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[null,"This report is required by law (42 USC 1395mm and 42 USC 1995I).",{"$nulls":9},"                                              FORM APPROVED"]
[null,"Failure to report can result in all interim payments made since",{"$nulls":9},"                                              OMB NO. 0938-0165"]
[null,"the beginning of the cost reporting period being deemed overpayments."]
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[null,null,"PREPAID HEALTH PLAN COST REPORT",{"$nulls":8},"WORKSHEET S "]
[null,null,"GENERAL INFORMATION                   "]
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[null," 1","Name and Address of Plan:"]
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[null," 3","a. Type of Report:",null,"b.  Bill Processing Option:",null,null,null,"c.  Reimbursement Under:"]
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[null,null,"    [  ]  Budget Forecast","Budget Forecast",null,"Select Option",{"$nulls":5},1876]
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[null,null,"    [  ]","Interim Reports"]
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[null,null,"    [x]","Final Cost Report"]
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[null,null,null,"                MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST "]
[null,null,null,"                  REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW"]
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[{"$nulls":5},"               CERTIFICATION BY OFFICER OF THE PLAN"]
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[null,null,null,"          I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Cost, the allocation of "]
[null,null,null,"          expenses and services, and the attached Worksheets for the period from       01/00/1900    to    01/00/1900"]
[null,null,null,"          and that to the best of my knowledge and belief they are true and correct statements prepared from the books "]
[null,null,null,"          and records of the Plan in accordance with applicable instructions, except as noted."]
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[null,null,"SIGNATURE (Officer or Administrator of the Plan)",{"$nulls":5},"    DATE"]
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[null,null,"TITLE",{"$nulls":5},"     PHONE NUMBER"]
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[null,"FORM CMS 276-08 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2302)"]
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[null,"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"]
[null,"OMB control number for this information collection is 0938-0165.  The time required to complete this information is estimated to average as follows: (1) for HMOs/CMPs,"]
[null,"24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, and 12 hours to complete the first, second, and third quarterly reports;"]
[null,"and (2)for HCPPs, 16 hours to complete the budget forecast, 60 hours to complete the final cost report, and 8 hours to complete the mid-year report.  If you have any comments"]
[null,"concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HCFA, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland"]
[null,"21244-1850 and  to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503."]

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[null," ",{"$nulls":5},"        ___________",null,"        ___________"]
[null,110,"Total Page 2 (Col 4 must equal Col 5)..............................................................",".",".",".",null,0,null,0]
[null,null," ",{"$nulls":4},"       ============",null,"       ============"]
[null,null,"(1)  A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.",{"$nulls":4},"Summarized on Worksheet F, Page 3"]
[null,null,"(2)  Transfer to Worksheet E, Col. 2, lines as appropriate."]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)"]
[]
[" ","RECLASSIFICATIONS",{"$nulls":7},"WORKSHEET F"]
[" ",null,"Name of Plan:",0,{"$nulls":5},"Page 3"]
[" ",null,"Plan #:","H-xxxx",null,"PERIOD FROM:",null,"00:00:00"]
[" ",{"$nulls":4},"TO:",null,"00:00:00"]
[]
[]
[null,null," ",null,null,"CC LINE",null,null,"AMOUNT"]
[null,null,null,"CODE","COST CENTER","NUMBER "]
[null,"LINE","EXPLANATION OF RECLASSIFICATION ENTRY","(1)","(Worksheet E)","(WKST E)",null,"INCREASES",null,"(DECREASES)"]
[null,null," ","1","2","3   ",null,"4",null,"5"]
[null,111,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,154,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,161,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,162,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,163,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,164,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,165,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,166,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null," ",{"$nulls":5},"        ___________",null,"        ___________"]
[null,167,"Total Page 3 (Col 4 must equal Col 5)..............................................................",".",".",".",null,0,null,0]
[null,null," ",{"$nulls":4},"       ============",null,"       ============"]
[null,null,"(1)  A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.",{"$nulls":4},"Summarized on Worksheet F, Page 3"]
[null,null,"(2)  Transfer to Worksheet E, Col. 2, lines as appropriate."]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)"]
[]
[" ","RECLASSIFICATIONS",{"$nulls":7},"WORKSHEET F"]
[" ",null,"Name of Plan:",0,{"$nulls":5},"Page 4"]
[" ",null,"Plan #:","H-xxxx",null,"PERIOD FROM:",null,"00:00:00"]
[" ",{"$nulls":4},"TO:",null,"00:00:00"]
[]
[]
[null,null," ",null,null,"CC LINE",null,null,"AMOUNT"]
[null,null,null,"CODE","COST CENTER","NUMBER "]
[null,"LINE","EXPLANATION OF RECLASSIFICATION ENTRY","(1)","(Worksheet E)","(WKST E)",null,"INCREASES",null,"(DECREASES)"]
[null,null," ","1","2","3   ",null,"4",null,"5"]
[null,168,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,169,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,170,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,171,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,172,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,173,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,174,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,175,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,176,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,177,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,178,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,179,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,180,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,183,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,184,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,186,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,187,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,188,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,192,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,200,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,202,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,203,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,204,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,205,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,206,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,207,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,208,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,209,"____________________________________________","______","_________________________","___________",null,0,null,0]
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[null,211,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,212,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,213,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,214,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,215,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,216,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,217,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,218,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,219,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,220,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,221,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,222,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null,223,"____________________________________________","______","_________________________","___________",null,0,null,0]
[null," ",{"$nulls":5},"        ___________",null,"        ___________"]
[null,224,"Total Page 4 (Col 4 must equal Col 5)..............................................................",".",".",".",null,0,null,0]
[null,null," ",{"$nulls":4},"       ============",null,"       ============"]
[null,null,"(1)  A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.",{"$nulls":4},"Summarized on Worksheet F, Page 3"]
[null,null,"(2)  Transfer to Worksheet E, Col. 2, lines as appropriate."]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)"]
[]
[" ",null,"SUMMARY OF RECLASSIFICATIONS",{"$nulls":6},"WORKSHEET F"]
[" ",null,"Name of Plan:",0,{"$nulls":5},"Page 5"]
[" ",null,"Plan #:","H-xxxx",null,"PERIOD FROM:",null,"00:00:00"]
[" ",{"$nulls":4},"TO:",null,"00:00:00"]
[]
[null,null," "," "," "]
[null,null,null," "," ","               SUMMARY OF RECLASSIFICATIONS"]
[]
[{"$nulls":5},"INCREASES",null,"(DECREASES)",null,"NET"]
[null," CC",null," "," ","         (From Worksheet F, Pgs 1 & 2)"]
[null,"LINE","COST CENTER DESCRIPTIONS"," "," ","4",null,"5",null,"6"]
[]
[null,1,"Inpatient Hospitals ………………………………………………………………..","………………..",".",0,null,0,null,0]
[null,2,"Outpatient Hospitals ……………………………………………………………","…………………",".",0,null,0,null,0]
[null,3,"Skilled Nursing Facilities.............................................................................................................................",".",".",0,null,0,null,0]
[null,4,"Home Health Agencies..........................................................................................................................................",".",".",0,null,0,null,0]
[null,5,"Clinics..........................................................................................................................................................",".",".",0,null,0,null,0]
[null,6,"Physician Groups................................................................................................................................................",".",".",0,null,0,null,0]
[null,7,"Individual Physicians...........................................................................................................................................",".",".",0,null,0,null,0]
[null,8,"Certified Labs..................................................................................................................................................",".",".",0,null,0,null,0]
[null,9,"X-Ray Units.................................................................................................................................................",".",".",0,null,0,null,0]
[null,10,"ESRD Facilities........................................................................................................................",".",".",0,null,0,null,0]
[null,11,"Durable Medical Equipment..............................................................................................................",".",".",0,null,0,null,0]
[null,12,"Ambulances................................................................................................................................",".",".",0,null,0,null,0]
[null,13,"Pharmacy (Outpatient)..........................................................................................................................................",".",".",0,null,0,null,0]
[null,"13a","Pharmacy-Medicare Covered Rx...............................................................................................................................",".",".",0,null,0,null,0]
[null,14,"Emergency-Urgently Needed Svcs.................................................................................................",".",".",0,null,0,null,0]
[null,15,"Mental Health Services...........................................................................................................................................",".",".",0,null,0,null,0]
[null,16,"DED+CO pd by the MAC/Carriers/Intermediaries...........................................................................................................",".",".",0,null,0,null,0]
[null,17,"Other - Medicare Bad Debts...…",".",".",0,null,0,null,0]
[null,18,"Other - Blood Deductible.....…",".",".",0,null,0,null,0]
[null,19,"Other - (Specify)...…….......…",".",".",0,null,0,null,0]
[null,20,"Other - (Specify)...…….......…",".",".",0,null,0,null,0]
[null,21,"Other - (Specify)...…….......…",".",".",0,null,0,null,0]
[null,22,"Other - (Specify)...…….......…",".",".",0,null,0,null,0]
[null,23,"Other - (Specify)...…….......…",".",".",0,null,0,null,0]
[null,24]
[null,25,"Plan Administration..................................................................................................",".",".",0,null,0,null,0]
[null,26,"Special Admin Costs....................................................................................",".",".",0,null,0,null,0]
[null,27]
[null,28,"Admin & General Costs.............................................................................",".",".",0,null,0,null,0]
[null,null," ",null,null,"      ____________",null,"      ____________",null,"      ____________"]
[null,29,"Total Reclassifications (Lines 1 thru 28) (Col 6 must net to zero)......................................",null,".",0,null,0,null,0]
[{"$nulls":4}," ","    =============",null,"    =============",null,"    ============="]
[{"$nulls":4}," "]
[null,null,"DIFFERENCES from total of pages 1 & 2 on page 1, Line 53……………………………………………………………………………..",null,null,0,null,0]
[{"$nulls":5},"    =============",null,"    =============",null,"Must net to zero."]
[]
[{"$nulls":9},"To Worksheet E"]
[{"$nulls":4}," ","If these differences are not",null,null,null,"Column 2"]
[{"$nulls":5},"zero there is a problem!!"]
[{"$nulls":4}," ",{"$nulls":4}," "," "]
[" ",null,null,null," ",{"$nulls":4}," "," "]
[" ",null,"FORM CMS 276-08",null,null,null," "," ",null," "," "]
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[]
[]
[" ",null,null,null," "," "," "," "," "," "," "]
[null,null,"SUPPLEMENT TO WORKSHEET F - RECLASSIFICATIONS"]
[null,null,"Name of Plan:",0]
[null,null,"Plan #:","H-xxxx","                      Period","From:",null,"00:00:00"]
[{"$nulls":5},"    To:",null,"00:00:00",null," AD181...AN240"]
[]
[]
[null,null,"THIS IS A SUPPLEMENTAL WORKSHEET TO SUM UP RECLASSIFICATIONS BY COST CENTER"]
[]
[null,"CCNO",null,null,null,"INCREASES",null,"(DECREASES)"]
[null,1,"IP Hosp",null,null,0,null,0]
[null,"CCNO"]
[null,2,"OP Hosp",null,null,0,null,0]
[null,"CCNO"]
[null,3,"SNF",null,null,0,null,0]
[null,"CCNO"]
[null,4,"HHA",null,null,0,null,0]
[null,"CCNO"]
[null,5,"Clinic",null,null,0,null,0]
[null,"CCNO"]
[null,6,"Physicians Groups",null,null,0,null,0]
[null,"CCNO"]
[null,7,"Ind Phy",null,null,0,null,0]
[null,"CCNO"]
[null,8,"Labs",null,null,0,null,0]
[null,"CCNO"]
[null,9,"Xray",null,null,0,null,0]
[null,"CCNO"]
[null,10,"ESRD",null,null,0,null,0]
[null,"CCNO"]
[null,11,"DME",null,null,0,null,0]
[null,"CCNO"]
[null,12,"Amb",null,null,0,null,0]
[null,"CCNO"]
[null,13,"Phrm",null,null,0,null,0]
[null,"CCNO"]
[null,14,"Emerg",null,null,0,null,0]
[null,"CCNO"]
[null,15,"Mental",null,null,0,null,0]
[null,"CCNO"]
[null,16,"Ded & Coins",null,null,0,null,0]
[null,"CCNO"]
[null,17,null,null,null,0,null,0]
[null,"CCNO"]
[null,18,"Other",null,null,0,null,0]
[null,"CCNO"]
[null,19,"Nonallowable",null,null,0,null,0]
[null,"CCNO"]
[null,21,"Plan Admin",null,null,0,null,0]
[null,"CCNO"]
[null,22,"Spec Admin",null,null,0,null,0]
[null,"CCNO"]
[null,24,"A&G",null,null,0,null,0]
[null," ",null,null,null,"  ------------",null,"  ------------"]
[null," ",null,null,null,0,null,0]
[null," ",null,null,null," =============",null," ============="]
[{"$nulls":5}," ",null," "]

{"sheet":"Worksheet G","index":4,"n_rows":361,"n_cols":10,"rows_kept":361,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,null,"ADJUSTMENTS TO EXPENSES",{"$nulls":4},"                                          WORKSHEET G"]
[null,null,"Name of Plan:",0,null,null,null,"                                          PART I"]
[null,null,"Plan #:","H-xxxx","PERIOD FROM:","00:00:00",null,"                                          Page 1"]
[{"$nulls":4},"TO:","00:00:00"]
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[{"$nulls":4},"1","2"," ","3","4"]
[]
[null,1,"Investment income on commingled restricted & unrestricted funds.......................................................",null,"_",0,null," _____________________________","__"]
[null,2,"Trade, quantity, time & other discounts on purchases.......................................................",null,"_",0,null," _____________________________","__"]
[null,3,"Rebates & refunds of expenses......................................................................................................",null,"_",0,null," _____________________________","__"]
[null,4,"Rental of space by suppliers.................................................................................................",null,"_",0,null," _____________________________","__"]
[null,5,"Telephone service.....................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,6,"Television & radio service....................................................................................................",null,"_",0,null," _____________________________","__"]
[null,7,"Parking lot...................................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,8,"Home Office Costs (Attach copy of Home Office Cost Statemenmt)..........",null,"_",0,null," _____________________________","__"]
[null,9,"Sale of scrap, waste, etc......................................................................................................",null,"_",0,null," _____________________________","__"]
[null,10,"Adj. resulting from transactions with related organizations (3).....................................",null,"_",0,null," _____________________________","__"]
[null,"10a","Adj. resulting from transactions with related organizations (3).....................................",null,"_",0,null," _____________________________","__"]
[null,"10b","Adj. resulting from transactions with related organizations (3).....................................",null,"_",0,null," _____________________________","__"]
[null,"10c","Adj. resulting from transactions with related organizations (3).....................................",null,"_",0,null," _____________________________","__"]
[null,11,"Laundry and linen service.........................................................................................................",null,"_",0,null," _____________________________","__"]
[null,12,"Cafeteria - employees, guests, etc...................................................................................",null,"_",0,null," _____________________________","__"]
[null,13,"Rental of living quarters to employees and others.....................................................",null,"_",0,null," _____________________________","__"]
[null,14,"Sale of medical and surgical supplies to other than patients...............................",null,"_",0,null," _____________________________","__"]
[null,15,"Sale of drugs to other than patients...............................................................................",null,"_",0,null," _____________________________","__"]
[null,16,"Sale of medical records and abstracts..........................................................................",null,"_",0,null," _____________________________","__"]
[null,17,"Nursing school (tuition, fees, uniforms, finance charges)........................................",null,"_",0,null," _____________________________","__"]
[null,18,"Income from vending machines..........................................................................................",null,"_",0,null," _____________________________","__"]
[null,19,"Income from imposition of interest and finance charges.......................................",null,"_",0,null," _____________________________","__"]
[null,20,"Payments - Physicians' assumption of operating costs........................................",null,"_",0,null," _____________________________","__"]
[null,21,"Undistributed risk pool........................................................................................................",null,"_",0,null," _____________________________","__"]
[null,22,"Charges in excess of MAC screens............................................................................",null,"_",0,null," _____________________________","__"]
[null,23,"Part B coinsurance on services paid by CMS's  MAC/Carriers.........................................",null,"_",0,null," _____________________________","__"]
[null,24,"Part B coinsurance on services paid by CMS's MAC/Intermediaries..........................................",null,"_",0,null," _____________________________","__"]
[null,25,"Adjustment for physicial therapy costs in excess of limit (4)......................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,26,"Reinsurance...........................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,27,"Depreciation in excess of limits (Attach worksheet) ........................................................................................................",null,"_",0,null," _____________________________","__"]
[null,28,"Noncovered purchased service (Attach worksheet)...................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,29,"Medicare Bad Debts",null,"_",0,null," _____________________________","__"]
[null,30,"..................................................................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,31,"..................................................................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,32,"..................................................................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,33,"..................................................................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,34,"..................................................................................................................................................................",null,"_",0,null," _____________________________","__"]
[null,35,"..................................................................................................................................................................",null,"_",0,null," _____________________________","__"]
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[null,null,"ADJUSTMENTS TO EXPENSES",{"$nulls":4},"                                             WORKSHEET G"]
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[null,null,"SUMMARY OF ADJUSTMENTS TO EXPENSES",{"$nulls":4},"                                           WORKSHEET G"]
[null,null,"Name of Plan:",0,null,null,null,"                                           PART II"]
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[{"$nulls":4},"TO:","00:00:00"]
[null,null," "]
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[{"$nulls":4},"PART I",null," "]
[{"$nulls":4},"1","2",null,"3      ","4"]
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[null," "," "," "," "," "," "," "," "]
[null,1,"Inpatient Hospitals………………………………","."," ___________",0," ",null,1]
[null,2,"Outpatient Hospitals…………………………..","."," ___________",0," ",null,2]
[null,3,"Skilled Nursing Facilities.................................","."," ___________",0," ",null,3]
[null,4,"Home Health Agencies......................................","."," ___________",0," ",null,4]
[null,5,"Clinics..............................................................................","."," ___________",0," ",null,5]
[null,6,"Physician Groups.......................................","."," ___________",0," ",null,6]
[null,7,"Individual Physicians.....................................","."," ___________",0," ",null,7]
[null,8,"Certified Labs...............................................","."," ___________",0," ",null,8]
[null,9,"X-Ray Units...................................................","."," ___________",0," ",null,9]
[null,10,"ESRD Facilities........................................................................................................................","."," ___________",0," ",null,10]
[null,11,"Durable Medical Equipment..............................................................................................................","."," ___________",0," ",null,11]
[null,12,"Ambulances...................................................","."," ___________",0," ",null,12]
[null,13,"Pharmacy (Outpatient)....................................","."," ___________",0," ",null,13]
[null,"13a","Pharmacy-Medicare Covered Rx.......","."," ___________",0," ",null,13]
[null,14,"Emergency-Urgently Needed Svcs.................................................................................................","."," ___________",0," ",null,14]
[null,15,"Mental Health Services............................","."," ___________",0," ",null,15]
[null,16,"DED+CO on Svcs pd by the CMS  MAC…………………………...................................................",null," ___________",0," ",null,16]
[null,17,"Other - Medicare Bad Debts...…","."," ___________",0," ",null,17]
[null,18,"Other - Blood Deductible.....…","."," ___________",0," ",null,18]
[null,19,"Other - (Specify)...…….......…","."," ___________",0," ",null,19]
[null,20,"Other - (Specify)...…….......…","."," ___________",0," ",null,20]
[null,21,"Other - (Specify)...…….......…","."," ___________",0," ",null,21]
[null,22,"Other - (Specify)...…….......…","."," ___________",0," ",null,22]
[null,23,"Other - (Specify)...…….......…","."," ___________",0," ",null,23]
[null,24,{"$nulls":6},24]
[null,25,"Plan Administration......................................","."," ___________",0," ",null,25]
[null,26,"Special Admin Costs.....................................","."," ___________",0," ",null,26]
[null,27,{"$nulls":5}," ",27]
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{"sheet":"Worksheet H","index":5,"n_rows":75,"n_cols":11,"rows_kept":75,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,null,"STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS",null,null,null," ",null,null,null,"WORKSHEET H"]
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[null,"A.","Are there any costs included on Worksheet E which resulted from transactions with related organizations?"]
[null,null,"Select",null,"(If \"YES\", complete Parts B and C.)",{"$nulls":5}," "]
[null,"B.","Costs incurred and adjustments required as a result of transactions with related organizations."]
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[null,"(1)  Transfer the sum of this column to Worksheet G, Part I, Column 2 line 10"]
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[null,"C.","Interrelationship of Plan to related organization(s):"]
[null,null,null,"The Secretary, by virtue of authority granted under section 1814(b)(1) of the Health Insurance for the Aged and Disabled Act,"]
[null,null,null,"required organizations to furnish the information requested on Part C of this worksheet. The information will be used by the Health"]
[null,null,null,"Care Financing Administration in determining that the costs applicable to services, facilities and supplies furnished by"]
[null,null,null,"organizations related to the Plan by common ownership or control, represent reasonable costs as determined under section 1861 of the "]
[null,null,null,"Health Insurance for the Aged and Disabled Act.  If the Plan does not provide all or any part of the requested information, the cost"]
[null,null,null,"report will be considered incomplete and not acceptable for purposes of claiming reimbursement under Title XVIII."]
[]
[{"$nulls":6}," ----------RELATED ORGANIZATION(S)--------"]
[null," ","SYMBOL (2)","NAME OF INDIVIDUAL","OWNERSHIP OF PLAN",null,"ORGANIZATION",null,"OWNERSHIP",null,"TYPE OF"]
[null,null,null," ",null,null,"NAME",null,"%",null,"BUSINESS"]
[null," ","1","2","3",null,"4",null,"5",null,"6"]
[]
[null,1,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,2,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,3,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,4,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,5,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,6,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,7,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,8,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,9,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,10,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,11,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,12,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,13,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,14,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,15,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,16,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[null,17,"_"," ________________________________"," _______________________________",null,"______________",null,0,null,"  _____________"]
[]
[null,null,"(2)","Use the following symbols to indicate the interrelationship of the Plan to related organizations:"]
[null,null,"A","Individual has financial interest (stockholder, partner, etc) in both related organization and in the Plan."]
[null,null,"B","Corporation, partnership, or other organization has financial interest in the Plan."]
[null,null,"D","Director, officer, administrator or key person of the Plan or relative of such person has financial interest "]
[null,null,null,"in related organization."]
[null,null,"E","Individual is director, officer, administrator, or key person of the Plan and related organization."]
[null,null,"F","Director, officer, administrator, or key person of related organization or relative of such person has "]
[null,null,null,"financial interest in the Plan."]
[null,null,"G","Other (financial or nonfinancial) specify."]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2310)"]
[" "]

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[]
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[{"$nulls":15}," "]
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[{"$nulls":4},"",null,"(Time Spent)",null,"(Cost Req's)",null,"",{"$nulls":4}," "]
[{"$nulls":15}," "]
[null,1,"Inpatient Hospitals ……………….",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,2,"Outpatient Hospitals …………….",null,0,null,0,null,0,null,0,null,0,0,0]
[null,3,"Skilled Nursing Facilities.......….…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,4,"Home Health Agencies........….….",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,5,"Clinics..........……….........….......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,6,"Physician Groups.......................…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,7,"Individual Physicians.....…...….…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,8,"Certified Labs..................…......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,9,"X-Ray Units....................……....…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,10,"ESRD Facilities.........................…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,11,"Durable Medical Equipment.......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,12,"Ambulance...............……….......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,13,"Pharmacy (Outpatient).......…...…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,"13a","Pharmacy-Medicare Covered Rx",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,14,"Emergency-Urgent Needed Svcs..",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,15,"Mental Health Services....….……",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,16,"DED+CO pd by MAC/Carrier/Inter",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,17,"Other - Medicare Bad Debts...…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,18,"Other - Blood Deductible.....…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,19,"Other - (Specify)...…….......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,20,"Other - (Specify)...…….......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,21,"Other - (Specify)...…….......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,22,"Other - (Specify)...…….......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[null,23,"Other - (Specify)...…….......…",null,0,null,0,null,0,null,0,null,0,0,0," "]
[{"$nulls":4},"       ___________"," ","       ___________"," ","       ___________"," ","       ___________"," ","       ___________","       ___________","       ___________"," "]
[null,24,"Subtotal (Sum of Lines 1 thru 23)...........…",null,0," ",0," ",0," ",0," ",0,0,0," "]
[{"$nulls":12}," ",null," "," "]
[null,25,"Plan Administration....................................",null,null," ",null,null,null," ",0,null,0,null,0," "]
[null,26,"Special Administrative Costs............…",{"$nulls":7},0,null,0,null,0," "]
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[{"$nulls":14}," "," "]
[null,28,"Admin & General Costs...............................",null,0,null,0,null,0,null,0,null,0,0,0," "]
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[null,29,"Net A&G Costs (Lines 24+27+28)....................................",null,0,null,0,null,0,null,0,null,0,0,0]
[{"$nulls":4},"      ==========="," ","      ===========","      ======","      ==========="," ","      ============"," ","      ============","        ===========","        ==========="," "]
[{"$nulls":15}," "]
[null,30,"Computation - Fr Worksheet, Col........",null,"Fr Wkst I,",null,"Fr Wkst I,",null,"Fr Wkst I,",null,"Fr Wkst I,",null,null,"Fr Wkst I,"]
[{"$nulls":4},"Pt II, Col 1",null,"Pt II, Col 2",null,"Pt II, Col 3",null,"Pt II, Col 4",null,null,"Pt II, Col 7"]
[]
[null,31,"To Worksheet, Column........................",{"$nulls":9},"To Wkst I,",null,"To Wkst E,"," "]
[null," "," ",{"$nulls":9},"Pt II, Col 6",null,"Col 5"," "]
[]
[null,null,"FORM CMS 276-08",{"$nulls":12}," "]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)"]
[]
[]
[]
[]
[null,"ADMINISTRATIVE AND GENERAL STATISTICS",{"$nulls":12},"WORKSHEET I"]
[]
[null,null,"Name of Plan:",{"$error":"#REF!"},0,{"$nulls":9},"PART II"]
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[]
[]
[]
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[null,null,"COST CENTER",null,"(Salaries)",null,"PROCESSING",null,"SUPPLIES",null,null," ","Worksheet E","Wkst I,","STATS"]
[null,null," ",null,null,null,"(Time Spent)",null,"(Cost Req's)",null,null," ","Column 4)","Pt I, Col 5)","(Cols 5+6)"]
[{"$nulls":4},"1"," ","2"," ","3"," ","4"," ","5","6","7"]
[null,null,null," "]
[null,1,"Inpatient Hospitals ………………."," ",0,null,0,null,0,null,0,null,0,0,0]
[null,2,"Outpatient Hospitals …………….",null,0,null,0,null,0,null,0,null,0,0,0]
[null,3,"Skilled Nursing Facilities.......….…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,4,"Home Health Agencies........….…."," ",0,null,0,null,0,null,0,null,0,0,0]
[null,5,"Clinics..........……….........….......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,6,"Physician Groups.......................…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,7,"Individual Physicians.....…...….…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,8,"Certified Labs..................…......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,9,"X-Ray Units....................……....…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,10,"ESRD Facilities.........................…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,11,"Durable Medical Equipment.......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,12,"Ambulance...............……….......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,13,"Pharmacy (Outpatient).......…...…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,"13a","Pharmacy-Medicare Covered Rx"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,14,"Emergency-Urgent Needed Svcs.."," ",0,null,0,null,0,null,0,null,0,0,0]
[null,15,"Mental Health Services....….……"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,16,"DED+CO pd by MAC/Carrier/Inter"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,17,"Other - Medicare Bad Debts...…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,18,"Other - Blood Deductible.....…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,19,"Other - (Specify)...…….......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,20,"Other - (Specify)...…….......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,21,"Other - (Specify)...…….......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,22,"Other - (Specify)...…….......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[null,23,"Other - (Specify)...…….......…"," ",0,null,0,null,0,null,0,null,0,0,0]
[{"$nulls":4},"     ___________",null,"     ___________",null,"     ___________",null,"     ___________",null,"     ___________","     ___________","     ___________"]
[null,24,"Subtotal (Sum of Lines 1 thru 23)...........…"," ",0,null,0,null,0,null,0,null,0,0,0]
[{"$nulls":12}," "," "," "]
[null,25,"Plan Administration...................................."," ",{"$nulls":6},0]
[null,26,"Special Administrative Costs............…"," ",{"$nulls":6},0]
[null," ",null,null,"     ___________",null,"     ___________",null,"     ___________",null,"     ___________"]
[null,27,"Subtotal (Sum of 25 and 26) ..................."," ",{"$nulls":6},0]
[{"$nulls":4},"     ___________",null,"     ___________",null,"     ___________",null,"     ___________",null,"     ___________","     ___________","     ___________"]
[null,null,"Total (Sum of Lines 24 & 27)...................."," ",0,null,0,null,0,null,0,null,0,0,0]
[{"$nulls":13}," "," "]
[null,28,"Administrative & General Costs.........................................."," "]
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[null,30,"COSTS TO BE ALLOCATED....................."," ",0,null,0,null,0,null,0,null,0,null,0]
[null,null,"(Input here)"]
[]
[null,31,"UNIT COST MULTIPLIER.........................................."," ",0,null,0,null,0,null,0,null,null,null,0]
[null," ","  (Line 30 / Line 29)"]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)"]

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[null,null,"SUMMARY OF PROVIDER COSTS ",{"$nulls":11},"WORKSHEET J"]
[null,null," "]
[" ",{"$nulls":13},"PAGE 1"]
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[]
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[null,2,"Hospitals",null,null,null," ",null," ",null," ",null," "]
[null,3,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,4,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,5,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,6,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,7,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,8,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,9,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,10,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,11,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,12,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,13,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,14,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,15,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,16,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,17,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
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[null,19,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,20,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,21,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,22,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
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[null,29,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,30,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,31,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,32,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,33,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,34,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,35,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,36,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,37,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,38,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,39,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,40,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,41,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,42,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,43,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,44,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,45,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,46,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,47,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,48,"Total  Hospital ………………………………………………………………………………………",null,null,null,0,null,0,null,0,0,0]
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[null," "," ",null," "]
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[]
[null,null,"SUMMARY OF PROVIDER COSTS",{"$nulls":11},"WORKSHEET J"]
[null,null," ",{"$nulls":11},"(Continued)"]
[{"$nulls":14},"PAGE 2"]
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[]
[null,51,"Skilled Nursing Facilities:",null," ",null," "," "," ",null," "," "," "," "]
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[null,53,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
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[null,59,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,60,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,61,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,62,"Total (Sum of Lines 52 thru 61)………………………………………………………………",null,null,null,0,null,0,null,0,null,0]
[{"$nulls":6},"=========",null,"=========",null,"=========",null,"========="]
[null,63,"  Cost PMPM (Line 63 / Line 1)......................................................................",null,null,null,0,null,0,null,0,null,0]
[]
[null,64,"  Enter on Wkst, Col, Line.................................................................................",null,null,null,"M, 2, 2"," ","M, 2, 2&8"," ","M, 3, 2"," ","M, 3, 2"," "]
[]
[null,65,"Home Health Agencies:"]
[null,66,"  __________________________________",null,"  ____________"]
[null,67,"  __________________________________",null,"  ____________"]
[null,68,"  __________________________________",null,"  ____________"]
[null,69,"  __________________________________",null,"  ____________"]
[null,70,"  __________________________________",null,"  ____________"]
[null,71,"  __________________________________",null,"  ____________"]
[null,72,"  __________________________________",null,"  ____________"]
[null,73,"  __________________________________",null,"  ____________"]
[null,74,"  __________________________________",null,"  ____________"]
[null,75,"Total (Sum of Lines 68 thru 76)………………………………………………………………"]
[]
[null,76,"  Cost PMPM (Line 78 / Line 1)......................................................................"]
[]
[null,77,"  Enter on Wkst, Col, Line................................................................................."]
[]
[null,78,"Other Providers (Specify Type):",null," ",null," ",null," "," "," "," "," "," "]
[null,79,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,80,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,81,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,82,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,83,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,84,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,85,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,86,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,87,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,88,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[null,89,"  __________________________________",null,"  ____________",null,0,null,0,null,0,null,0]
[{"$nulls":6},"_____________",null,"_____________",null,"_____________",null,"_____________"]
[null,90,"  Total (Sum Lines 82 thru 92)..........................................................................",null,null,null,0,null,0,null,0,null,0]
[{"$nulls":6},"=========",null,"=========",null,"=========",null,"========"]
[null,91,"  Cost PMPM (Line 93 / Line 1)......................................................................",null,null,null,0,null,0,null,0,null,0]
[]
[null,92,"  Enter on Wkst,  Col, Line................................................................................",null,null,null,"M, 2, 4",null,"M, 2, 4&8",null,"M, 3, 4",null,"M, 3, 4"]
[]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312)"]

{"sheet":"Worksheet K","index":8,"n_rows":58,"n_cols":18,"rows_kept":58,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,null,"SUMMARY APPORTIONMENT OF NON-PROVIDER COSTS"]
[null,null," "]
[{"$nulls":16}," "]
[null,null,"Name of Plan:",null,0,{"$nulls":11}," "]
[null,null,"Plan #:",null,"H-xxxx",null,null,null,"PERIOD FROM:",null,"00:00:00",{"$nulls":5}," "]
[{"$nulls":8},"TO:",null,"00:00:00"]
[]
[]
[null,null,null," ","1",null,"2"," ","3"," ","4"," ","5"," ","6"," ","7"]
[null,null,null," "," ",null," "," ","COVERED MED"," ","SUBPART E"," ","RATIO"," ","TOTAL COSTS"," ","MEDICARE"]
[null,null,"COST CENTERS"," ","STATISTIC",null,"TOTAL"," ","ENROLLEE"," ","LIMITS IF"," ","Col 3 or Col"," ","(Fr Wkst E"," ","COSTS"]
[null,null,null," ","USED",null,"STATISTICS"," ","STATISTICS"," ","APPLICABLE"," ","4 / Col 2"," "," Col 6)"," ","Col 5 X Col 6"]
[]
[null,1,"Clinics (furnished directly).............................................","  ","  ___________",null,0,null,0,null,null,null,0," ",null,null,0]
[null,2,"Physician Groups:"," "]
[null,3,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0]
[null,4,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0]
[null,5,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,6,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,7,"Individual Physicians......................................................."," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,8,"Certified Labs...................................................................."," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,9,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,10,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,11,"X-Ray Units........................................................................."," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,12,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,13,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,14,"ESRD Facilities................................................................"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,15,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,16,"Durable Medical Equipment........................................."," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,17,"Ambulance.........................................................................."," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,18,"Emergency-Urgently Needed Svcs............................"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,19,"Professional Component - Mental Health…….."," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,20,"Mental Health Svcs - Non-Prof Component……"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,21,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,22,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,23,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,24,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,25,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,26,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,27,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,28,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,29,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,30,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,31,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,32,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,33,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[null,34,"_________________________________"," ","  ___________",null,0,null,0,null,0,null,0," ",0,null,0,0]
[]
[null,35,"Total (Sum Lines 1 thru 34).............................................................................",null,null,null," ",{"$nulls":9},0,0]
[{"$nulls":6}," ",{"$nulls":9},"========="]
[null,36,"Member Months - Part B (W/S D, Part II, Pg 2, Pt E, Col 2, Line 1)..........................................................................................................",null,null,null," ",{"$nulls":9},0]
[{"$nulls":6}," ",{"$nulls":9},"========="]
[null,37,"Cost PMPM (Line 51 / Line 52)..............................................................…..",null,null,null," ",{"$nulls":9},0]
[{"$nulls":16}," "]
[null,38,"Enter on Worksheet, Col, Line..................................................................….",null,null,null," ",{"$nulls":9},"M, 3, 5"]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2313)"]

{"sheet":"Worksheet L","index":9,"n_rows":39,"n_cols":17,"rows_kept":39,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[null,null,"SUMMARY OF MISCELLANEOUS ITEMS",{"$nulls":13},"WORKSHEET L"]
[null,null," "]
[{"$nulls":16}," "]
[null,null,"Name of Plan:",null,0,{"$nulls":11}," "]
[null,null,"Plan #:",null,"H-xxxx",null,null,null,"PERIOD FROM:",null,"00:00:00",{"$nulls":5}," "]
[{"$nulls":8},"TO:",null,"00:00:00"]
[]
[]
[{"$nulls":6},"1",null,"2",null,"3",null,"4",null,"5",null,"6"]
[{"$nulls":6}," ",null," ",null," ",null,"NON-",null," "]
[null,null,"DESCRIPTION",null,null,null,"MEDICARE",null,"MEDICARE",null,"TOTAL",null,"MEDICARE",null,null,null,"ENTER ON"]
[{"$nulls":5}," ","PART A",null,"PART B",null,"Col 1+Col 2",null,"Col 5 - Col 2",null,"TOTAL",null,"WKST LINE"]
[{"$nulls":5}," "]
[null,1,"Member Months (Wkst D, Pt II,  Pg 2, Pt E, Col 1 and 2,  Ln 1)",null,null," ",0,null,0,null,null,null,0]
[null,2," ",null,null,"  "]
[null,3,"Plan Administration (Wkst E, Col 6, Ln 21)................................................",null,null," ",{"$nulls":8},0]
[null,4,"Cost PMPM (Line 3 / Line 1)..........................................................................",null,null," ",0,null,0,{"$nulls":5},0,null,"  M     6"]
[null,5," ",null,null," "]
[null,6,"Special Admin Costs (Wkst E, Col 6, Ln 22)............................................",null,null,"",null,null,0]
[null,7,"Cost PMPM (Line 6 / Line 1)..........................................................................",null,null," ",null,null,0,{"$nulls":7},"  M    15"]
[null,8," "]
[null,9,"Allowable Medicare Bad Debts (Wkst E, Col 6, Line 17).....................",null,null,"  ",null," ",null," ",0]
[null,10,"Cost PMPM (Line 9 / Line 1)..........................................................................",null,null," ",0,null,0,null,0,{"$nulls":5},"  M    16"]
[null,11," "]
[null,12,"Part B Blood Deductible.................................................................................",null,null," ",{"$nulls":4},0]
[null,13,"Cost PMPM (Line 12 / Line 1).........................................................................",null,null," ",null,null,0,null,0,{"$nulls":5},"  M    10"]
[null,14," ",null,null," "]
[null,15,"Third Party Insurer Revenue (see Instructions)......................................",null,null," ",{"$nulls":4},0]
[null,16,"Cost PMPM (Line 15 / Line 1)........................................................................",null,null," ",0,null,0,null,0,{"$nulls":5},"  M    18"]
[null,17," "]
[null,18,"Part B Ded on Svcs Pd by CMS Carrier (Wkst E, Col 9, Ln 16)......",null,null,"",null,null,0,null,0]
[null,19,"Cost PMPM (Line 18 / Line 1).........................................................................",null,null,"",null,null,0,null,0,{"$nulls":5},"  M    5a"]
[null,20," "]
[null,21,"Pro Component of Mental Hlth Svcs (W/S K, Line 19)........................",null,null,"",null," ",0," ",0]
[null,22,"Line 21 times 37.5%.............................................................................................",null,null,"",null,null,0,null,0]
[null,23,"Cost PMPM (Line 22 / Line 1)........................................................................",null,null,"",null,null,0,null,0,{"$nulls":5},"  M    11"]
[]
[null,null,"FORM CMS 276-08"]
[null,null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2314)"]

{"sheet":"Worksheet M","index":10,"n_rows":50,"n_cols":12,"rows_kept":50,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
[" ",null,"SETTLEMENT SHEET","Name of Plan:  ",null,null,null,"PERIOD FROM:",null,"00:00:00","WORKSHEET M"]
[null,null,null,"            Plan #:  H-xxxx",null,null,null,"TO:",null,"00:00:00"]
[]
[null,"   "]
[null," ","DESCRIPTION",null,null,"FROM",null,"MEDICARE",null,"MEDICARE",null,"TOTAL"]
[null," ",null,null,null,"WKST",null,"PART A",null,"PART B",null,"Col 2 + Col 3"]
[{"$nulls":5},"1",null,"2",null,"3",null,"4"]
[null,1,"  Hospital Costs………………………………………………………………………………………………………….........",null,"","J",null,0,null,0,null,0]
[null,2,"  Skilled Nursing Facility Costs………………………………………………………………………………………..",null,"","J",null,0,null,0,null,0]
[null,3,"  Home Health Agency Costs………………………………………………………………………………………….",null,"","J",null,0,null,0,null,0]
[null,4,"  Other Provider's Costs ………………………………………………………………………………………………….",null,"","J",null,0,null,0,null,0]
[null,5,"  Nonprovider Costs………………………………………………………………………………………………………….",null,"","K",null,null,null,0,null,0]
[null,"  5a","  Part B Deduct on Svcs Pd by CMS' Carriers/Intermediaries/MAC ………..………………………………………………………..",null,"","L",null,null,null,0,null,0]
[null,6,"  Plan Administration Costs…………………………………………………………………………………………….",null,"","L",null,0,null,0,null,0]
[{"$nulls":4},"",null,null,"___________",null,"___________"]
[null,7,"  Totals (Sum Lines 1 - 6)………………………………………………………………………………………………….",null,"",null,null,0,null,0,null,0]
[{"$nulls":4},"",null,null," ",null," "]
[null,8,"  Part A Deductible and Coinsurance…………………………………………………………………………….",null,"","J",null,0,null,null,null,0]
[null,9,"  Part B Standard Deductible……………………………………………………………………………………………",null,""," ",{"$nulls":5},0]
[null,10,"  Part B Blood Deductible…………………………………………………………………………………………………",null,"","L",null,null,null,0,null,0]
[null,11,"  Copayment on Mental Health Services……………………………………………………………………….",null,"","L",null,null,null,0,null,0]
[{"$nulls":4},""," ",null,"___________",null,"___________"]
[null,12,"  Line 7 Minus (The Sum of Lines 8 - 11)………………………………………………………………………….",null,""," ",null,0,null,0,null,0]
[{"$nulls":4},""," ",null," ",null," "]
[null,13,"  20% of (Col 3 Line 12 minus Col 3 Line 3)…………………………………………………………………….",null,""," ",null,null,null,0,null,0]
[{"$nulls":4},""," ",null,"___________",null,"___________"]
[null,14,"  Reimbursable Costs (Line 12 Minus Line 13)……………………………………………………………….",null,""," ",null,0,null,0,null,0]
[null,15,"  Special Administrative Costs……………………………………………………………………………………….",null,"","L",null,null,null,0,null,0]
[null,16,"  Medicare Bad Debts……………………………………………………………………………………………………….",null,"","L",null,0,null,0,null,0]
[null,"16a","  Part B Cost Not Subject to Coinsurance……………………………………………………………………………………………………….",null,"",null,null,0,null,null,null,0]
[null,17,"  Total (Sum Lines 14 thru 16a)…………………………………………………………………………………………….",null,""," ",null,0,null,0,null,0]
[null,18,"  Less: Third Party Insurer Revenue………………………………………………………………………………..",null,"","L",null,0,null,0,null,0]
[{"$nulls":4},""," ",null,"___________",null,"___________"]
[null,19,"  Medicare Costs (Line 17 minus Line 18)……………………………………………………………………….",null,""," ",null,0,null,0,null,0]
[null,20,"  Medicare Primary Member Months…………………………………………………………………………….",null,"","D",null,0,null,0]
[{"$nulls":7},"___________",null,"___________"]
[null,21,"  Reimbursable Costs (Line 19 X Line 20)……………………………………………………………………….",null," ",null,null,0,null,0,null,0]
[null,22,"  Interim Payments (by) to HCFA…………………………………………………………………………………….",null,""]
[{"$nulls":4},"",{"$nulls":6},"___________"]
[null,23,"  Balance (Line 21 minus Line 22)…………………………………………………………………………………….",null,"",{"$nulls":6},0]
[null,null,"  Adjustments from Prior Years:",null,""]
[null,24,"  ____________________________________________",null,""]
[null,25,"  ____________________________________________",null,""]
[null,26,"  ____________________________________________",null,""]
[{"$nulls":4},"",{"$nulls":6},"___________"]
[null,27,"  Balance Due Plan (CMS) (Line 23 + or - Lines 24-26).....……………………………………….",null,"",{"$nulls":6},0]
[{"$nulls":11},"========="]
[]
[null,"FORM CMS 276-08"]
[null,"(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2315)"]

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["MEDICARE PREMIUM RECONCILIATION",{"$nulls":8},"WORKSHEET N"]
[]
[null,null,"Name of Plan:",0,null,null,null,"Period From:","00:00:00"]
[null,null,"Plan Number:","H-xxxx",null,null,null,"To:","00:00:00"]
[]
["Under and Over Collection of Medicare Premiums - Current Year"]
[{"$nulls":8},"Member","Cost Per"]
["Premium Determinations Covered by this Part",{"$nulls":6},"Totals","Months","Member Month","Line"]
[{"$nulls":7},1,2,3]
[0,"Total Medicare Member Months",{"$nulls":5},"XXXXXXXXXXXX",null,"XXXXXXXXXXXX",0]
[]
[1,"Total Premiums/Dues collected during the period",{"$nulls":6},"XXXXXXXXXXXX",0,1]
[2,"Total Copayments collected during the period",{"$nulls":6},"XXXXXXXXXXXX",0,2]
[{"$nulls":8},"XXXXXXXXXXXX"]
[3,"Total Collections (Line 1 plus Line 2)",{"$nulls":5},0,"XXXXXXXXXXXX",0,3]
[{"$nulls":8},"XXXXXXXXXXXX"]
[4,"Less: Accounts Receivable for premiums/dues and copayments (beg of period)",{"$nulls":6},"XXXXXXXXXXXX",0,4]
[{"$nulls":8},"XXXXXXXXXXXX"]
[5,"Net Collections for period (Line 3 minus Line 4)",{"$nulls":5},0,"XXXXXXXXXXXX",0,5]
[6,"Add: Accounts Receivable for premiums/dues and copayments (end of period)",{"$nulls":6},"XXXXXXXXXXXX",0,6]
[{"$nulls":8},"XXXXXXXXXXXX"]
[7,"Net Collections and Amounts to be Collected (Line 5 plus Line 6)",{"$nulls":5},0,"XXXXXXXXXXXX",0,7]
[]
[]
[8,"Total Medicare Deductible and Coinsurance from Cost Report:",{"$nulls":8},8]
[null,"a.  Deductible and copayments (Worksheet M, Col 2 + 3 , Sum lines 8 thru 11)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",null,"8a"]
[null,"b.  Part B Coinsurance (Worksheet M, Col 3, Line 13)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",null,"8b"]
[null,"c.  Part B Coinsurance on services paid by CMS (Worksheet G, Col 2, Lines 23 + 24)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",null,"8c"]
[]
[null,"d.  Total (Sum of Lines 8a thru 8c)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",0,"8d"]
[]
[9,"Voluntary under collection for the period (Worksheet B, Part II, Line 7)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",null,9]
[10,"Over collection from prior period (Prior Worksheet B, Part II, Excess of Ln 6 over Ln 5)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",null,10]
[]
[11,"Total amount allowed to be charged (Line 8d minus sum of Lines 9 and 10)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",0,11]
[]
[12,"Under (over) collection for the period (Line 11 minus Line 7)",{"$nulls":5},"XXXXXXXXXXXX","XXXXXXXXXXXX",0,12]
[]
["FORM CMS 276-08"]
["(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2316)"]

{"sheet":"Special Administration Costs","index":12,"n_rows":6,"n_cols":2,"rows_kept":6,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["Special Administration Costs","Amount"]
["Accretion/Deletion Cost"]
["Certification Cost"]
["Special Studies"]
["Other (Specify)"]
["Total Special Administration Cost",0]

{"sheet":"Subpart E Limits","index":13,"n_rows":974,"n_cols":12,"rows_kept":974,"cut":false,"hidden":false,"merged":[[44,2,44,6],[7,8,11,8],[7,2,7,7],[8,2,8,7],[9,2,11,7],[40,2,40,6],[41,2,41,6],[42,2,42,6],[43,2,43,6],[36,2,36,6],[29,2,29,6],[30,2,30,6],[31,2,31,6],[37,2,37,6],[38,2,38,6],[39,2,39,6],[32,2,32,6],[33,2,33,6],[34,2,34,6],[35,2,35,6],[18,2,18,6],[24,2,24,6],[25,2,25,6],[26,2,26,6],[27,2,27,6],[28,2,28,6],[13,2,13,6],[14,2,14,6],[22,2,22,6],[23,2,23,6],[19,2,19,6],[20,2,20,6],[21,2,21,6],[15,2,15,6],[16,2,16,6],[17,2,17,6]],"flags":["formulas_cached_only"]}
[null,null,"SUBPART E LIMITS"]
[]
[null,null,"Name of Plan:",null,0,null,null,null,"Period From:",null,0]
[null,null,"Plan #:",null,"H-xxxx",null,null,null,"To:",null,0]
[]
[null,"Is this Plan an HCPP subject to the Subpart E Limits?"]
[]
[{"$nulls":8},"COMPARABLE   CARRIER    PAYMENTS"]
[]
[null,null,"COST CENTERS"]
[]
[]
[null,1,"Physician Groups:"]
[null,2,"_________________________________"]
[null,3,"_________________________________"]
[null,4,"_________________________________"]
[null,5,"_________________________________"]
[null,6,"Individual Physicians....................................................................................................................."]
[null,7,"Certified Labs..................................................................................................................................."]
[null,8,"_________________________________"]
[null,9,"_________________________________"]
[null,10,"X-Ray Units......................................................................................................................................."]
[null,11,"_________________________________"]
[null,12,"_________________________________"]
[null,13,"ESRD Facilities..............................................................................................................................."]
[null,14,"_________________________________"]
[null,15,"Durable Medical Equipment........................................................................................................"]
[null,16,"Ambulance........................................................................................................................................."]
[null,17,"Emergency-Urgently Needed Svcs.........................................................................................."]
[null,18,"Professional Component - Mental Health…………………………………………………………….….."]
[null,19,"Mental Health Svcs - Non-Prof Component……………………………………………………….……"]
[null,20,"_________________________________"]
[null,21,"_________________________________"]
[null,22,"_________________________________"]
[null,23,"_________________________________"]
[null,24,"_________________________________"]
[null,25,"_________________________________"]
[null,26,"_________________________________"]
[null,27,"_________________________________"]
[null,28,"_________________________________"]
[null,29,"_________________________________"]
[null,30,"_________________________________"]
[null,31,"_________________________________"]
[null,32,"_________________________________"]
[null,33,"_________________________________"]
{"$rows_empty":927}
[{"$nulls":11},"Yes"]
[{"$nulls":11},"No"]

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