESIDENTS","SERVICE"]
[null,null,null,10,11,12,13,14,15]
[" 1"," Administrative  and  General",{"$nulls":7}," 1"]
[" 2"," Skilled Nursing",{"$nulls":7}," 2"]
[" 3"," Physical Therapy",{"$nulls":7}," 3"]
[" 4"," Occupational Therapy",{"$nulls":7}," 4"]
[" 5"," Speech Pathology",{"$nulls":7}," 5"]
[" 6"," Medical Social Services",{"$nulls":7}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":7}," 7"]
[" 8"," Psychiatric/Psychological Services",{"$nulls":7}," 8"]
[" 9"," Individual Therapy",{"$nulls":7}," 9"]
[" 10"," Group Therapy",{"$nulls":7}," 10"]
[" 11"," Individualized Activity Therapy",{"$nulls":7}," 11"]
[" 12"," Family Counseling",{"$nulls":7}," 12"]
[" 13"," Diagnostic Services",{"$nulls":7}," 13"]
[" 14"," Appr. Patient Training & Education",{"$nulls":7}," 14"]
[" 15"," Prosthetic and Orthotic Devices",{"$nulls":7}," 15"]
[" 16"," Drugs and Biologicals",{"$nulls":7}," 16"]
[" 17"," Medical Supplies",{"$nulls":7}," 17"]
[" 18"," Medical Appliances",{"$nulls":7}," 18"]
[" 19"," Durable Medical Equipment - Rented",{"$nulls":7}," 19"]
[" 20"," Durable Medical Equipment - Sold",{"$nulls":7}," 20"]
[" 21"," Other General Service Cost",{"$nulls":7}," 21"]
[" 22"," Totals  ( Sum of lines 1-21)  ","(1)",{"$nulls":6}," 22"]
[null,"(1)     Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line)."]
[]
[]
[]
[]
[]
[]
["FORM  CMS 2540-10 ( 12/10 )    ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4153)"]
[]
["41-373",{"$nulls":8},"Rev. 1"]
[null,"2011-02-11",null,"FORM CMS-2540-10",{"$nulls":5},"4190 ( Cont. )"]
[null,null,null,"  PROVIDER NO.:",null,"  PERIOD:",null,"  WORKSHEET  J-1"]
["ALLOCATION  OF  GENERAL  SERVICE  COSTS",{"$nulls":4},"  FROM ____________",null,"  PART I ( CONT. )"]
["TO  COST  CENTERS FOR C.M.H.C.",null,null,"  COMPONENT  NO.: ______",null,"  TO _______________"]
[]
[]
[]
[{"$nulls":5},"POST",null,"ALLOCATED","TOTAL"]
[null,"COMPONENT  COST  CENTER",null,null,"SUBTOTAL","STEP-DOWN","SUBTOTAL","A & G","(SUM OF COLS"]
[null,"(Omit Cents)",null,null,null,"ADJUSTMENTS",null,"(SEE  PART  II)","18  AND  19)"]
[{"$nulls":4},"16","17","18","19","20"]
[" 1"," Administrative  and  General",{"$nulls":7}," 1"]
[" 2"," Skilled Nursing",{"$nulls":7}," 2"]
[" 3"," Physical Therapy",{"$nulls":7}," 3"]
[" 4"," Occupational Therapy",{"$nulls":7}," 4"]
[" 5"," Speech Pathology",{"$nulls":7}," 5"]
[" 6"," Medical Social Services",{"$nulls":7}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":7}," 7"]
[" 8"," Psychiatric/Psychological Services",{"$nulls":7}," 8"]
[" 9"," Individual Therapy",{"$nulls":7}," 9"]
[" 10"," Group Therapy",{"$nulls":7}," 10"]
[" 11"," Individualized Activity Therapy",{"$nulls":7}," 11"]
[" 12"," Family Counseling",{"$nulls":7}," 12"]
[" 13"," Diagnostic Services",{"$nulls":7}," 13"]
[" 14"," App. Patient Training & Education",{"$nulls":7}," 14"]
[" 15"," Prosthetic and Orthotic Devices",{"$nulls":7}," 15"]
[" 16"," Drugs and Biologicals",{"$nulls":7}," 16"]
[" 17"," Medical Supplies",{"$nulls":7}," 17"]
[" 18"," Medical Appliances",{"$nulls":7}," 18"]
[" 19"," Durable Medical Equipment - Rented",{"$nulls":7}," 19"]
[" 20"," Durable Medical Equipment - Sold",{"$nulls":7}," 20"]
[" 21"," Other General Service Cost",{"$nulls":7}," 21"]
[" 22"," Totals  ( Sum of lines 1-21)",{"$nulls":7}," 22"]
[23," Unit Cost Multiplier (See Instructions)",{"$nulls":7},23]
[]
["FORM  CMS 2540-10 ( 12/10 )    ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4153)"]
["Rev. 1",{"$nulls":8},"41-374"]
{"$rows_empty":90}
[{"$nulls":11},"Rev. 1"]

{"sheet":"J-1-II","index":48,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[6,4,6,5]],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,null,"  PROVIDER NO.:",null,"  PERIOD:"]
["ALLOCATION  OF  GENERAL  SERVICE  COSTS",null,null,null,"  FROM ____________",null,"  WORKSHEET J - 1"]
[null,"TO  COST  CENTERS FOR C.M.H.C.","  COMPONENT  NO.: ______",null,"  TO _______________",null,"    PART  II  "]
[]
[]
[{"$nulls":4},"CAPITAL RELATED COST",null,null,"ADMINIS-"]
[{"$nulls":4},"COST BUILDS.","COST MOVABLE","EMPLOYEE","TRATIVE"]
[null,"COMPONENT  COST  CENTER",null,null,"& FIXTURES","EQUIPMENT","BENEFITS","& GENERAL"]
[{"$nulls":4},"(Square Feet)","(Value or","(Gross Salaries)","(Accumulated"]
[{"$nulls":5},"Square Feet",null,"Cost)"]
[null,"(Omit Cents)",null,null,1,2,"3","4"]
[" 1"," Administrative  and  General",{"$nulls":6}," 1"]
[" 2"," Skilled Nursing",{"$nulls":6}," 2"]
[" 3"," Physical Therapy",{"$nulls":6}," 3"]
[" 4"," Occupational Therapy",{"$nulls":6}," 4"]
[" 5"," Speech Pathology",{"$nulls":6}," 5"]
[" 6"," Medical Social Services",{"$nulls":6}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":6}," 7"]
[" 8"," Psychiatric/Psychological Services",{"$nulls":6}," 8"]
[" 9"," Individual Therapy",{"$nulls":6}," 9"]
[" 10"," Group Therapy",{"$nulls":6}," 10"]
[" 11"," Individualized Activity Therapy",{"$nulls":6}," 11"]
[" 12"," Family Counseling",{"$nulls":6}," 12"]
[" 13"," Diagnostic Services",{"$nulls":6}," 13"]
[" 14"," App. Patient Training & Education",{"$nulls":6}," 14"]
[" 15"," Prosthetic and Orthotic Devices",{"$nulls":6}," 15"]
[" 16"," Drugs and Biologicals",{"$nulls":6}," 16"]
[" 17"," Medical Supplies",{"$nulls":6}," 17"]
[" 18"," Medical Appliances",{"$nulls":6}," 18"]
[" 19"," Durable Medical Equipment - Rented",{"$nulls":6}," 19"]
[" 20"," Durable Medical Equipment - Sold",{"$nulls":6}," 20"]
[" 21"," Other General Service Cost",{"$nulls":6}," 21"]
[" 22"," Totals  ( Sum of lines 1-21)",{"$nulls":6}," 22"]
[" 23"," Total Cost to be Allocated",{"$nulls":6}," 23"]
[" 24"," Unit Cost Multiplier",{"$nulls":6}," 24"]
[]
[]
[]
[]
["FORM CMS 2540-10 ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4153 )"]
[]
["41-375",{"$nulls":7},"Rev. 1"]
[null,"2011-02-11","FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[null,null,"  PROVIDER NO.:",null,"  PERIOD:"]
["ALLOCATION  OF  GENERAL  SERVICE  COSTS",null,null,null,"  FROM ____________",null,"  WORKSHEET J - 1"]
[null,"TO  COST  CENTERS FOR C.M.H.C.","  COMPONENT  NO.: ______",null,"  TO _______________",null,"    PART  II   (Cont.)"]
[]
[]
[null,null,null,"PLANT","LAUNDRY",null,null,"NURSING"]
[null,null,null,"OPERATION","&  LINEN","HOUSE -",null,"ADMINIS"]
[null,null,null,"MAINTENANCE","SERVICE","KEEPING","DIETARY","TRATION"]
[null,"COMPONENT  COST  CENTER",null,"&  REPAIRS","(Pounds of","(Hours  of","(Meals","(Direct Nursing"]
[null,null,null,"(Square Feet)","Laundry)","Service)","Served)","Hours of Service)"]
[null,"(Omit Cents)",null,"5","6","7","8","9"]
[" 1"," Administrative  and  General",{"$nulls":6}," 1"]
[" 2"," Skilled Nursing",{"$nulls":6}," 2"]
[" 3"," Physical Therapy",{"$nulls":6}," 3"]
[" 4"," Occupational Therapy",{"$nulls":6}," 4"]
[" "," Speech Pathology",{"$nulls":6}," 5"]
[" 6"," Medical Social Services",{"$nulls":6}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":6}," 7"]
[" 8"," Psychiatric/Psychological Services",{"$nulls":6}," 8"]
[" 9"," Individual Therapy",{"$nulls":6}," 9"]
[" 10"," Group Therapy",{"$nulls":6}," 10"]
[" 11"," Individualized Activity Therapy",{"$nulls":6}," 11"]
[" 12"," Family Counseling",{"$nulls":6}," 12"]
[" 13"," Diagnostic Services",{"$nulls":6}," 13"]
[" 14"," App. Patient Training & Education",{"$nulls":6}," 14"]
[" 15"," Prosthetic and Orthotic Devices",{"$nulls":6}," 15"]
[" 16"," Drugs and Biologicals",{"$nulls":6}," 16"]
[" 17"," Medical Supplies",{"$nulls":6}," 17"]
[" 18"," Medical Appliances",{"$nulls":6}," 18"]
[" 19"," Durable Medical Equipment - Rented",{"$nulls":6}," 19"]
[" 20"," Durable Medical Equipment - Sold",{"$nulls":6}," 20"]
[" 21"," Other General Service Cost",{"$nulls":6}," 21"]
[" 22"," Totals  ( Sum of lines 1-21)",{"$nulls":6}," 22"]
[" 23"," Total Cost to be Allocated",{"$nulls":6}," 23"]
[" 24"," Unit Cost Multiplier",{"$nulls":6}," 24"]
[]
[]
[]
[]
[]
["FORM CMS 2540-10 ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4153 )"]
["Rev. 1",{"$nulls":7},"41-376"]
["4190 (Cont.)",null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,"ALLOCATION OF GENERAL SERVICE COSTS","  PROVIDER NO.:",null,"  PERIOD:"]
[{"$nulls":4},"  FROM ______________________",null,"  WORKSHEET  J - 1"]
[null,"TO  COST  CENTERS FOR C.M.H.C.","  COMPONENT  NO.: ______",null,"  TO ____________________",null,"  PART  II  (Cont.)  "]
[]
[]
[null,null,"CENTRAL"]
[null,null,"SERVICES",null,"MEDICAL",null,"INTERNS &","OTHER"]
[null,null,"&  SUPPLY","PHARMACY","RECORDS  &","SOCIAL","RESIDENTS","GENERAL"]
[null,"COMPONENT  COST  CENTER","(Costed","(Costed","LIBRARY","SERVICES",null,"SERVICE"]
[null,"(Omit Cents)","Requisitions)","Requisitions)","(Time Spent)","(Time Spent)","(Assigned Time)","(                      )"]
[null,null,"10","11","12","13","14","15"]
[" 1"," Administrative  and  General",{"$nulls":6}," 1"]
[" 2"," Skilled Nursing",{"$nulls":6}," 2"]
[" 3"," Physical Therapy",{"$nulls":6}," 3"]
[" 4"," Occupational Therapy",{"$nulls":6}," 4"]
[" 5"," Speech Pathology",{"$nulls":6}," 5"]
[" 6"," Medical Social Services",{"$nulls":6}," 6"]
[" 7"," Respiratory Therapy",{"$nulls":6}," 7"]
[" 8"," Psychiatric/Psychological Services",{"$nulls":6}," 8"]
[" 9"," Individual Therapy",{"$nulls":6}," 9"]
[" 10"," Group Therapy",{"$nulls":6}," 10"]
[" 11"," Individualized Activity Therapy",{"$nulls":6}," 11"]
[" 12"," Family Counseling",{"$nulls":6}," 12"]
[" 13"," Diagnostic Services",{"$nulls":6}," 13"]
[" 14"," App. Patient Training & Education",{"$nulls":6}," 14"]
[" 15"," Prosthetic and Orthotic Devices",{"$nulls":6}," 15"]
[" 16"," Drugs and Biologicals",{"$nulls":6}," 16"]
[" 17"," Medical Supplies",{"$nulls":6}," 17"]
[" 18"," Medical Appliances",{"$nulls":6}," 18"]
[" 19"," Durable Medical Equipment - Rented",{"$nulls":6}," 19"]
[" 20"," Durable Medical Equipment - Sold",{"$nulls":6}," 20"]
[" 21"," Other General Service Cost",{"$nulls":6}," 21"]
[" 22"," Totals  ( Sum of lines 1-21)",{"$nulls":6}," 22"]
[" 23"," Total Cost to be Allocated",{"$nulls":6}," 23"]
[" 24"," Unit Cost Multiplier",{"$nulls":6}," 24"]
[null,"`"]
["FORM  CMS 2540-10 ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION  4153  )"]
[]
[]
[]
[]
["41-377",{"$nulls":7},"Rev. 1"]
{"$rows_empty":127}
[{"$nulls":11},"Rev. 1"]

{"sheet":"J-2","index":49,"n_rows":257,"n_cols":13,"rows_kept":257,"cut":false,"hidden":false,"merged":[[52,6,52,7],[52,8,52,9],[52,10,52,11],[5,6,5,7],[5,8,5,9],[5,10,5,11]],"flags":["formulas_cached_only"]}
[null,"2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
["COMPUTATION  OF   C.M.H.C.",null,null,null,"  PROVIDER NO.:",null,null,"  PERIOD:"]
["REHABILITATION  COSTS",{"$nulls":6},"  FROM ____________",null,null,"  WORKSHEET  J - 2"]
[{"$nulls":4},"  COMPONENT  NO.: __________",null,null,"  TO _______________",null,null,"PART  I"]
["PART  I  -  APPORTIONMENT  OF REHABILITATION COST CENTERS"]
[null,null,null,"TOTAL  COSTS",null,"RATIO  OF","TITLE  V",null,"TITLE  XVIII",null,"TITLE  XIX"]
[null,null,null,"(FR. WKST. J-1","TOTAL","COSTS  TO","CHARGES","COSTS","CHARGES","COSTS","CHARGES","COSTS"]
[null,null,null,"PART  I, Col. 20)","CHARGES","CHARGES  (1)",null,"(Col 3 X Col 4)",null,"(Col 3 X col 6)",null,"(Col. 3 X Col 6)"]
[null,null,null,"1","2","3","4","5",6,7,8,9]
[1," Administrative  and  General",{"$nulls":10},1]
[2," Skilled Nursing Care",{"$nulls":10},2]
[3," Physical Therapy",{"$nulls":10},3]
[4," Occupational Therapy",{"$nulls":10},4]
[5," Speech Pathology",{"$nulls":10},5]
[6," Medical Social Services",{"$nulls":10},6]
[7," Respiratory Therapy",{"$nulls":10},7]
[8," Psychiatric/Psychological Services",{"$nulls":10},8]
[9," Individual Therapy",{"$nulls":10},9]
[10," Group Therapy",{"$nulls":10},10]
[11," Individualized Activity Therapy",{"$nulls":10},11]
[12," Family Counseling",{"$nulls":10},12]
[13," Diagnostic Services",{"$nulls":10},13]
[14," App. Patient Training & Education",{"$nulls":10},14]
[15," Prosthetic and Orthotic Devices",{"$nulls":10},15]
[16," Drugs and Biologicals",{"$nulls":10},16]
[17," Medical Supplies",{"$nulls":10},17]
[18," Medical Appliances",{"$nulls":10},18]
[19," Durable Medical Equipment - Rented",{"$nulls":10},19]
[20," Durable Medical Equipment - Sold",{"$nulls":10},20]
[21," Other General Service Cost",{"$nulls":10},21]
[22," Totals  ( Sum of lines 2-21)","(2)",{"$nulls":9},22]
{"$rows_empty":12}
["FORM  CMS 2540-10 ( 12/10 )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTIONS 4154) "]
[]
["Rev. 1",{"$nulls":11},"41-378"]
[]
["4190 (Cont.)",{"$nulls":4},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
["COMPUTATION  OF   C.M.H.C.",null,null,null,"  PROVIDER NO.:",null,null,"  PERIOD:"]
["REHABILITATION  COSTS",{"$nulls":6},"  FROM ____________",null,null,"  WORKSHEET  J - 2"]
[{"$nulls":4},"  COMPONENT  NO.: __________",null,null,"  TO _______________",null,null,"PART  II"]
["PART  II  -  APPORTIONMENT  OF COST OF REHAB SERVICES FURNISHED BY SHARED DEPARTTMENTS"]
[{"$nulls":5},"RATIO  OF","TITLE  V",null,"TITLE  XVIII",null,"TITLE  XIX"]
[{"$nulls":5},"COSTS  TO","CHARGES","COSTS","CHARGES","COSTS","CHARGES","COSTS"]
[{"$nulls":5},"CHARGES ",null,"(Col 3 X Col 4)",null,"(Col 3 X col 6)",null,"(Col. 3 X Col 8)"]
[{"$nulls":5},3,"4","5",6,7,8,9]
[23,"Oxygen (Inhalation) Therapy",{"$nulls":10},23]
[24," Physical Therapy",{"$nulls":10},24]
[25," Occupational Therapy",{"$nulls":10},25]
[" "," Speech Pathology",{"$nulls":10},26]
[27," Medical Supplies Charged to Patients",{"$nulls":10},27]
[28," Drugs Charged to Patients",{"$nulls":10},28]
[29," Other Costs Furnished by shared Departments",{"$nulls":10},29]
[30," Total (Sum of lines 23 through 29)",{"$nulls":10},30]
[31,"Total component cost.  Add the amount from Part I, line ",{"$nulls":10},31]
[null,"22 and the amount from line 30, columns 5, 7, and 9."]
[null," (Transfer  Titles V , XVIII, and XIX amounts "]
[null,"to Worksheet J-3, columns 1,2 & 3 respectively.)"]
["(1)  Ratio of cost to charges:  Part I - column 1 divided by column 2;  Part  II - From Wkst. C,  col. 3, lines as applicable",{"$nulls":9},"i"]
["(2)  Charges for Part II, col. 2 are obtained from provider records"]
[]
[]
[]
["FORM  CMS 2540-10 (  12/10  )  ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTIONS 4154 ) "]
[]
[]
["41-379",{"$nulls":11},"Rev. 1"]
{"$rows_empty":179}
[{"$nulls":11},"Rev. 1"]

{"sheet":"J-3","index":50,"n_rows":257,"n_cols":22,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11","FORM CMS-2540-10",null,null,"4190 (Cont.)"]
["CALCULATION  OF ",null," PROVIDER NO.:","  PERIOD:"]
["           REIMBURSEMENT  SETTLEMENT",null,null,"  FROM ____________","  WORKSHEET  J - 3"]
["OF  C.M.H.C. SERVICES",null," COMPONENT  NO.:","  TO ______________"]
[]
[null,null,"Title  V","Title  XVIII","Title  XIX"]
[null,null,"PROGRAM","PROGRAM","PROGRAM"]
[null,null,"COST","COST","COST"]
[null,null,"1","2","3"]
[" 1"," Cost of REHAB services (From  Wkst. J-2,",null,null,null," 1",{"$nulls":15}," 2"]
[null," Part II,  line. 31:  Title V - col.  5; Title"]
[null," XVIII  'col 7;  Title XIX - column 9)"]
[" 2"," Amounts paid and payable by Worker's",null,null,null," 2",{"$nulls":15}," 5"]
[null," Compensation and other primary payers"]
[" 3"," Subtotal (Line 1 minus line 2)",null,null,null," 3",{"$nulls":15}," 7"]
[]
[" 4"," Part B deductible billed to Program",null,null,null," 4",{"$nulls":15}," 9"]
[null," patients  (Exclude coinsurance amounts)"]
[" 5"," Net Cost (Line 3 minus line 4)",null,null,null," 5",{"$nulls":15}," 11"]
[]
[" 6"," 80% of Part B cost (80% X line 5)",null,null,null," 6",{"$nulls":15}," 13"]
[]
[" 7"," Actual coinsurance billed to Program",null,null,null," 7",{"$nulls":15}," 15"]
[null," patients  (From provider records)"]
[" 8"," Net cost less actual billed coinsurance",null,null,null," 8"]
[null," (Line 5 minus line 7)"]
[" 9"," Reimbursable bad debts (See Instructions)",null,null,null," 9"]
[]
[" 10"," Reimbursable bad debts for dual eligible",null,null,null,10]
[null,"beneficiaries (see instructions)"]
[" 11"," Net reimbursable amount (See Instructions)",null,null,null,11]
[]
[" 12"," Amounts applicable to prior cost reporting",null,null,null,12]
[null," periods resulting from disposition of"]
[null," depreciable assets"]
[" 13"," Recovery of excess depreciation resulting",null,null,null,13]
[null," from facility's termination or a decrease"]
[null," in Program utilization"]
[14,"Other Adjustments",null,null,null,14]
[]
[15," Total cost - reimbursable to provider",null,null,null,15]
[]
[16," Interim payments",null,null,null,16]
[]
[17," Balance due Component/Program",null,null,null,17]
[null," (Line 15 minus line 16)"]
[null," (Indicate overpayments in brackets)"]
[18," Protested amounts (Non allowable",null,null,null,18]
[null," cost report items) in accordance with"]
[null," CMS Pub. 15-II, section 115.2"]
["FORM  CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN"]
["CMS PUB 15-II, SECTION 4155 )"]
[]
["Rev. 1",{"$nulls":4},"41-380"]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"J-4","index":51,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,"FORM CMS-2540-10",null,null,"2011-02-11"]
["ANALYSIS  OF  PAYMENTS  TO",null," PROVIDER NO.:  ",null," PERIOD: "]
["PROVIDER - BASED  C.M.H.C.",null,"  ___________________",null,"FROM ______________",null,"   WORKSHEET  J - 4"]
["FOR  SERVICES  RENDERED",null," COMPONENT NO.:"]
["TO PROGRAM BENEFICIARIES",null,"  ___________________",null,"TO"]
[{"$nulls":5},"mm/dd/yyyy","Amount"]
[null,"Description",null,null,null,"1","2"]
[1," Total interim payments paid to provider",{"$nulls":5},"1"]
[2," Interim payments payable on individual bills,  either submitted or to",{"$nulls":5},"2"]
[null," be submitted to the intermediary, for services rendered in the cost"]
[null," reporting period.  If none, write \"none\", or enter zero."]
[3," List separately each retroactive",null,null," .01",null,null,"3.01"]
[null," lump sum adjustment amount",null,null," .02",null,null,"3.02"]
[null," based on subsequent revision ",null,"Program to "," .03",null,null,"3.03"]
[null," of the interim rate for the cost",null,"Provider"," .04",null,null,"3.04"]
[null," reporting period.",null,null," .05",null,null,"3.05"]
[{"$nulls":4}," .50",null,null,"3.50"]
[null," Also show date of each payment.",null,null," .51",null,null,"3.51"]
[null,null,null,"Provider to "," .52",null,null,"3.52"]
[null," If none, write \"NONE,\" or enter a zero.(1)",null,"Program"," .53",null,null,"3.53"]
[{"$nulls":4}," .54",null,null,"3.54"]
[null,"SUBTOTAL (Sum of lines 3.01 - 3.05",null,null," .99",null,null,"3.99"]
[null,"minus sum of lines 3.50 - 3.55)"]
[4,"TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99) ",{"$nulls":5},4]
[null,"(Transfer to Worksheet J-3: Part I  line 17)"]
[]
[null,"TO  BE  COMPLETED  BY  INTERMEDIARY/CONTRACTOR"]
[5,"List separately each tentative",null,"Program to",".01",null,null,"5.01"]
[null,"settlement payment after desk review.",null,"Provider",".02",null,null,"5.02"]
[{"$nulls":4},".03",null,null,"5.03"]
[null," Also show date of each payment.",null,"Provider to ",".50",null,null,"5.50"]
[null," If none, write \"NONE,\" or enter a zero.(1)",null,"Program",".51",null,null,"5.51"]
[{"$nulls":4},".52",null,null,"5.52"]
[null,"SUBTOTAL (Sum of lines 5.01 - 5.03",null,null,".99",null,null,"5.99"]
[null," minus sum of lines 5.50 - 5.52)"]
[6,"Determined net settlement",null,"Program to",".01",null,null,"6.01"]
[null,"amount  (balance due) based",null,"Provider",".02",null,null,"6.02"]
[null,"on the  cost report. (1)",null,"Provider to",".50",null,null,"6.50"]
[null,null,null,"Program",".51",null,null,"6.51"]
[7,"TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)",{"$nulls":5},"7"]
[8,"Name of Intermediary/Contractor",null,null,null,"Intermediary/Contractor  Number",null,8]
[]
[]
[9,"Signature of Authorized Person",null,null,null,"Date (mm/dd/yyyy)",null,9]
[]
[]
[" (1)   On lines 3, 5, and 6, where an amount is due \"Provider to Program,\" show the amount and date on which the"]
[null," provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date."]
[]
["FORM CMS 2540-10 ( 1210 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,"]
[null,"SECTION 4156)"]
[]
["41-381",{"$nulls":6},"Rev. 1"]
[]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K","index":52,"n_rows":257,"n_cols":13,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,"2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":6},"   4190 (Cont.)"]
[{"$nulls":7},"PROVIDER NO.: ___________",null,"PERIOD:"]
["ANALYSIS OF PROVIDER-BASED HOSPICE COSTS",{"$nulls":8},"FROM ____________",null,"WORKSHEET K"]
[{"$nulls":7},"HOSPICE NO.: ____________",null,"TO _______________"]
[{"$nulls":5},"CON-"]
[null,null,null,"EMPLOYEE",null,"TRACTED"]
[null,null,"SALARIES","BENEFITS","TRANSPOR-","SERVICES",null,null,null,"SUBTOTAL",null,"TOTAL"]
[null,"COST CENTER DESCRIPTIONS","(from","(from","TATION","(from",null,"TOTAL","RECLASSI-","(col. 6","ADJUST-","(col. 8"]
[null,null,"Wkst. K-1)","Wkst. K-2)","(see inst.)","Wkst. K-3)","OTHER","(cols. 1-5)","FICATION","± col. 7)","MENTS","± col. 9)"]
[null,null,"1","2","3","4","5","6",7,"8","9","10"]
[null,"GENERAL SERVICE COST CENTERS"]
[1,"Capital Related Costs-Bldg and Fixt.",null,null," ",{"$nulls":7},1]
[2,"Capital Related Costs-Movable Equip.",null,null," ",{"$nulls":7},2]
[3,"Plant Operation and Maintenance",{"$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",{"$nulls":10},10]
[11,"Nursing Care-Continuous Home Care",{"$nulls":10},11]
[12,"Physical Therapy",{"$nulls":10},12]
[13,"Occupational Therapy",{"$nulls":10},13]
[14,"Speech/ Language Pathology",{"$nulls":10},14]
[15,"Medical Social Services ",{"$nulls":10},15]
[16,"Spiritual Counseling",null," "," "," ",{"$nulls":4}," ",null,16]
[17,"Dietary Counseling",{"$nulls":10},17]
[18,"Counseling - Other",{"$nulls":10},18]
[19,"Home Health Aide and Homemaker",{"$nulls":10},19]
[20,"HH Aide & Homemaker-Cont. Home Care",{"$nulls":10},20]
[21,"Other",{"$nulls":10},21]
[null,"OTHER HOSPICE SERVICE COSTS"]
[22,"Drugs, Biological and Infusion Therapy",{"$nulls":10},22]
[23,"Analgesics",{"$nulls":10},23]
[24,"Sedatives / Hypnotics",{"$nulls":10},25]
[25,"Other - Specify",{"$nulls":10},25]
[26,"Durable Medical Equipment/Oxygen",{"$nulls":10},26]
[27,"Patient Transportation",{"$nulls":10},27]
[28,"Imaging Services",{"$nulls":10},28]
[29,"Labs and Diagnostics",{"$nulls":10},29]
[30,"Medical Supplies",{"$nulls":10},30]
[31,"Outpatient Services (including E/R Dept.)",{"$nulls":10},31]
[32,"Radiation Therapy",{"$nulls":10},32]
[33,"Chemotherapy",{"$nulls":10},33]
[34,"Other",{"$nulls":10},34]
[null,"HOSPICE NONREIMBURSABLE SERVICE"]
[35,"Bereavement Program Costs",{"$nulls":10},35]
[36,"Volunteer Program Costs",{"$nulls":10},36]
[37,"Fundraising",{"$nulls":10},37]
[38,"Other Program Costs",{"$nulls":10},38]
[39,"Total (sum of lines 1 thru 38)",{"$nulls":10},39]
["FORM CMS-2540-10  ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4157)"]
["Rev. 1",{"$nulls":11},"41-382"]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-1","index":53,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[2,0,2,2]],"flags":["formulas_cached_only"]}
["   4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":6},"2011-02-11"]
[null,null,null,"PROVIDER NO:",null," HOSPICE NO:",null,"PERIOD:"]
["HOSPICE  COMPENSATION  ANALYSIS",{"$nulls":6},"FROM ________________",null,"WORKSHEET K-1"]
["SALARIES  AND  WAGES",null,null,null,"_",null,null,"TO _______________"]
[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," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Moveable Equip.",null," "," ",{"$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,"Nursing Care- Continuous Home Care",{"$nulls":9},11]
[12,"Physical Therapy",{"$nulls":9},12]
[13,"Occupational Therapy",{"$nulls":9},13]
[14,"Speech/ Language Pathology",{"$nulls":9},14]
[15,"Medical Social Services ",{"$nulls":9},15]
[16,"Spiritual Counseling",null," "," "," ",null,null,null," ",null,16]
[17,"Dietary Counseling",{"$nulls":9},17]
[18,"Counseling - Other",{"$nulls":9},18]
[19,"Home Health Aide and Homemaker",{"$nulls":9},19]
[20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":9},20]
[21,"Other",{"$nulls":9},21]
[null,"OTHER HOSPICE SERVICE COSTS"]
[22,"Drugs, Biological and Infusion Therapy",{"$nulls":9},22]
[23,"Analgesics",{"$nulls":9},23]
[24,"Sedative/Hypnotics",{"$nulls":9},24]
[25,"Other - Specify",{"$nulls":9},25]
[26,"Durable Medical  Equipment/Oxygen",null," ",{"$nulls":7},26]
[27,"Patient Transportation",{"$nulls":9},27]
[28,"Imaging Services",{"$nulls":9},28]
[29,"Labs and Diagnostics",{"$nulls":9},29]
[30,"Medical Supplies",{"$nulls":9},30]
[31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},31]
[32,"Radiation Therapy",{"$nulls":9},32]
[33,"Chemotherapy",{"$nulls":9},33]
[34,"Other",{"$nulls":9},34]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[35,"Bereavement Program Costs",{"$nulls":9},35]
[36,"Volunteer Program Costs",{"$nulls":9},36]
[37,"Fundraising",{"$nulls":9},37]
[38,"Other Program Costs",{"$nulls":9},38]
[39,"Total",{"$nulls":9},39]
["(1) Transfer the amount in column 9 to Wkst K, column 1"]
["FORM CMS-2540-10 (  12/10  ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4158)"]
["41-383",{"$nulls":10},"Rev.1"]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-2","index":54,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[2,0,2,2],[3,0,3,2]],"flags":["formulas_cached_only"]}
["2011-02-11",{"$nulls":4},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[null,null,null,"PROVIDER NO:",null,"HOSPICE NO:",null,"PERIOD:"]
["HOSPICE  COMPENSATION  ANALYSIS",{"$nulls":6},"FROM ____________________",null,"WORKSHEET K-2"]
["EMPLOYEE  BENEFITS  (PAYROLL  RELATED)",{"$nulls":6},"TO _______________"]
[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," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Moveable Equip.",null," "," ",{"$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",{"$nulls":9},9]
[10,"Nursing Care- Continuous Home Care",{"$nulls":9},10]
[11,"Nursing Care",{"$nulls":9},11]
[12,"Physical Therapy",{"$nulls":9},12]
[13,"Occupational Therapy",{"$nulls":9},13]
[14,"Speech/ Language Pathology",{"$nulls":9},14]
[15,"Medical Social Services ",{"$nulls":9},15]
[16,"Spiritual Counseling",null," "," "," ",null,null,null," ",null,16]
[17,"Dietary Counseling",{"$nulls":9},17]
[18,"Counseling - Other",{"$nulls":9},18]
[19,"Home Health Aide and Homemaker",{"$nulls":9},19]
[20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":9},20]
[21,"Other",{"$nulls":9},21]
[null,"OTHER HOSPICE SERVICE COSTS"]
[22,"Drugs Biological and Infusion Therapy",{"$nulls":9},22]
[23,"Analgesics",{"$nulls":9},23]
[24,"Sedative/Hypnotics",{"$nulls":9},24]
[25,"Other - Specify",{"$nulls":9},25]
[26,"Durable Medical Equipment/ Oxygen",{"$nulls":9},26]
[27,"Patient Transportation",{"$nulls":9},27]
[28,"Imaging Services",{"$nulls":9},28]
[29,"Labs and Diagnostics",{"$nulls":9},29]
[30,"Medical Supplies",{"$nulls":9},30]
[31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},31]
[32,"Radiation Therapy",{"$nulls":9},32]
[33,"Chemotherapy",{"$nulls":9},33]
[34,"Other",{"$nulls":9},34]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[35,"Bereavement Program Costs",{"$nulls":9},35]
[36,"Volunteer Program Costs",{"$nulls":9},36]
[37,"Fundraising",{"$nulls":9},37]
[38,"Other Program Costs",{"$nulls":9},38]
[39,"Total",{"$nulls":9},39]
["(1) Transfer the amounts in column 9 to Wkst K, column 2"]
["FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4159)"]
["Rev. 1",{"$nulls":10},"41-384"]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-3","index":55,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[2,0,2,2],[3,0,3,2]],"flags":["formulas_cached_only"]}
["   4190 (Cont.)",{"$nulls":4},"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[null,null,null,"PROVIDER NO:",null,"HOSPICE NO:",null,"PERIOD:"]
["HOSPICE  COMPENSATION  ANALYSIS  ",{"$nulls":6},"FROM ___________________",null,"WORKSHEET K-3"]
["CONTRACTED  SERVICES / PURCHASED  SERVICES",null,null,null,"_",null,null,"TO _______________"]
[null,"COST CENTER DESCRIPTIONS","ADMINIS",null,"SOCIAL","SUPER-",null,"TOTAL"]
[null,"(omit cents)","TRATOR","DIRECTOR","SERVICES","VISORS","NURSES","THERAPISTS","AIDES","ALL OTHER","TOTAL (1)"]
[null,null,"1","2","3","4","5","6","7","8","9"]
[null,"GENERAL SERVICE COST CENTERS",null," "," "," ",null,null,null," "]
[1,"Capital Related Costs-Bldg and Fixt.",null," "," ",{"$nulls":6},1]
[2,"Capital Related Costs-Moveable 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",{"$nulls":9},10]
[11,"Nursing Care- Continuous Home Care",{"$nulls":9},11]
[12,"Physical Therapy",{"$nulls":9},12]
[13,"Occupational Therapy",{"$nulls":9},13]
[14,"Speech/ Language Pathology",{"$nulls":9},14]
[15,"Medical Social Services ",{"$nulls":9},15]
[16,"Spiritual Counseling",null," "," "," ",null,null,null," ",null,16]
[17,"Dietary Counseling",{"$nulls":9},17]
[18,"Counseling - Other",{"$nulls":9},18]
[19,"Home Health Aide and Homemaker",{"$nulls":9},19]
[20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":9},20]
[21,"Other",{"$nulls":9},21]
[null,"OTHER HOSPICE SERVICE COSTS"]
[22,"Drugs, Biological and Infusion Therapy",{"$nulls":9},22]
[23,"Analgesics",{"$nulls":9},23]
[24,"Sedative/Hypnotics",{"$nulls":9},24]
[25,"Other - Specify",{"$nulls":9},25]
[26,"Durable Medical Equipment/Oxygen",{"$nulls":7}," ",null,26]
[27,"Patient Transportation",{"$nulls":9},27]
[28,"Imaging Services",{"$nulls":9},28]
[29,"Labs and Diagnostics",{"$nulls":9},29]
[30,"Medical Supplies",{"$nulls":9},30]
[31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},31]
[32,"Radiation Therapy",{"$nulls":9},32]
[33,"Chemotherapy",{"$nulls":9},33]
[34,"Other",{"$nulls":9},34]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[35,"Bereavement Program Costs",{"$nulls":9},35]
[36,"Volunteer Program Costs",{"$nulls":9},36]
[37,"Fundraising",{"$nulls":9},37]
[38,"Other Program Costs",{"$nulls":9},38]
[39,"Total",{"$nulls":9},39]
["(1) Transfer the amounts in column 9 to Wkst K, column 4"]
["FORM CMS-2540-10 ( 12/10  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4160)"]
["41-385",{"$nulls":10},"Rev. 1"]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-4-1","index":56,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[2,0,2,2],[3,0,3,2]],"flags":["formulas_cached_only"]}
["2011-02-11",{"$nulls":4},"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)"]
[null,null,null,"PROVIDER NO:",null,"HOSPICE NO:",null,"PERIOD:"]
["COST ALLOCATION  -  HOSPICE",{"$nulls":6},"FROM ____________",null,"WORKSHEET K-4"]
["GENERAL  SERVICE  COST",{"$nulls":4},"_",null,"TO _______________",null,"PART  I"]
[null,null,"FR. WKST. K","CAPITAL","CAPITAL","PLANT","TRANS","VOLUNTEER","SUBTOTAL","ADMINIS-","TOTAL"]
[null,null,"COL. 10: NET","RELATED","RELATED","OPERATION","PORTATION","SERV.","(col. 0 - 5)","TRATIVE &"]
[null,null,"EXPENSES","COST BLDG","COST","& MAINT.",null,"COORDI-",null,"GENERAL"]
[null,"COST CENTER DESCRIPTIONS","FOR COST","& FIXTURES","MOVABLE",null,null,"NATOR"]
[null,null,"ALLOC.    (1)",null,"EQUIPMENT"]
[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,"Nursing Care- Continuous Home Care",{"$nulls":9},11]
[12,"Physical Therapy",{"$nulls":9},12]
[13,"Occupational Therapy",{"$nulls":9},13]
[14,"Speech/ Language Pathology",{"$nulls":9},14]
[15,"Medical Social Services - Direct",{"$nulls":9},15]
[16,"Spiritual Counseling",null," "," ",{"$nulls":6},16]
[17,"Dietary Counseling",{"$nulls":9},17]
[18,"Counseling - Other",{"$nulls":9},18]
[19,"Home Health Aide and Homemakers",{"$nulls":9},19]
[20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":9},20]
[21,"Other",{"$nulls":9},21]
[null,"OTHER HOSPICE SERVICE COSTS"]
[22,"Drugs, Biologicals and Infusion",{"$nulls":9},22]
[23,"Analgesics",{"$nulls":9},23]
[24,"Sedative/Hypnotics",{"$nulls":9},24]
[25,"Other - Specify",{"$nulls":9},25]
[26,"Durable Medical Equipment/Oxygen",{"$nulls":9},26]
[27,"Patient Transportation",{"$nulls":9},27]
[28,"Imaging Services",{"$nulls":9},28]
[29,"Labs and Diagnostics",{"$nulls":9},29]
[30,"Medical Supplies",{"$nulls":9},30]
[31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":9},31]
[32,"Radiation Therapy",{"$nulls":9},32]
[33,"Chemotherapy",{"$nulls":9},33]
[34,"Other",{"$nulls":9},34]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[35,"Bereavement Program Costs",{"$nulls":9},35]
[36,"Volunteer Program Costs",{"$nulls":9},36]
[37,"Fundraising",{"$nulls":9},37]
[38,"Other Program Costs",{"$nulls":9},38]
[39,"Total",{"$nulls":9},39]
[null,"(1) Column 0, line 29 must agree with Wkst. A, column 7, line 83."]
["FORM CMS-2540-10 ( 12/10  ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4161)"]
["Rev.1",{"$nulls":10},"41-386"]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-4-2","index":57,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11"]
[null,null,"PROVIDER NO:",null,"HOSPICE NO:",null,"PERIOD:"]
["COST  ALLOCATION  -",{"$nulls":5},"FROM ____________",null,"WORKSHEET K-4"]
["HOSPICE  STATISTICAL  BASIS",null,null,null,"_",null,"TO _______________",null,"PART II"]
[null,null,"CAPITAL","CAPITAL","PLANT","TRANS-","VOLUNTEER","RECONCI-","ADMINIS-"]
[null,null,"RELATED","RELATED","OPERATION","PORTATION","SERV.","LIATION","TRATIVE  &"]
[null,null,"COST BLDG ","COST","& MAINT.","MILEAGE","COORDI-",null,"GENERAL"]
[null,null,"& FIXTURES","MOVABLE","(SQ. FT.)",null,"NATOR",null,"(ACC. COST)"]
[null,"COST CENTER DESCRIPTIONS","(SQ. FT.)","EQUIPMENT",null,null,"(HOURS)"]
[null,null,null,"$ VALUE)"]
[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,"Nursing Care- Continuous Home Care",{"$nulls":7},11]
[12,"Physical Therapy",{"$nulls":7},12]
[13,"Occupational Therapy",{"$nulls":7},13]
[14,"Speech/ Language Pathology",{"$nulls":7},14]
[15,"Medical Social Services - Direct",{"$nulls":7},15]
[16,"Spiritual Counseling"," "," ",{"$nulls":5},16]
[17,"Dietary Counseling",{"$nulls":7},17]
[18,"Counseling - Other",{"$nulls":7},18]
[19,"Home Health Aide and Homemakers",{"$nulls":7},19]
[20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":7},20]
[21,"Other",{"$nulls":7},21]
[null,"OTHER HOSPICE SERVICE COSTS"]
[22,"Drugs, Biologicals and Infusion",{"$nulls":7},22]
[23,"Analgesics",{"$nulls":7},23]
[24,"Sedative/Hypnotics",{"$nulls":7},24]
[25,"Other - Specify",{"$nulls":7},25]
[26,"Durable Medical Equipment/Oxygen",{"$nulls":7},26]
[27,"Patient Transportation",{"$nulls":7},27]
[28,"Imaging Services",{"$nulls":7},28]
[29,"Labs and Diagnostics",{"$nulls":7},29]
[30,"Medical Supplies",{"$nulls":7},30]
[31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":7},31]
[32,"Radiation Therapy",{"$nulls":7},32]
[33,"Chemotherapy",{"$nulls":7},33]
[34,"Other",{"$nulls":7},34]
[null,"HOSPICE NONREIMBURSABLE SERV."]
[35,"Bereavement Program Costs",{"$nulls":7},35]
[36,"Volunteer Program Costs",{"$nulls":7},36]
[37,"Fundraising",{"$nulls":7},37]
[38,"Other Program Costs",{"$nulls":7},38]
[49,"Cost To be Allocated (per Wkst K-4, Part I)",{"$nulls":7},49]
[50,"Unit Cost Multiplier",{"$nulls":7},50]
["FORM CMS-2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4161)"]
["41-387",{"$nulls":8},"Rev.1"]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-5-1","index":58,"n_rows":257,"n_cols":31,"rows_kept":257,"cut":false,"hidden":false,"merged":[[2,8,2,9],[3,8,3,9],[2,28,2,29],[3,28,3,29],[2,21,2,22],[3,21,3,22],[2,0,2,3],[3,0,3,3],[2,18,2,19],[3,18,3,19],[2,11,2,12],[3,11,3,12]],"flags":["formulas_cached_only"]}
["2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":5},"4190 (Cont.)","4190 (Cont.)",null,null,null,"FORM CMS-2540-10",{"$nulls":4},"2011-02-11","2011-02-11",null,null,null,"FORM CMS-2540-10",{"$nulls":4},"4190 (Cont.)"]
[{"$nulls":4},"PROVIDER NO.:",null,"PERIOD",{"$nulls":7},"PROVIDER NO.:",null,"PERIOD",{"$nulls":7},"PROVIDER NO.:",null,"PERIOD"]
["ALLOCATION  OF  GENERAL  SERVICE",{"$nulls":5}," FROM:_______________",null,"WORKSHEET K-5,",null,null,"ALLOCATION  OF  GENERAL  SERVICE",{"$nulls":4}," FROM:_______________",null,"WORKSHEET K-5,",null,null,"ALLOCATION  OF  GENERAL  SERVICE",{"$nulls":4}," FROM:_______________",null,"WORKSHEET K-5,"]
["COSTS  TO  HOSPICE  COST  CENTERS",null,null,null,"HOSPICE NO.:",null," TO: _________________",null,"PART I",null,null,"COSTS  TO  HOSPICE  COST  CENTERS",null,null,"HOSPICE NO.:",null," TO: _________________",null,"Part I (Cont.)",null,null,"COSTS  TO  HOSPICE  COST  CENTERS",null,null,"HOSPICE NO.:",null," TO: _________________",null,"Part I (Cont.)"]
[null,null,null,"From","HOSPICE","CAPITAL","CAPITAL","EMPLOYEE","SUBTOTAL","ADMINIS-",null,null,null,"PLANT","LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY",null,null,null,"MEDICAL","SOCIAL","INTERNS &","OTHER","SUBTOTAL","ALLOCATED","TOTAL"]
[null,null,null,"Wkst.","TRIAL","RELATED","RELATED","BENEFITS","(cols. 0-3)","TRATIVE &",null,null,null,"OPERATION","& LINEN","KEEPING",null,"ADMINIS-","SERVICES &",{"$nulls":4},"RECORDS &","SERVICE","RESIDENTS","GENERAL","(Sum of Columns","HOSPICE","HOSPICE"]
[null,"HOSPICE COST CENTER",null,"K-4","BALANCE","BLDGS. &","MOVABLE"," "," ","GENERAL",null,null,"HOSPICE COST CENTER","MAINTENANCE","SERVICE",null,null,"TRATION","SUPPLY",null,null,null,"HOSPICE COST CENTER","LIBRARY",null,null,"SERVICE"," 4a through 15)","A&G (see","COSTS"]
[null,"(omit cents)",null,"Part I,","(1)","FIXTURES","EQUIPMENT",{"$nulls":5},"(omit cents)"," & REPAIRS",{"$nulls":8},"(omit cents)",{"$nulls":5},"Part II)"]
[null,null,null,"col. 6,"]
[null,null,null,"line -","0","1","2","3","4A","4",null,null,null,"5","6",7,8,9,"10","11",null,null,null,"12","13","14","15","16","17","18"]
[6,"Administrative and General",null,6,{"$nulls":6},6,6,"Administrative and General",{"$nulls":7},6,6,"Administrative and General",{"$nulls":7},6]
[7,"Inpatient - General Care",null,7,{"$nulls":6},7,7,"Inpatient - General Care",{"$nulls":7},7,7,"Inpatient - General Care",{"$nulls":7},7]
[8,"Inpatient - Respite Care",null,8,{"$nulls":6},8,8,"Inpatient - Respite Care",{"$nulls":7},8,8,"Inpatient - Respite Care",{"$nulls":7},8]
[9,"Physician Services",null,9,{"$nulls":6},9,9,"Physician Services",{"$nulls":7},9,9,"Physician Services",{"$nulls":7},9]
[10,"Nursing Care",null,10,{"$nulls":6},10,10,"Nursing Care",{"$nulls":7},10,10,"Nursing Care",{"$nulls":7},10]
[11,"Nursing Care- Continuous Home Care",null,11,{"$nulls":6},11,11,"Nursing Care- Continuous Home Care",{"$nulls":7},11,11,"Nursing Care- Continuous Home Care",{"$nulls":7},11]
[12,"Physical Therapy",null,12,{"$nulls":6},12,12,"Physical Therapy",{"$nulls":7},12,12,"Physical Therapy",{"$nulls":7},12]
[13,"Occupational Therapy",null,13,{"$nulls":6},13,13,"Occupational Therapy",{"$nulls":7},13,13,"Occupational Therapy",{"$nulls":7},13]
[14,"Speech/ Language Pathology",null,14,{"$nulls":6},14,14,"Speech/ Language Pathology",{"$nulls":7},14,14,"Speech/ Language Pathology",{"$nulls":7},14]
[15,"Medical Social Services - Direct",null,15,{"$nulls":6},15,15,"Medical Social Services - Direct",{"$nulls":7},15,15,"Medical Social Services - Direct",{"$nulls":7},15]
[16,"Spiritual Counseling",null,16,{"$nulls":6},16,16,"Spiritual Counseling",{"$nulls":7},16,16,"Spiritual Counseling",{"$nulls":7},16]
[17,"Dietary Counseling",null,17,{"$nulls":6},17,17,"Dietary Counseling",{"$nulls":7},17,17,"Dietary Counseling",{"$nulls":7},17]
[18,"Counseling - Other",null,18,{"$nulls":6},18,18,"Counseling - Other",{"$nulls":7},18,18,"Counseling - Other",{"$nulls":7},18]
[19,"Home Health Aide and Homemakers",null,19,{"$nulls":6},19,19,"Home Health Aide and Homemakers",{"$nulls":7},19,19,"Home Health Aide and Homemakers",{"$nulls":7},19]
[20,"HH Aide & Homaker - Cont. Home Care",null,20,{"$nulls":6},20,20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":7},20,20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":7},20]
[21,"Other",null,21,{"$nulls":6},21,21,"Other",{"$nulls":7},21,21,"Other",{"$nulls":7},21]
[22,"Drugs, Biologicals and Infusion",null,22,{"$nulls":6},22,22,"Drugs, Biologicals and Infusion",{"$nulls":7},22,22,"Drugs, Biologicals and Infusion",{"$nulls":7},22]
[23,"Analgesics",null,23,{"$nulls":6},23,23,"Analgesics",{"$nulls":7},23,23,"Analgesics",{"$nulls":7},23]
[24,"Sedative/Hypnotics",null,24,{"$nulls":6},24,24,"Sedative/Hypnotics",{"$nulls":7},24,24,"Sedative/Hypnotics",{"$nulls":7},24]
[25,"Other - Specify",null,25,{"$nulls":6},25,25,"Other - Specify",{"$nulls":7},25,25,"Other - Specify",{"$nulls":7},25]
[26,"Durable Medical Equipment/Oxygen",null,26,{"$nulls":6},26,26,"Durable Medical Equipment/Oxygen",{"$nulls":7},26,26,"Durable Medical Equipment/Oxygen",{"$nulls":7},26]
[27,"Patient Transportation",null,27,{"$nulls":6},27,27,"Patient Transportation",{"$nulls":7},27,27,"Patient Transportation",{"$nulls":7},27]
[28,"Imaging Services",null,28,{"$nulls":6},28,28,"Imaging Services",{"$nulls":7},28,28,"Imaging Services",{"$nulls":7},28]
[29,"Labs and Diagnostics",null,29,{"$nulls":6},29,29,"Labs and Diagnostics",{"$nulls":7},29,29,"Labs and Diagnostics",{"$nulls":7},29]
[30,"Medical Supplies",null,30,{"$nulls":6},30,30,"Medical Supplies",{"$nulls":7},30,30,"Medical Supplies",{"$nulls":7},30]
[31,"Outpatient Services (incl. E/R Dept.)",null,31,{"$nulls":6},31,31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":7},31,31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":7},31]
[32,"Radiation Therapy",null,32,{"$nulls":6},32,32,"Radiation Therapy",{"$nulls":7},32,32,"Radiation Therapy",{"$nulls":7},32]
[33,"Chemotherapy",null,33,{"$nulls":6},33,33,"Chemotherapy",{"$nulls":7},33,33,"Chemotherapy",{"$nulls":7},33]
[34,"Other",null,34,{"$nulls":6},34,34,"Other",{"$nulls":7},34,34,"Other",{"$nulls":7},34]
[35,"Bereavement Program Costs",null,35,{"$nulls":6},35,35,"Bereavement Program Costs",{"$nulls":7},35,35,"Bereavement Program Costs",{"$nulls":7},35]
[36,"Volunteer Program Costs",null,36,{"$nulls":6},36,36,"Volunteer Program Costs",{"$nulls":7},36,36,"Volunteer Program Costs",{"$nulls":7},36]
[37,"Fundraising",null,37,{"$nulls":6},37,37,"Fundraising",{"$nulls":7},37,37,"Fundraising",{"$nulls":7},37]
[38,"Other Program Costs",null,38,{"$nulls":6},38,38,"Other Program Costs",{"$nulls":7},38,38,"Other Program Costs",{"$nulls":7},38]
[39,"Totals (sum of lines 1-28) ",{"$nulls":8},39,39,"Totals (sum of lines 1-28) (2)",{"$nulls":7},39,39,"Totals (sum of lines 1-28) (2)",{"$nulls":7},39]
[50,"Unit Cost Multiplier:",{"$nulls":8},50,50,"Unit Cost Multiplier:",{"$nulls":7},50,50,"Unit Cost Multiplier:",{"$nulls":7},50]
[null,"Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.",{"$nulls":10},"Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.",{"$nulls":9},"Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places."]
["(2) Columns 0 through 16 , line 29 must agree with the corresponding columns of  Wkst. B, Part I, line 83."]
["FORM CMS-2540-10 ( 12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)",{"$nulls":10},"FORM CMS-2540-10 ( 12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)",{"$nulls":9},"FORM CMS-2540-10 ( 12/10)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)"]
[]
["Rev. 1",{"$nulls":9},"41-388","41-389",{"$nulls":8},"Rev. 1","Rev. 1",{"$nulls":8},"41-390"]
[]
[]
[" "]
[]
[]
[]
[]
[]
[]
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-5-II","index":59,"n_rows":257,"n_cols":31,"rows_kept":257,"cut":false,"hidden":false,"merged":[[2,0,2,3],[2,8,2,9],[3,0,3,3],[3,8,3,9],[3,11,3,12],[3,18,3,19],[2,11,2,12],[2,18,2,19],[2,21,2,22],[2,28,2,29],[3,21,3,22],[3,28,3,29]],"flags":["formulas_cached_only"]}
[" 4190 (Cont.)",{"$nulls":4},"FORM CMS-2540-10",{"$nulls":4},"2011-02-11","2011-02-11",null,null,"FORM CMS-2540-10",{"$nulls":5}," 4190 (Cont.)"," 4190 (Cont.)",null,null,"FORM CMS-2540-10",{"$nulls":5},"2011-02-11"]
[{"$nulls":4},"PROVIDER NO.:",null,"PERIOD",{"$nulls":7},"PROVIDER NO.:",null,"PERIOD",{"$nulls":7},"PROVIDER NO.:",null,"PERIOD"]
["ALLOCATION OF GENERAL SERVICE",{"$nulls":5}," FROM:_______________",null,"WORKSHEET K-5,",null,null,"ALLOCATION OF GENERAL SERVICE",{"$nulls":4}," FROM:_______________",null,"WORKSHEET K-5,",null,null,"ALLOCATION OF GENERAL SERVICE",{"$nulls":4}," FROM:_______________",null,"WORKSHEET K-5,"]
["COSTS TO HOSPICE COST CENTERS",null,null,null,"HOSPICE NO.:",null," TO: _________________",null,"PART II",null,null,"COSTS TO HOSPICE COST CENTERS",null,null,"HOSPICE NO.:",null," TO: _________________",null,"Part II (Cont.)",null,null,"COSTS TO HOSPICE COST CENTERS",null,null,"HOSPICE NO.:",null," TO: _________________",null,"Part II (Cont.)"]
[{"$nulls":5},"CAPITAL","CAPITAL","EMPLOYEE","RECONCIL","ADMINIS-",null,null,null,"PLANT","LAUNDRY","HOUSE","DIETARY","NURSING","CENTRAL","PHARMACY",null,null,null,"MEDICAL","SOCIAL","INTERNS &","OTHER"]
[null,"HOSPICE COST CENTER",null,null,null,"RELATED","RELATED","BENEFITS","LATION","TRATIVE &",null,null,"HOSPICE COST CENTER","OPERATION","& LINEN","KEEPING","(Meals Served)","ADMINIS-","SERVICES &","(Costed",null,null,"HOSPICE COST CENTER","RECORDS &","SERVICE","RESIDENTS","GENERAL"]
[null,"(omit cents)",null,null,null,"BLDGS. &","MOVABLE","(Gross Salaries)",null,"GENERAL",null,null,"(omit cents)","MAINTENANCE","SERVICE","(Hours of",null,"TRATION","SUPPLY","Requisitions)",null,null,"(omit cents)","LIBRARY","(Time Spent)","(Assigned Time)","SERVICE"]
[{"$nulls":5},"FIXTURES","EQUIPMENT",null,null,"(Accum. Cost)",null,null,null,"& REPAIRS","(Pounds of ","Service)",null,"(Direct Nursing","(Costed",{"$nulls":4},"(Time Spent)",null,null,"(Specify)"]
[{"$nulls":5},"(Square Feet)","(Dollar Value)",{"$nulls":6},"(Square Feet)","Laundry)",null,null,"Hours)","Requisitions)"]
[{"$nulls":5},"1","2","3","4a","4",null,null,null,"5","6",null,8,9,"10","11",null,null,null,"12","13","14","15"]
[6,"Administrative and General",{"$nulls":8},6,6,"Administrative and General",{"$nulls":7},6,6,"Administrative and General",{"$nulls":7},6]
[7,"Inpatient - General Care",{"$nulls":8},7,7,"Inpatient - General Care",{"$nulls":7},7,7,"Inpatient - General Care",{"$nulls":7},7]
[8,"Inpatient - Respite Care",{"$nulls":8},8,8,"Inpatient - Respite Care",{"$nulls":7},8,8,"Inpatient - Respite Care",{"$nulls":7},8]
[9,"Physician Services",{"$nulls":8},9,9,"Physician Services",{"$nulls":7},9,9,"Physician Services",{"$nulls":7},9]
[10,"Nursing Care",{"$nulls":8},10,10,"Nursing Care",{"$nulls":7},10,10,"Nursing Care",{"$nulls":7},10]
[11,"Nursing Care- Continuous Home Care",{"$nulls":8},11,11,"Nursing Care- Continuous Home Care",{"$nulls":7},11,11,"Nursing Care- Continuous Home Care",{"$nulls":7},11]
[12,"Physical Therapy",{"$nulls":8},12,12,"Physical Therapy",{"$nulls":7},12,12,"Physical Therapy",{"$nulls":7},12]
[13,"Occupational Therapy",{"$nulls":8},13,13,"Occupational Therapy",{"$nulls":7},13,13,"Occupational Therapy",{"$nulls":7},13]
[14,"Speech/ Language Pathology",{"$nulls":8},14,14,"Speech/ Language Pathology",{"$nulls":7},14,14,"Speech/ Language Pathology",{"$nulls":7},14]
[15,"Medical Social Services - Direct",{"$nulls":8},15,15,"Medical Social Services - Direct",{"$nulls":7},15,15,"Medical Social Services - Direct",{"$nulls":7},15]
[16,"Spiritual Counseling",{"$nulls":8},16,16,"Spiritual Counseling",{"$nulls":7},16,16,"Spiritual Counseling",{"$nulls":7},16]
[17,"Dietary Counseling",{"$nulls":8},17,17,"Dietary Counseling",{"$nulls":7},17,17,"Dietary Counseling",{"$nulls":7},17]
[18,"Counseling - Other",{"$nulls":8},18,18,"Counseling - Other",{"$nulls":7},18,18,"Counseling - Other",{"$nulls":7},18]
[19,"Home Health Aide and Homemakers",{"$nulls":8},19,19,"Home Health Aide and Homemakers",{"$nulls":7},19,19,"Home Health Aide and Homemakers",{"$nulls":7},19]
[20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":8},20,20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":7},20,20,"HH Aide & Homaker - Cont. Home Care",{"$nulls":7},20]
[21,"Other",{"$nulls":8},21,21,"Other",{"$nulls":7},21,21,"Other",{"$nulls":7},21]
[22,"Drugs, Biologicals and Infusion",{"$nulls":8},22,22,"Drugs, Biologicals and Infusion",{"$nulls":7},22,22,"Drugs, Biologicals and Infusion",{"$nulls":7},22]
[23,"Analgesics",{"$nulls":8},23,23,"Analgesics",{"$nulls":7},23,23,"Analgesics",{"$nulls":7},23]
[24,"Sedative/Hypnotics",{"$nulls":8},24,24,"Sedative/Hypnotics",{"$nulls":7},24,24,"Sedative/Hypnotics",{"$nulls":7},24]
[25,"Other - Specify",{"$nulls":8},25,25,"Other - Specify",{"$nulls":7},25,25,"Other - Specify",{"$nulls":7},25]
[26,"Durable Medical Equipment/Oxygen",{"$nulls":8},26,26,"Durable Medical Equipment/Oxygen",{"$nulls":7},26,26,"Durable Medical Equipment/Oxygen",{"$nulls":7},26]
[27,"Patient Transportation",{"$nulls":8},27,27,"Patient Transportation",{"$nulls":7},27,27,"Patient Transportation",{"$nulls":7},27]
[28,"Imaging Services",{"$nulls":8},28,28,"Imaging Services",{"$nulls":7},28,28,"Imaging Services",{"$nulls":7},28]
[29,"Labs and Diagnostics",{"$nulls":8},29,29,"Labs and Diagnostics",{"$nulls":7},29,29,"Labs and Diagnostics",{"$nulls":7},29]
[30,"Medical Supplies",{"$nulls":8},30,30,"Medical Supplies",{"$nulls":7},30,30,"Medical Supplies",{"$nulls":7},30]
[31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":8},31,31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":7},31,31,"Outpatient Services (incl. E/R Dept.)",{"$nulls":7},31]
[32,"Radiation Therapy",{"$nulls":8},32,32,"Radiation Therapy",{"$nulls":7},32,32,"Radiation Therapy",{"$nulls":7},32]
[33,"Chemotherapy",{"$nulls":8},33,33,"Chemotherapy",{"$nulls":7},33,33,"Chemotherapy",{"$nulls":7},33]
[34,"Other",{"$nulls":8},34,34,"Other",{"$nulls":7},34,34,"Other",{"$nulls":7},34]
[35,"Bereavement Program Costs",{"$nulls":8},35,35,"Bereavement Program Costs",{"$nulls":7},35,35,"Bereavement Program Costs",{"$nulls":7},35]
[36,"Volunteer Program Costs",{"$nulls":8},36,36,"Volunteer Program Costs",{"$nulls":7},36,36,"Volunteer Program Costs",{"$nulls":7},36]
[37,"Fundraising",{"$nulls":8},37,37,"Fundraising",{"$nulls":7},37,37,"Fundraising",{"$nulls":7},37]
[38,"Other Program Costs",{"$nulls":8},38,38,"Other Program Costs",{"$nulls":7},38,38,"Other Program Costs",{"$nulls":7},38]
[39,"Totals (sum of lines 1-28) ",{"$nulls":8},39,39,"Totals (sum of lines 1-28)",{"$nulls":7},39,39,"Totals (sum of lines 1-28)",{"$nulls":7},39]
[50,"Unit Cost Multiplier",{"$nulls":8},50,50,"Unit Cost Multiplier",{"$nulls":7},50,50,"Unit Cost Multiplier",{"$nulls":7},50]
["FORM CMS-2540-10 (  12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)",{"$nulls":10},"FORM CMS-2540-10 (  12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)",{"$nulls":9},"FORM CMS-2540-10 (  12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)"]
["41-391",{"$nulls":9},"Rev. 1","Rev. 1",{"$nulls":8},"41-392","41-393",{"$nulls":8},"Rev. 1"]
[]
[]
[" "]
{"$rows_empty":9}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K-5-III","index":60,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[[7,2,7,3],[7,4,7,5],[8,2,8,3],[8,4,8,5]],"flags":["formulas_cached_only"]}
[null,"2011-02-11",null,null,"FORM CMS-2540-10",{"$nulls":5},"4190(Cont.)"]
[{"$nulls":4},"PROVIDER NO.:",null,"PERIOD:",null,"WORKSHEET "]
["APPORTIONMENT  OF  HOSPICE  SHARED  SERVICES",{"$nulls":5},"From:",null,null,"K-5"]
[{"$nulls":4},"HOSPICE  NO.:",null,"To:",null,null,"Part III"]
[]
["PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS"]
["Hospice shared cost computation",{"$nulls":6},"Total Hospice",null,"Hospice Shared"]
[null,null,"Facility  Cost",null,"Cost to Charge Ratio",null,null,"Charges",null,"Ancillary Costs"]
[null,null,"From Worksheet K-5, Part I",null,"From Worksheet C, Col. 3",null,null,"(From Provider",null,"(col. 4 x col. 5)"]
[null,"COST CENTER ","Line:","Amount:","Line :","Ratio",null,"Records)"]
[null,null,1,2,3,4,null,5,null,6]
["ANCILLARY SERVICE COST CENTERS"]
[1,"Physical Therapy",12,null,44,{"$nulls":5},1]
[2,"Occupational Therapy",13,null,45,{"$nulls":5},2]
[3,"Speech/ Language Pathology",14,null,46,{"$nulls":5},3]
[4,"Drugs, Biologicals and Infusion",22,null,49,{"$nulls":5},4]
[5,"Labs and Diagnostics",29,null,41,{"$nulls":5},5]
[6,"Medical Supplies",30,null,48,{"$nulls":5},6]
[7,"Radiation Therapy",32,null,40,{"$nulls":5},7]
[8,"Other",34,null,52,{"$nulls":5},8]
[9,"Total (sum of lines 1-8) ",{"$nulls":8},9]
{"$rows_empty":13}
["FORM CMS-2540-10 ( 12/10 )  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)"]
[]
["Rev. 1",{"$nulls":9},"41-394"]
{"$rows_empty":22}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]

{"sheet":"K6","index":61,"n_rows":257,"n_cols":12,"rows_kept":257,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[" 4190 (Cont.)",null,null,"FORM CMS-2540-10",null,null,null,"2011-02-11"]
[null,"CALCULATION OF","PROVIDER NO.",null,"PERIOD:"]
[null,"PER DIEM COST",null,null," FROM ________________",null," WORKSHEET  K-6"]
[null,null," _________________",null," TO   ________________"]
[]
[]
[null,"COMPUTATION OF PER DIEM COST",null,"TITLE XVIII","TITLE XIX","OTHER","TOTAL"]
[null,null,null,"1",2,3,4]
["1","Total cost (Worksheet K, line 39  less line 38, col. 7)",{"$nulls":5},"1"]
["2","Total Unduplicated Days (Worksheet S-8, line 5, col. 6)",{"$nulls":5},"2"]
["3","Average cost per diem (line 1 divided by line 2)",{"$nulls":5},"3"]
["4","Unduplicated Medicare Days (Worksheet S-8, line 5, col. 1)",{"$nulls":5},"4"]
["5","Average Medicare cost (line 3 times line 4)",{"$nulls":5},"5"]
["6","Unduplicated Medicaid Days (Worksheet S-8, line 5, col. 2)",{"$nulls":5},"6"]
["7","Average  Medicaid cost (line 3 times line 6)",{"$nulls":5},"7"]
["8","Unduplicated SNF days (Worksheet S-8, line 5, col. 3)",{"$nulls":5},"8"]
[9,"Average SNF cost (line 3 times line 8)",{"$nulls":5},9]
[10,"Unduplicated NF days (Worksheet S-8, line 5, col. 4)",{"$nulls":5},10]
[11,"Average NF cost (line 3 times line 10)",{"$nulls":5},11]
[12,"Other Unduplicated days (Worksheet S-8, line 5, col. 5)",{"$nulls":5},12]
[13,"Average cost for other days (line  3 times line 12)",{"$nulls":5},13]
{"$rows_empty":18}
["FORM  CMS 2540-10 ( 12/10  ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.  15-II, SECTION 4163)"]
["41-395",{"$nulls":6},"Rev. 1"]
{"$rows_empty":18}
[" "]
{"$rows_empty":196}
[{"$nulls":11},"Rev. 1"]