{"text_format":"2","workbook":"xls","n_sheets":16,"sheets":["S","S-1","S-2","A","A-1","A-2","A-3","A-4","B","B-1","C","D","E","E1","F","F-1"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":1,"defined_names":64,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"run_cost":"one","rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900","formulas":"cached_only"}

{"sheet":"S","index":0,"n_rows":75,"n_cols":12,"rows_kept":75,"cut":false,"hidden":false,"merged":[[35,9,36,10],[32,9,32,10],[33,9,33,10],[42,9,42,10],[37,9,37,10],[5,5,5,6],[27,9,27,10],[28,7,28,8],[29,7,29,8],[30,2,30,4],[30,7,30,8],[30,9,30,10],[34,7,34,8],[34,9,34,10],[4,7,4,8],[5,7,5,8],[29,9,29,10],[31,7,31,8],[27,7,27,8]],"flags":["formulas_cached_only"]}
["06-13",null,null,"                        FORM CMS-265-11",{"$nulls":7},"4290 (Cont.)"]
[" This report is required by law (42 USC 1395g; 42 CFR 413.20(b)).  Failure to report can result in all interim",{"$nulls":8},"FORM APPROVED"]
[" payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).",{"$nulls":8},"OMB NO: 0938-0236"]
[" INDEPENDENT  RENAL  DIALYSIS  FACILITY",{"$nulls":4}," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET S"]
[" COST  REPORT  CERTIFICATION",{"$nulls":6}," From:   "]
[{"$nulls":7}," To:   "]
[" PART  I  -  COST  REPORT  STATUS"]
[" Provider use only",null," 1.   [  ]  Electronically filed cost report",null,"Date (mm/dd/yyyy):  ____________________",null,null,"Time:  ____________________"]
[null,null," 2.   [  ]  Manually submitted cost report"]
[null,null," 3.   If this is an amended report enter the number of times the provider resubmitted this cost report. ______"]
[" Contractor ",null," 4.   [  ] Cost Report Status",null,null,"5.   Date Received: _________"]
[" use only",null,"            (1) As Submitted",null,null,"6.   Contractor No._________"]
[null,null,"            (2) Settled without Audit",null,null,"7.   [  ]  First Cost Report for this Provider CCN"]
[null,null,"            (3) Settled with Audit",null,null,"8.   [  ]  Last Cost Report for this Provider CCN"]
[null,null,"            (4) Reopened",null,null,"9.   NPR Date: __________"]
[null,null,"            (5) Amended ",null,null,"10. If line 4, column 1 is \"4\", enter number of times reopened _______"]
[{"$nulls":5},"11. Contractor Vendor Code ________"]
[]
[" PART  II  -  GENERAL"]
[1," Name:  ",{"$nulls":9},1]
[2," Street: ",{"$nulls":5}," P.O. Box:",null,null,null,2]
[3," City:  ",null,null," State:  ",null,null," ZIP Code:   ",null,null,null,3]
[4," County:  ",null,null," CBSA:  ",{"$nulls":6},4]
[5," Provider CCN:   ",{"$nulls":9},5]
[6," Date Certified:   ",{"$nulls":9},6]
[7," Contact Person Name :  ",{"$nulls":5}," Phone Number:  ",null,null,null,7]
[8," Cost reporting period (mm/dd/yyyy)",null," From:  ",null,"To:  ",{"$nulls":5},8]
[{"$nulls":7},1,null,2]
[9," Type of control (see instructions)",{"$nulls":9},9]
[10," Is this facility approved as a low-volume facility for this cost reporting period?  Enter \"Y\" for yes or \"N\" for no.",{"$nulls":9},10]
[{"$nulls":7},1,null,2]
[11," Type of physicians' reimbursement (see instructions)",{"$nulls":9},11]
[12," Was this facility previously certified as a hospital-based unit?  Enter \"Y\" for yes or \"N\" for no.",{"$nulls":9},12]
[13," Did your facility elect 100% PPS effective January 1, 2011?  Enter \"Y\" for yes or \"N\" for no.   (If certified on/after 1/1/2011, see instructions.)",{"$nulls":9},13]
[{"$nulls":7},1,null,2]
[14," If you responded \"N\" to line 13, enter in column 1 the year of transition for periods prior to January 1 and",{"$nulls":9},14]
[null," enter in column 2 the year of transition for periods after December 31.  (see instructions)"]
[15," Malpractice premiums",{"$nulls":9},15]
[16," Malpractice paid losses",{"$nulls":9},16]
[17," Malpractice self insurance",{"$nulls":9},17]
[18," Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center?  Enter \"Y\" for yes or \"N\" for no.",{"$nulls":9},18]
[null," If yes, submit a supporting schedule listing cost centers and amounts contained therein."]
[19," Are you part of a chain organization?  Enter \"Y\" for yes or \"N\" for no.  If yes, complete lines 20 through 22.",{"$nulls":9},19]
[20," Name:",{"$nulls":9},20]
[21," Street:",{"$nulls":5}," P.O. Box:",null,null,null,21]
[22," City:",null,null," State:",null,null," ZIP Code: ",null,null,null,22]
[]
[" PART  III  -  CERTIFICATION  BY  OFFICER  OR  ADMINISTRATOR"]
[" MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,  CIVIL, AND "]
[" ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW.  FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED "]
[" 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 PROVIDER"]
[]
[null,"I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted cost report"]
[null,"and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Provider CCN(s)} for the cost reporting"]
[null,"period beginning _______________ and ending _______________ and that to the best of my knowledge and belief, this report and statement are true, correct, complete and"]
[null,"prepared from the books and records of the provider in accordance with applicable instructions, except as noted.  I further certify that I am familiar with the laws and regulations "]
[null,"regarding the provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and regulations."]
[]
[null,"OFFICER OR ADMINISTRATOR OF PROVIDER"]
[]
[null,"        Printed Name___________________________________________",null,null,"Signed________________________________________________"]
[]
[null,"        Title__________________________________________________",null,null,"Date__________________________________________________"]
[]
[" 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 0938-0236.  The time required to complete this information collection is estimated 65 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-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4204, 4204.1 AND 4204.2)"]
[]
["Rev. 2",{"$nulls":10},"42-303"]

{"sheet":"S-1","index":1,"n_rows":75,"n_cols":17,"rows_kept":75,"cut":false,"hidden":false,"merged":[[67,13,67,15],[68,13,68,15],[66,10,66,12],[67,10,67,12],[68,10,68,12],[60,13,60,15],[61,13,61,15],[62,13,62,15],[63,13,63,15],[64,13,64,15],[66,13,66,15],[65,13,65,15],[66,7,66,9],[67,7,67,9],[68,7,68,9],[59,10,59,12],[60,10,60,12],[61,10,61,12],[62,10,62,12],[63,10,63,12],[64,10,64,12],[65,10,65,12],[60,7,60,9],[61,7,61,9],[62,7,62,9],[63,7,63,9],[64,7,64,9],[65,7,65,9],[48,13,48,15],[51,7,53,9],[51,10,53,12],[51,13,53,15],[56,13,56,15],[59,7,59,9],[59,13,59,15],[34,13,34,15],[36,13,36,15],[37,13,37,15],[43,13,43,15],[44,13,44,15],[47,13,47,15],[40,13,40,15],[25,13,25,15],[26,13,26,15],[27,13,27,15],[28,13,28,15],[31,7,33,9],[31,10,33,12],[31,13,33,15],[17,13,17,15],[18,13,18,15],[20,13,20,15],[21,13,21,15],[22,13,22,15],[24,13,24,15],[11,13,11,15],[12,13,12,15],[13,13,13,15],[14,13,14,15],[15,13,15,15],[16,13,16,15],[22,10,22,12],[24,10,24,12],[25,10,25,12],[26,10,26,12],[27,10,27,12],[28,10,28,12],[15,10,15,12],[16,10,16,12],[17,10,17,12],[18,10,18,12],[20,10,20,12],[21,10,21,12],[24,7,24,9],[25,7,25,9],[26,7,26,9],[27,7,27,9],[28,7,28,9],[10,10,10,12],[11,10,11,12],[12,10,12,12],[13,10,13,12],[14,10,14,12],[16,7,16,9],[17,7,17,9],[18,7,18,9],[20,7,20,9],[21,7,21,9],[22,7,22,9],[25,4,25,6],[26,4,26,6],[27,4,27,6],[28,4,28,6],[10,7,10,9],[11,7,11,9],[12,7,12,9],[13,7,13,9],[14,7,14,9],[15,7,15,9],[17,4,17,6],[18,4,18,6],[20,4,20,6],[21,4,21,6],[22,4,22,6],[24,4,24,6],[11,4,11,6],[12,4,12,6],[13,4,13,6],[14,4,14,6],[15,4,15,6],[16,4,16,6],[6,10,6,15],[6,4,6,9],[3,5,3,8],[2,9,2,12],[3,9,3,12],[10,4,10,6],[10,13,10,15]],"flags":["formulas_cached_only"]}
["4290 (Cont.)",null,null,"                                  FORM CMS-265-11",{"$nulls":12},"06-13"]
[" INDEPENDENT  RENAL  DIALYSIS  FACILITY",{"$nulls":4}," PROVIDER CCN:",null,null,null," PERIOD:",null,null,null," WORKSHEET S-1"]
[" STATISTICAL  DATA",{"$nulls":8}," From:   "]
[{"$nulls":9}," To:   "]
[]
[" RENAL  DIALYSIS  STATISTICS"]
[{"$nulls":4},"OUTPATIENT",{"$nulls":5},"TRAINING"]
[{"$nulls":8},"PERITONEAL",{"$nulls":5},"PERITONEAL"]
[{"$nulls":5},"HEMODIALYSIS",null,null,"DIALYSIS",null,null,"HEMODIALYSIS",null,null,"DIALYSIS"]
[{"$nulls":5},1,null,null,2,null,null,3,null,null,4]
[1," Number of treatments not billed to Medicare and furnished directly",{"$nulls":14},1]
[2," Number of treatments not billed to Medicare and furnished under arrangements",{"$nulls":14},2]
[3," Number of patients currently in dialysis program",{"$nulls":14},3]
[4," Average times per week patient receives dialysis",{"$nulls":14},4]
[5," Number of days in an average week for patient dialysis treatments",{"$nulls":14},5]
[6," Average time of patient dialysis treatment including set up time",{"$nulls":14},6]
[7," Number of machines regularly available for use",{"$nulls":14},7]
[8," Number of standby machines",{"$nulls":14},8]
[9," Number of shifts in typical week during regular reporting period",{"$nulls":14},9]
[10," Hours per shift in typical week during regular reporting period",{"$nulls":14},10]
[null,".01 "," First shift",{"$nulls":13},".01 "]
[null,".02 "," Second Shift",{"$nulls":13},".02 "]
[null,".03 "," Third shift",{"$nulls":13},".03 "]
[11," Number of treatments provided",{"$nulls":14},11]
[null,".01 "," One (1) time per week",{"$nulls":13},".01 "]
[null,".02 "," Two (2) times per week",{"$nulls":13},".02 "]
[null,".03 "," Three (3) times per week",{"$nulls":13},".03 "]
[null,".04 "," More than three  (3) times per week",{"$nulls":13},".04 "]
[null,".05 "," Total",{"$nulls":13},".05 "]
[{"$nulls":8},"Type of Dialyzers",null,null,"Dialyzer Reuse Count",null,null,"Other Dialyzers"]
[{"$nulls":8},1,null,null,2,null,null,3]
[12," Column 1:  Type of dialyzers used (see instructions)",{"$nulls":14},12]
[null," Column 2:  Number of times dialyzers are reused (see instructions)"]
[null," Column 3:  If column 1 is \"Other,\" enter type of dialyzer used"]
[13," Number of back-up sessions furnished to home patients (see instructions) ",{"$nulls":14},13]
[]
[14," Number of units of Epoetin furnished during cost reporting period",{"$nulls":14},14]
[15," Number of units of Aranesp furnished during cost reporting period",{"$nulls":14},15]
[]
[{"$nulls":11},1,null,null,2]
[15.01,"ESA and units furnished to patients during the cost reporting period  (see instructions)",{"$nulls":14},15.01]
[]
[" TRANSPLANT  STATISTICS"]
[16," Number of patients awaiting transplants ",{"$nulls":14},16]
[17," Number of patients who received transplants ",{"$nulls":14},17]
[]
[" HOME  PROGRAM"]
[18," Number of patients commencing home dialysis training during this period",{"$nulls":14},18]
[19," Number of patients currently in home program",{"$nulls":14},19]
[{"$nulls":8},"Type of Dialyzers",null,null,"Dialyzer Reuse Count",null,null,"Other Dialyzers"]
[{"$nulls":8},1,null,null,2,null,null,3]
[20," Column 1:  Type of dialyzers used (see instructions)",{"$nulls":14},20]
[null," Column 2:  Number of times dialyzers were reused (see instructions)"]
[null," Column 3:  If column 1 is \"Other,\" enter type of dialyzer used"]
[]
[" RENAL  DIALYSIS  FACILITY  --  NUMBER  OF  EMPLOYEES  (FULL TIME EQUIVALENTS)"]
[21," Enter the number of hours in your normal work week  ",{"$nulls":14},21]
[{"$nulls":8},"Staff",null,null,"Contract",null,null,"Total"]
[{"$nulls":8},1,null,null,2,null,null,3]
[22," Physicians",{"$nulls":14},22]
[23," Registered Nurses",{"$nulls":14},23]
[24," Licensed Practical Nurses",{"$nulls":14},24]
[25," Nurses Aides",{"$nulls":14},25]
[26," Technicians",{"$nulls":14},26]
[27," Social Workers",{"$nulls":14},27]
[28," Dieticians",{"$nulls":14},28]
[29," Administrative",{"$nulls":14},29]
[30," Management",{"$nulls":14},30]
[31," Other (Specify)",{"$nulls":14},31]
[]
[]
[]
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205)"]
[]
["42-304",{"$nulls":15},"Rev. 2"]

{"sheet":"S-2","index":2,"n_rows":75,"n_cols":23,"rows_kept":75,"cut":false,"hidden":false,"merged":[[39,12,40,16],[41,12,42,16],[43,12,44,16],[45,12,46,16],[47,12,48,16],[14,7,17,11],[22,7,24,11],[22,12,24,16],[22,17,24,21],[25,7,26,11],[31,17,31,21],[2,6,2,13],[3,6,3,13],[8,7,10,11],[6,7,6,11],[20,7,20,11],[20,12,20,16],[20,17,20,21],[6,17,6,21],[6,12,6,16],[11,7,13,11],[32,17,32,21],[33,17,33,21],[37,12,38,16],[37,17,38,21],[30,17,30,21],[35,12,35,16],[35,17,35,21]],"flags":["formulas_cached_only"]}
["12-11",null,null,null,"        FORM CMS-265-11",{"$nulls":17},"4290 (Cont.)"]
[" INDEPENDENT  RENAL  DIALYSIS  FACILITY",{"$nulls":4}," PROVIDER CCN:"," PERIOD:",{"$nulls":7}," WORKSHEET S-2"]
[" REIMBURSEMENT  QUESTIONNAIRE",{"$nulls":5}," From:   "]
[{"$nulls":6}," To:   "]
[]
[]
[{"$nulls":7},"Y/N",{"$nulls":4},"DATE",{"$nulls":4},"V/I"]
[" PROVIDER  ORGANIZATION  AND  OPERATION",{"$nulls":8},1,{"$nulls":4},2,{"$nulls":4},3]
[1," Has the provider changed ownership immediately prior to the beginning of the cost reporting period? ",{"$nulls":20},1]
[null," Enter \"Y\" for yes or \"N\" for no in column 1.  If yes, enter the date (mm/dd/yyyy) of the change in column 2. "]
[null," (see instructions)"]
[2," Has the provider terminated participation in the Medicare Program?  Enter \"Y\" for yes or \"N\" for no in column 1. ",{"$nulls":20},2]
[null," If yes, enter in column 2 the termination date (mm/dd/yyyy); and, enter in column 3, \"V\" for voluntary or \"I\""]
[null," for involuntary."]
[3," Is the provider involved in business transactions, including management contracts, with individuals or entities",{"$nulls":20},3]
[null," (e.g., chain home offices, drug or medical supply companies) that were related to the provider or its officers,"]
[null," medical staff, management personnel, or members of the board of directors through ownership, control, or"]
[null," family and other similar relationships?  Enter \"Y\" for yes or \"N\" for no in column 1.   (see instructions)"]
[]
[]
[{"$nulls":7},"Y/N",{"$nulls":4},"A/C/R",{"$nulls":4},"DATE"]
[" FINANCIAL  DATA  AND  REPORTS",{"$nulls":8},1,{"$nulls":4},2,{"$nulls":4},3]
[4," Column 1:  Were the financial statements prepared by a Certified Public Accountant?  Enter \"Y\" for yes or \"N\" for no.",{"$nulls":20},4]
[null," Column 2:  If yes, enter in column 2:  \"A\" for Audited, \"C\" for Compiled, or \"R\" for Reviewed.  Submit complete copy"]
[null," of financial statements or enter date available (mm/dd/yyyy) in column 3.  (see instructions)  If no, see instructions."]
[5," Are the cost report total expenses and total revenues different from those on the filed financial statements?  Enter \"Y\"",{"$nulls":20},5]
[null," for yes or \"N\" for no in column 1.  If yes, submit reconciliation."]
[]
[]
[]
[" BAD  DEBTS",{"$nulls":16},"Y/N"]
[6," Is the provider seeking reimbursement for bad debts?  Enter \"Y\" for yes or \"N\" for no.  If yes, see instructions.",{"$nulls":20},6]
[7," If line 6 is yes, did the provider's bad debt collection policy change during the cost reporting period?  \"Y\" for yes or \"N\" for no.  If yes, submit copy.",{"$nulls":20},7]
[8," If line 6 is yes, were patient deductibles and/or co-payments waived?  Enter \"Y\" for yes or \"N\" for no.  If yes, see instructions.",{"$nulls":20},8]
[]
[{"$nulls":12},"Y/N",{"$nulls":4},"DATE"]
[" PS&R  REPORT  DATA",{"$nulls":13},1,{"$nulls":4},2]
[9," Was the cost report prepared using the PS&R report only?  Enter \"Y\" for yes or \"N\" for no in column 1.  If yes, enter in column 2 the",{"$nulls":20},9]
[null," paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report.  (see instructions.)"]
[10," Was the cost report prepared using the PS&R report for totals and the provider's records for allocation?  Enter \"Y\" for yes or \"N\" for no",{"$nulls":20},10]
[null," in col.1.   If yes, enter in col. 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report.   (see instructions)"]
[11," If line 9 or 10 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included on the",{"$nulls":20},11]
[null," PS&R report used to file the cost report?  Enter \"Y\" for yes or \"N\" for no.  If yes, see instructions."]
[12," If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information?  Enter \"Y\" for yes",{"$nulls":20},12]
[null," or \"N\" for no.  If yes, see instructions."]
[13," If line 9 or 10 is yes, were adjustments made to PS&R report data for Other?  Enter \"Y\" for yes or \"N\" for no.",{"$nulls":20},13]
[null," If yes, describe the other adjustments: ",null,"__________________________________________________________________________"]
[14," Was the cost report prepared only using the provider's records?  Enter \"Y\" for yes or \"N\" for no.  ",{"$nulls":20},14]
[null," If yes, see instructions."]
{"$rows_empty":23}
["FORM CMS-265-11 (12/2011)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205.1)"]
[]
["Rev. 1",{"$nulls":21},"42-305"]

{"sheet":"A","index":3,"n_rows":56,"n_cols":12,"rows_kept":56,"cut":false,"hidden":false,"merged":[[5,3,5,4],[3,6,3,7],[2,8,2,9],[3,8,3,9]],"flags":["formulas_cached_only"]}
["4290 (Cont.)",null,null,null,"             FORM CMS-265-11",{"$nulls":6},"12-11"]
[" RECLASSIFICATION  AND  ADJUSTMENT  OF  TRIAL BALANCE ",{"$nulls":5}," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET A"]
[" OF  EXPENSES",{"$nulls":7}," From:   "]
[{"$nulls":8}," To:   "]
[{"$nulls":7},"RECLASS.",null,null,"NET EXPENSES"]
[null,null,null,"SALARIES",null,null,"TOTAL","TO EXPENSES","RECLASSIFIED","ADJUSTMENTS","FOR COST"]
[null,null,"FACILITY  HEALTH  CARE  COSTS","PHYSICIAN","              ",null,"( col. 1 through","( from","TRIAL BALANCE","TO EXPENSES","ALLOCATION"]
[null,null,null,"COMPENSATION","OTHER","OTHER","col. 3 )","Wkst. A-1 )","( col 4. +/- col. 5 )","( from Wkst. A-2 )","( col. 6+/-col. 7 )"]
[null,null,null,1,"2","3","4","5","6","7",8]
[" ",null,"COST  CENTERS"]
[1,"0100"," Cap Rel Costs-Bldg & Fixt",null,null,null,"",{"$nulls":4},1]
[2,"0200"," Cap Rel Costs-Mvble Equip",null,null,null,"",{"$nulls":4},2]
[3,"0300"," Operation & Maintenance of Plant",null,null,null,"",{"$nulls":4},3]
[4,"0400"," Housekeeping",null,null,null,"",{"$nulls":4},4]
[5,null," Subtotal (sum of lines 1 through 4)*",null,null,null,"",null,null,"",null,5]
[6,"0600"," Machine Cap-Rel or Rental & Maint*",null,null,null,"",{"$nulls":4},6]
[7,"0700"," Salaries for Direct Patient Care*",null,null,null,"",{"$nulls":4},7]
[8,"0800"," EH&W Benefits for Direct Pt. Care",null,null,null,"",{"$nulls":4},8]
[9,"0900"," Supplies*",null,null,null,"",{"$nulls":4},9]
[10,"1000"," Laboratory*",null,null,null,"",{"$nulls":4},10]
[11,"1100"," Administrative & General",null,null,null,"",{"$nulls":4},11]
[12,"1200"," Drugs*",null,null,null,"",{"$nulls":4},12]
[13,"1300"," Interest Expense",null,null,null,"",{"$nulls":4},13]
[14,"1400"," Laundry and Linen",null,null,null,"",{"$nulls":4},14]
[15,"1500"," Medical Records",null,null,null,"",{"$nulls":4},15]
[16,"1600"," Phy Rout Prof Svcs-Initial Method",null,null,null,"",{"$nulls":4},16]
[17,"1700"," Other (Specify)",null,null,null,"",{"$nulls":4},17]
[18,null," Subtotal (sum of line 11 plus lines 13 through 17)*","",null,null,null,"",null,"",null,18]
[19,"1900"," Phy Rout Prof Svcs-MCP Method",null,null,null,"",{"$nulls":4},19]
[20,"2000"," Whole Blood & Packed Red Blood Cells*",null,null,null,"",{"$nulls":4},20]
[21,"2100"," Vaccines*",null,null,null,"",{"$nulls":4},21]
[null,null,"NONREIMBURSABLE  COSTS  CENTERS"]
[22,"2200"," Physicians Private Offices*",{"$nulls":8},22]
[23,"2300"," ESAs (prior to January 1, 2011)",{"$nulls":8},23]
[24,"2400"," Method II Patients (prior to January 1, 2011)",{"$nulls":8},24]
[25,"2500"," Other Nonreimbursable (Specify)*",{"$nulls":8},25]
[26,"2600"," Other Nonreimbursable (Specify)*",{"$nulls":8},26]
[27,null," Total",{"$nulls":5},"",null,"",27]
[]
[" * Transfer the amounts in column 8 to Worksheet B and B-1, as appropriate."]
{"$rows_empty":13}
["FORM CMS-265-11 (12/2011)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4206)"]
[]
["42-306",{"$nulls":10},"Rev. 1"]

{"sheet":"A-1","index":4,"n_rows":75,"n_cols":10,"rows_kept":75,"cut":false,"hidden":false,"merged":[[5,6,5,8],[5,3,5,5],[3,4,3,5],[2,6,2,7],[3,6,3,7]],"flags":["formulas_cached_only"]}
["06-13",null,"    FORM CMS-265-11",{"$nulls":6},"4290 (Cont.)"]
[" RECLASSIFICATIONS",null,null,null," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET A-1"]
[{"$nulls":6}," From:   "]
[{"$nulls":6}," To:   "]
[]
[null,null,null,"INCREASE",null,null,"DECREASE"]
[null,null,"CODE","COST","LINE",null,"COST","LINE"]
[null,"EXPLANATION  OF  ENTRY","(1)","CENTER","NO.","AMOUNT (2)","CENTER","NO.","AMOUNT (2)"]
[null,null,"1","2","3","4","5","6","7"]
[1,{"$nulls":8},1]
[2,{"$nulls":8},2]
[3,{"$nulls":8},3]
[4,{"$nulls":8},4]
[5,{"$nulls":8},5]
[6,{"$nulls":8},6]
[7,{"$nulls":8},7]
[8,{"$nulls":8},8]
[9,{"$nulls":8},9]
[10,{"$nulls":8},10]
[11,{"$nulls":8},11]
[12,{"$nulls":8},12]
[13,{"$nulls":8},13]
[14,{"$nulls":8},14]
[15,{"$nulls":8},15]
[16,{"$nulls":8},16]
[17,{"$nulls":8},17]
[18,{"$nulls":8},18]
[19,{"$nulls":8},19]
[20,{"$nulls":8},20]
[21,{"$nulls":8},21]
[22,{"$nulls":8},22]
[23,{"$nulls":8},23]
[24,{"$nulls":8},24]
[25,{"$nulls":8},25]
[26,{"$nulls":8},26]
[27,{"$nulls":8},27]
[28,{"$nulls":8},28]
[29,{"$nulls":8},29]
[30,{"$nulls":8},30]
[31,{"$nulls":8},31]
[32,{"$nulls":8},32]
[33,{"$nulls":8},33]
[34,{"$nulls":8},34]
[35,{"$nulls":8},35]
[100," Total Reclassifications (Sum of col. 4 must equal sum of col. 7)",{"$nulls":7},100]
[]
[" (1)   A letter (A, B, etc.) must be entered on each line to identify each reclassification entry."]
[" (2)   Transfer to Worksheet A, col. 5, line as appropriate."]
{"$rows_empty":24}
["FORM CMS-265-11 (12/2011)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4207)"]
[]
["Rev. 2",{"$nulls":8},"42-307"]

{"sheet":"A-2","index":5,"n_rows":75,"n_cols":10,"rows_kept":75,"cut":false,"hidden":false,"merged":[[8,5,8,7],[9,5,9,7],[2,5,2,6],[3,5,3,6],[3,3,3,4]],"flags":["formulas_cached_only"]}
["4290 (Cont.)",null,"FORM CMS-265-11",{"$nulls":6},"06-13"]
[" ADJUSTMENTS  TO  EXPENSES",null,null," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET A-2"]
[{"$nulls":5}," From:   "]
[{"$nulls":5}," To:   "]
[]
[{"$nulls":5}," Expense classification on Worksheet A from which"]
[null,null,null,"BASIS FOR",null," amount is to be deducted or to which the amount is"]
[null,null,null,"ADJUSTMENT",null," to be added"]
[null,"DESCRIPTION (1)",null,"(2)","AMOUNT","COST CENTER",null,null,"LINE NO."]
[null,null,null,1,"2",3,null,null,"4"]
[1," Investment income on commingled restricted and unrestricted funds  (Chapter 2)",{"$nulls":7},1]
[2," Trade, quantity and time discounts on purchases  (Chapter 8)",{"$nulls":7},2]
[3," Rebates and refunds of expenses  (Chapter 8)",{"$nulls":7},3]
[4," Rental of building or office space to others",{"$nulls":7},4]
[5," Physician non-routine professional patient care services",{"$nulls":7},5]
[6," Home office costs  (Chapter 21)",{"$nulls":7},6]
[7," Adjustment resulting from transactions with related organizations  (Chapter 10)",null,"From Wkst. A-3",{"$nulls":5},7]
[8," Vending machines",{"$nulls":7},8]
[9," Meals served to patients",{"$nulls":7},9]
[10," Physicians' professional services--MCP Method",null,"A ",null," Physicians' professional services--MCP Method",null,null,19,10]
[11," Services under arrangement",{"$nulls":7},11]
[12," Provision for doubtful accounts",{"$nulls":7},12]
[13," Capital Related--Buildings & Fixtures",null,null,null," Capital Related--Buildings & Fixtures",null,null,1,13]
[14," Capital Related--Moveable Equipment",null,null,null," Capital Related--Moveable Equipment",null,null,2,14]
[15," Rebates on Epoetin prior to January 1, 2011",null,null,null," Epoetin",null,null,23,15]
[16," Epoetin",null,"A ",null," Epoetin",null,null,23,16]
[17," Rebates on Aranesp prior to January 1, 2011",null,null,null," Aranesp",null,null,23,17]
[18," Aranesp",null,"A ",null," Aranesp",null,null,23,18]
[19," Rebates on Epoetin on or after January 1, 2011",null,null,null," Epoetin",null,null,12,19]
[20," Rebates on Aranesp on or after January 1, 2011",null,null,null," Aranesp",null,null,12,20]
["20.01"," Rebates on ESA drugs on or after January 1, 2012",null,null,null," Drugs",null,null,12,"20.01"]
[21," Physician malpractice premiums",{"$nulls":7},21]
[22," Other (specify)   ",{"$nulls":7},22]
[23," Other (specify) ",{"$nulls":7},23]
[24," Other (specify) ",{"$nulls":7},24]
[100," Total  (transfer to Wkst. A, col. 7, line 27)",{"$nulls":7},100]
[]
[null,"(1) Description-all chapter references in this column pertain to CMS Pub. 15-1"]
[null,"(2) Basis for adjustment (see instructions)"]
[null,"       A. Costs-if cost, including applicable overhead, can be determined"]
[null,"       B. Amount Received-if cost cannot be determined"]
{"$rows_empty":31}
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4208)"]
[]
["42-308",{"$nulls":8},"Rev. 2"]

{"sheet":"A-3","index":6,"n_rows":75,"n_cols":24,"rows_kept":75,"cut":false,"hidden":false,"merged":[[20,19,20,21],[20,1,20,3],[20,16,20,18],[23,16,23,18],[23,19,23,21],[38,20,38,22],[19,16,19,18],[19,19,19,21],[18,19,18,21],[17,19,17,21],[39,1,39,3],[39,9,39,11],[39,17,39,19],[37,20,37,22],[19,1,19,3],[2,16,2,20],[3,16,3,20],[17,1,17,3],[3,11,3,15],[18,1,18,3],[17,16,17,18],[18,16,18,18]],"flags":["formulas_cached_only"]}
["12-11",{"$nulls":7},"         FORM CMS-265-11",{"$nulls":14},"4290 (Cont.)"]
[" STATEMENT  OF  COSTS  OF  SERVICES",{"$nulls":10}," PROVIDER CCN:",{"$nulls":4}," PERIOD:",{"$nulls":4}," WORKSHEET A-3"]
[" FROM  RELATED  ORGANIZATIONS",{"$nulls":15}," From:   "]
[{"$nulls":16}," To:   "]
[]
[]
[" A.","Are there any costs included on Worksheet A which resulted from transactions with related organizations as defined in CMS Pub. 15-1, Chapter 10?"]
[null,"[   ] Yes  (If yes, complete Parts B and C)"]
[null,"[   ]  No"]
[]
[]
[" B."," Costs incurred and adjustments required as result of transactions with related organizations:"]
[{"$nulls":20},"AMOUNT",null,"NET"]
[null,"LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COL. 6",{"$nulls":15},"AMOUNT",null,null,"INCLUDED IN",null,"ADJUST-"]
[{"$nulls":17},"ALLOWABLE",null,null,"WKST. A",null,"MENT  (col. 4"]
[null,null,"LINE NO.",null,null,null,"COST CENTER",{"$nulls":5},"EXPENSES ITEMS",{"$nulls":4},"IN COST",null,null,"COL. 6",null,"minus col. 5)"]
[null,null,"1",null,null,null,"2",{"$nulls":5},3,{"$nulls":4},4,null,null,5,null,6]
[1,{"$nulls":22},1]
[2,{"$nulls":22},2]
[3,{"$nulls":22},3]
[4,{"$nulls":22},4]
[5," TOTALS (sum of lines 1-4) ",{"$nulls":21},5]
[null," (Transfer col. 6, lines 1-4 to Wkst. A, col. 7 as appropriate)"]
[null," (Transfer col. 6, line 5 to Wkst. A-2, col. 2, line 7) "]
[]
[]
[" C.","Interrelationship to organizations furnishing services, facilities, or supplies:     "]
[]
["The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the provider to furnish the information requested on Part C of this worksheet."]
[]
[" This information will be used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable to services, facilities, and supplies furnished"]
[" by organizations related to the facility by common ownership or control, represent reasonable costs as determined under 1861(v)(1)(a) of the Social Security Act.  If the provider does"]
[" not provide all or any part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII."]
[]
[{"$nulls":18},"RELATED ORGANIZATION(S)"]
[{"$nulls":10},"PERCENTAGE",{"$nulls":7},"PERCENTAGE"]
[null,null,"SYMBOL",{"$nulls":7},"OF",{"$nulls":7},"OF"]
[null,null,"(1)",null,null,null,"NAME",null,null,null,"OWNERSHIP",null,null,null,"NAME",null,null,null,"OWNERSHIP",null,"TYPE OF BUSINESS"]
[null,null,"1",null,null,null,2,null,null,null,3,null,null,null,4,null,null,null,5,null,6]
[1,{"$nulls":22},1]
[2,{"$nulls":22},2]
[3,{"$nulls":22},3]
[4,{"$nulls":22},4]
[]
[null,"(1) Use the following symbols to indicate interrelationship to related organizations:"]
[null,null,null,"A.","  Individual has financial interest (stockholder, partner, etc.) in both related organization and in the facility"]
[null,null,null,"B.","  Corporation, partnership, or other organization has financial interest in  the facility"]
[null,null,null,"C.","  Facility has financial interest in corporation, partnership, or other organization(s)"]
[null,null,null,"D.","  Director, officer, administrator, or key person of the facility or relative of such person has financial interest in related organization"]
[null,null,null,"E.","  Individual is director, officer, administrator, or key person of the facility and related organization"]
[null,null,null,"F.","  Director, officer, administrator, or key person of related organization or relative of such person has financial interest in the facility"]
[null,null,null,"G.","  Other (financial or non-financial) specify _____________________________"]
{"$rows_empty":20}
["FORM CMS-265-11 (12/2011)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4209) "]
[]
["Rev. 1",{"$nulls":22},"42-309"]

{"sheet":"A-4","index":7,"n_rows":75,"n_cols":20,"rows_kept":75,"cut":false,"hidden":false,"merged":[[8,6,8,11],[8,12,8,17],[31,1,31,8],[32,1,32,8]],"flags":["formulas_cached_only"]}
["4290 (Cont.)",{"$nulls":5},"       FORM CMS-265-11",{"$nulls":12},"12-11"]
[" STATEMENT  OF  COMPENSATION",{"$nulls":9}," PROVIDER CCN:",null,null,null," PERIOD:",null,null,null," WORKSHEET A-4"]
[{"$nulls":14}," From:"]
[{"$nulls":14}," To: "]
[]
[" PART  I  -  STATEMENT  OF  TOTAL  COMPENSATION  TO  OWNERS"]
[" (Include compensation of employees related to owners)"]
[{"$nulls":4},"SOLE",{"$nulls":13},"TOTAL"]
[{"$nulls":4},"PROPIETORSHIPS",null,"PARTNERS",{"$nulls":5},"CORPORATION OWNERS",{"$nulls":5},"COMPENSATION"]
[{"$nulls":4},"PERCENTAGE OF",{"$nulls":5},"PERCENTAGE",{"$nulls":5},"PERCENTAGE OF",null,"INCLUDED IN"]
[{"$nulls":4},"CUSTOMARY",{"$nulls":5},"OF CUSTOMARY",{"$nulls":5},"CUSTOMARY",null,"ALLOWABLE "]
[{"$nulls":4},"WORK WEEK",null,null,"PERCENT SHARE",null,null,"WORK WEEK",null,null,"PERCENTAGE OF",null,null,"WORK WEEK",null,"COSTS FOR"]
[{"$nulls":4},"DEVOTED TO",null,null,"OF OPERATING",null,null,"DEVOTED TO",null,null,"PROVIDER'S",null,null,"DEVOTED TO",null,"THE PERIOD"]
[null,"TITLE","FUNCTION (A)",null,"BUSINESS",null,null,"PROFIT OR (LOSS)",null,null,"BUSINESS",null,null,"STOCK OWNED",null,null,"BUSINESS",null,"(B)"]
[null,1,2,null,3,null,null,"4A",null,null,"4B",null,null,"5A",null,null,"5B",null,6]
[1,{"$nulls":18},1]
[2,{"$nulls":18},2]
[3,{"$nulls":18},3]
[4,{"$nulls":18},4]
[5,{"$nulls":18},5]
[6,{"$nulls":18},6]
[7,{"$nulls":18},7]
[8,{"$nulls":18},8]
[9,{"$nulls":18},9]
[10,{"$nulls":18},10]
[]
[]
[" PART  II  -  STATEMENT  OF  TOTAL  COMPENSATION  TO  ADMINISTRATORS,  ASSISTANT  ADMINISTRATORS  AND / OR  MEDICAL  DIRECTORS  OR  OTHERS"]
[null,"PERFORMING  THESE  DUTIES  (OTHER  THAN  OWNERS)     (To be completed by all facilities)"]
[{"$nulls":11},"PERCENTAGE OF",{"$nulls":5},"TOTAL COMPENSATION INCLUDED IN"]
[{"$nulls":11},"CUSTOMARY WORK WEEK",{"$nulls":5},"ALLOWABLE COSTS FOR THE PERIOD"]
[null,"TITLE",{"$nulls":9},"DEVOTED TO BUSINESS",{"$nulls":5},"(B)"]
[null,1,{"$nulls":9},2,{"$nulls":5},3]
[1,{"$nulls":18},1]
[2,{"$nulls":18},2]
[3,{"$nulls":18},3]
[4,{"$nulls":18},4]
[5,{"$nulls":18},5]
[6,{"$nulls":18},6]
[7,{"$nulls":18},7]
[8,{"$nulls":18},8]
[9,{"$nulls":18},9]
[10,{"$nulls":18},10]
[]
[]
[]
[]
[null,"(A)  Function or job description of each owner.  If employee is related to owner, cite relationship."]
[null,"(B)  Compensation as used in this worksheet has the same definition as 42 CFR 413.102"]
{"$rows_empty":23}
["FORM CMS-265-11 (12/2011)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4210)"]
[]
["42-310",{"$nulls":18},"Rev. 1"]

{"sheet":"B","index":8,"n_rows":118,"n_cols":11,"rows_kept":118,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["06-13",null,null,null,"    FORM CMS-265-11",{"$nulls":5},"4290 (Cont.)"]
[" COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":4}," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET B "]
[{"$nulls":7}," From:   "]
[{"$nulls":7}," To:   "]
[null,null,"NET"]
[null,null,"EXPENSE"]
[null,null,"FOR","CAP REL","STEP DOWN","MACH CAP","SALARIES","EH&W BENE"]
[null,null,"COST ALLOC.","OP & MAINT","OF","REL OR REN","FOR DIR","FOR DIR"]
[null,null,"( from Wkst. A, col. 8 )","& HOUSE","OF COL. 2","& MAINT","PT CARE","PT CARE","SUPPLIES","LABORATORY"]
[null,null,"1","2",3,4,5,6,7,8]
[1," COSTS TO BE ALLOCATED",null,null,0,{"$nulls":5},1]
[2," Drugs Included in Composite Rate ",{"$nulls":8},2]
[3," ESAs",{"$nulls":8},3]
[4," ESRD Related Other Drugs",{"$nulls":8},4]
[5," Non-ESRD Related Drugs, Supplies & Lab",{"$nulls":6},"","",5]
[6," Whole Blood and Packed Red Blood Cells",{"$nulls":8},6]
[7," Vaccines",{"$nulls":8},7]
[null,"REIMBURSABLE  COST  CENTERS"]
[8," Maintenance-Hemodialysis",null,0,{"$nulls":6},8]
[8.01," Maintenance-Hemo Adult",null,null,"",null,"","","","",8.01]
[8.02," Maintenance-Hemo Pediatric",null,null,"","","","","","",8.02]
[9," Maintenance -IPD",null,"",{"$nulls":6},9]
[9.01," Maintenance-IPD Adult",null,null,"","","","","","",9.01]
[9.02," Maintenance-IPD Pediatric",null,null,"","","","","","",9.02]
[10," Training-Hemodialysis",null,"",{"$nulls":6},10]
[10.01," Training-Hemo Adult",null,null,"","","","","","",10.01]
[10.02," Training-Hemo Pediatric",null,null,"","","","","","",10.02]
[11," Training-IPD",null,"",{"$nulls":6},11]
[11.01," Training-IPD Adult",null,null,"","","","","","",11.01]
[11.02," Training-IPD Pediatric",null,null,"","","","","","",11.02]
[12," Training-CAPD",null,"",{"$nulls":6},12]
[12.01," Training-CAPD Adult",null,null,"","","","","","",12.01]
[12.02," Training-CAPD Pediatric",null,null,"","","","","","",12.02]
[13," Training-CCPD",null,"",{"$nulls":6},13]
[13.01," Training-CCPD Adult",null,null,"","","","","","",13.01]
[13.02," Training-CCPD Pediatric",null,null,"","","","","","",13.02]
[14," Home Program-Hemodialysis",null,"",{"$nulls":6},14]
[14.01," Home Program-Hemo Adult",null,null,"","","","","","",14.01]
[14.02," Home Program-Hemo Pediatric",null,null,"","","","","","",14.02]
[15," Home Program-IPD",null,"",{"$nulls":6},15]
[15.01," Home Program-IPD Adult",null,null,"",null,"","","","",15.01]
[15.02," Home Program-IPD Pediatric",null,null,"",null,"","","","",15.02]
[16," Home Program-CAPD",null,"",{"$nulls":6},16]
[16.01," Home Program-CAPD Adult",null,null,"",null,"","","","",16.01]
[16.02," Home Program-CAPD Pediatric",null,null,"",null,"","","","",16.02]
[17," Home Program-CCPD",null,"",{"$nulls":6},17]
[17.01," Home Program-CCPD Adult",null,null,"",null,"","","","",17.01]
[17.02," Home Program-CCPD Pediatric",null,null,"",null,"","","","",17.02]
[18," Subtotal (lines 2-17.02)",{"$nulls":8},18]
[null,"NONREIMBURSABLE  COST  CENTERS"]
[19," Physicians' Private Offices",0,"",null,null,"","","","",19]
[20," Method II Patients prior to 1/1/2011",0,"",null,null,"","","","",20]
[21," Other Nonreimbursable ",null,"",null,null,"","","","",21]
[22," Other Nonreimbursable ",null,"",null,null,"","","","",22]
[23," Totals (see instructions) ",null,null,0,null,0,0,0,0,23]
[" *Transfer the amounts to Wkst. C, col. 2, as appropriate"]
[" The total of column 1, line 23 must equal the amount on Wkst. A, col. 8, line 27."]
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)"]
["Rev. 2",{"$nulls":9},"42-311"]
["4290 (Cont.)",null,null,null,"    FORM CMS-265-11",{"$nulls":5},"06-13"]
[" COST  ALLOCATION  -  GENERAL  SERVICE  COSTS",{"$nulls":4}," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET B "]
[{"$nulls":7}," From:   "]
[{"$nulls":7}," To:   "]
[null,null,null,"A & G",{"$nulls":5},"TOTAL"]
[null,null,null,"&",{"$nulls":5},"EXPENSES"]
[null,null,"SUBTOTAL","OTHER",null,"DRUGS",null,null,"ESRD","ALL"]
[null,null,"( col. 1 ","COST",null,"INCLUD. IN","SUBTOTAL",null,"RELATED","PAT. SVCS."]
[null,null,"through col. 8 )","CENTERS","DRUGS","COMP RATE","( see instructions )","ESA'S","DRUGS","( cols. 11A-13 )"]
[null,null,"8A",9,10,11,"11A",12,13,"13A"]
[1," COSTS TO BE ALLOCATED",{"$nulls":8},1]
[2," Drugs Included in Composite Rate ",{"$nulls":8},2]
[3," ESAs",{"$nulls":8},3]
[4," ESRD Related Other Drugs",{"$nulls":8},4]
[5," Non-ESRD Related Drugs, Supplies & Lab",{"$nulls":8},5]
[6," Whole Blood and Packed Red Blood Cells",{"$nulls":8},6]
[7," Vaccines",{"$nulls":8},7]
[null,"REIMBURSABLE  COST  CENTERS"]
[8," Maintenance-Hemodialysis",{"$nulls":8},8]
[8.01," Maintenance-Hemo Adult",{"$nulls":8},8.01]
[8.02," Maintenance-Hemo Pediatric",{"$nulls":8},8.02]
[9," Maintenance -IPD",{"$nulls":8},9]
[9.01," Maintenance-IPD Adult",{"$nulls":8},9.01]
[9.02," Maintenance-IPD Pediatric",{"$nulls":8},9.02]
[10," Training-Hemodialysis",{"$nulls":8},10]
[10.01," Training-Hemo Adult",{"$nulls":8},10.01]
[10.02," Training-Hemo Pediatric",{"$nulls":8},10.02]
[11," Training-IPD",{"$nulls":8},11]
[11.01," Training-IPD Adult",{"$nulls":8},11.01]
[11.02," Training-IPD Pediatric",{"$nulls":8},11.02]
[12," Training-CAPD",{"$nulls":8},12]
[12.01," Training-CAPD Adult",{"$nulls":8},12.01]
[12.02," Training-CAPD Pediatric",{"$nulls":8},12.02]
[13," Training-CCPD",{"$nulls":8},13]
[13.01," Training-CCPD Adult",{"$nulls":8},13.01]
[13.02," Training-CCPD Pediatric",{"$nulls":8},13.02]
[14," Home Program-Hemodialysis",{"$nulls":8},14]
[14.01," Home Program-Hemo Adult",{"$nulls":8},14.01]
[14.02," Home Program-Hemo Pediatric",{"$nulls":8},14.02]
[15," Home Program-IPD",{"$nulls":8},15]
[15.01," Home Program-IPD Adult",{"$nulls":8},15.01]
[15.02," Home Program-IPD Pediatric",{"$nulls":8},15.02]
[16," Home Program-CAPD",{"$nulls":8},16]
[16.01," Home Program-CAPD Adult",{"$nulls":8},16.01]
[16.02," Home Program-CAPD Pediatric",{"$nulls":8},16.02]
[17," Home Program-CCPD",{"$nulls":8},17]
[17.01," Home Program-CCPD Adult",{"$nulls":8},17.01]
[17.02," Home Program-CCPD Pediatric",{"$nulls":8},17.02]
[18," Subtotal (lines 2-17.02)",{"$nulls":8},18]
[null,"NONREIMBURSABLE  COST  CENTERS"]
[19," Physicians' Private Offices",{"$nulls":8},19]
[20," Method II Patients prior to 1/1/2011",{"$nulls":8},20]
[21," Other Nonreimbursable ",{"$nulls":8},21]
[22," Other Nonreimbursable ",{"$nulls":8},22]
[23," Totals (see instructions) ",{"$nulls":8},23]
[" *Transfer the amounts to Wkst. C, col. 2, as appropriate"]
[" The total of column 1, line 23 must equal the amount on Wkst. A, col. 8, line 27."]
["FORM CMS-265-11 (12/2011)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)"]
["42-312",{"$nulls":9},"Rev. 2"]

{"sheet":"B-1","index":9,"n_rows":177,"n_cols":11,"rows_kept":177,"cut":false,"hidden":false,"merged":[],"flags":["formulas_cached_only"]}
["06-13",null,null,null,"    FORM CMS-265-11",{"$nulls":5},"4290 (Cont.)"]
[" COST  ALLOCATION  -  STATISTICAL  BASIS",{"$nulls":4}," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET B-1"]
[{"$nulls":7}," From:   "]
[{"$nulls":7}," To:   "]
[null,null,null,"CAP REL","STEP DOWN","MACH CAP","SALARIES","EH&W BENE","SUPPLIES","LABORATORY"]
[null,null,"NET","OP & MAINT","OF COL. 2","REL OR RENT","FOR DIR","FOR DIR"]
[null,null,"EXPENSES","& HOUSE",null,"& MAINT","PT CARE","PT CARE"]
[null,null,"FOR","( SQUARE","( # TREAT","( % TIME )","( HRS OF","( GROSS","( CHARGES )","( CHARGES )"]
[null,null,"COST ALLOC.","FEET )  (1)","MENTS )  (3)","(3)","SERVICE )  (3)","SALARIES )  (3)","(3)","(3)"]
[null,null,"1","2",3,4,5,6,7,8]
[1," COSTS TO BE ALLOCATED",{"$nulls":8},1]
[2," Drugs Included in Composite Rate ",{"$nulls":8},2]
[3," ESAs",{"$nulls":8},3]
[4," ESRD Related Other Drugs",{"$nulls":8},4]
[5," Non-ESRD Related Drugs, Supplies & Lab",{"$nulls":8},5]
[6," Whole Blood and Packed Red Blood Cells",{"$nulls":8},6]
[7," Vaccines",{"$nulls":8},7]
[null,"REIMBURSABLE  COST  CENTERS"]
[8," Maintenance-Hemodialysis",{"$nulls":8},8]
[8.01," Maintenance-Hemo Adult",{"$nulls":8},8.01]
[8.02," Maintenance-Hemo Pediatric",{"$nulls":8},8.02]
[9," Maintenance -IPD",{"$nulls":8},9]
[9.01," Maintenance-IPD Adult",{"$nulls":8},9.01]
[9.02," Maintenance-IPD Pediatric",{"$nulls":8},9.02]
[10," Training-Hemodialysis",{"$nulls":8},10]
[10.01," Training-Hemo Adult",{"$nulls":8},10.01]
[10.02," Training-Hemo Pediatric",{"$nulls":8},10.02]
[11," Training-IPD",{"$nulls":8},11]
[11.01," Training-IPD Adult",{"$nulls":8},11.01]
[11.02," Training-IPD Pediatric",{"$nulls":8},11.02]
[12," Training-CAPD",{"$nulls":8},12]
[12.01," Training-CAPD Adult",{"$nulls":8},12.01]
[12.02," Training-CAPD Pediatric",{"$nulls":8},12.02]
[13," Training-CCPD",{"$nulls":8},13]
[13.01," Training-CCPD Adult",{"$nulls":8},13.01]
[13.02," Training-CCPD Pediatric",{"$nulls":8},13.02]
[14," Home Program-Hemodialysis",{"$nulls":8},14]
[14.01," Home Program-Hemo Adult",{"$nulls":8},14.01]
[14.02," Home Program-Hemo Pediatric",{"$nulls":8},14.02]
[15," Home Program-IPD",{"$nulls":8},15]
[15.01," Home Program-IPD Adult",{"$nulls":8},15.01]
[15.02," Home Program-IPD Pediatric",{"$nulls":8},15.02]
[16," Home Program-CAPD",{"$nulls":8},16]
[16.01," Home Program-CAPD Adult",{"$nulls":8},16.01]
[16.02," Home Program-CAPD Pediatric",{"$nulls":8},16.02]
[17," Home Program-CCPD",{"$nulls":8},17]
[17.01," Home Program-CCPD Adult",{"$nulls":8},17.01]
[17.02," Home Program-CCPD Pediatric",{"$nulls":8},17.02]
[18," Subtotal (lines 2-16.02)",{"$nulls":8},18]
[null,"NONREIMBURSABLE  COST  CENTERS"]
[19," Physicians' Private Offices",{"$nulls":8},19]
[20," Method II Patients prior to 1/1/2011",{"$nulls":8},20]
[21," Other Nonreimbursable ",{"$nulls":8},21]
[22," Other Nonreimbursable ",{"$nulls":8},22]
[23," Total (see instructions) ",{"$nulls":8},23]
[24," Total Costs to be Allocated",{"$nulls":8},24]
[25," Unit Cost Multiplier (Line 24 div. by Line 23)",{"$nulls":8},25]
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)"]
["Rev. 2",{"$nulls":9},"42-313"]
["4290 (Cont.)",null,null,null,"    FORM CMS-265-11",{"$nulls":5},"06-13"]
[" COST  ALLOCATION  -  STATISTICAL  BASIS",{"$nulls":4}," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET B-1"]
[{"$nulls":7}," From:   "]
[{"$nulls":7}," To:   "]
[null,null,null,"UNIT COST","DRUGS","DRUGS",null,"ESA'S","ESRD","TOTAL"]
[null,null,null,"MULTIPLIER",null,"INCLD IN",null,null,"REL DRUGS","EXPENSES"]
[{"$nulls":5},"COMP RATE",null,null,null,"ALL"]
[{"$nulls":4},"( CHARGES )","( CHARGES )",null,"( CHARGES )","( CHARGES )","PATIENT"]
[null,null,"SUBTOTAL","COMPUTATION","(3)","(3)","SUBTOTAL","(3)","(3)","SERVICES"]
[null,null,"8A",9,10,11,"11A",12,13,"13A"]
[1," COSTS TO BE ALLOCATED",{"$nulls":8},1]
[2," Drugs Included in Composite Rate ",{"$nulls":8},2]
[3," ESAs",{"$nulls":8},3]
[4," ESRD Related Other Drugs",{"$nulls":8},4]
[5," Non-ESRD Related Drugs, Supplies & Lab",{"$nulls":8},5]
[6," Whole Blood and Packed Red Blood Cells",{"$nulls":8},6]
[7," Vaccines",{"$nulls":8},7]
[null,"REIMBURSABLE  COST  CENTERS"]
[8," Maintenance-Hemodialysis",{"$nulls":8},8]
[8.01," Maintenance-Hemo Adult",{"$nulls":8},8.01]
[8.02," Maintenance-Hemo Pediatric",{"$nulls":8},8.02]
[9," Maintenance -IPD",{"$nulls":8},9]
[9.01," Maintenance-IPD Adult",{"$nulls":8},9.01]
[9.02," Maintenance-IPD Pediatric",{"$nulls":8},9.02]
[10," Training-Hemodialysis",{"$nulls":8},10]
[10.01," Training-Hemo Adult",{"$nulls":8},10.01]
[10.02," Training-Hemo Pediatric",{"$nulls":8},10.02]
[11," Training-IPD",{"$nulls":8},11]
[11.01," Training-IPD Adult",{"$nulls":8},11.01]
[11.02," Training-IPD Pediatric",{"$nulls":8},11.02]
[12," Training-CAPD",{"$nulls":8},12]
[12.01," Training-CAPD Adult",{"$nulls":8},12.01]
[12.02," Training-CAPD Pediatric",{"$nulls":8},12.02]
[13," Training-CCPD",{"$nulls":8},13]
[13.01," Training-CCPD Adult",{"$nulls":8},13.01]
[13.02," Training-CCPD Pediatric",{"$nulls":8},13.02]
[14," Home Program-Hemodialysis",{"$nulls":8},14]
[14.01," Home Program-Hemo Adult",{"$nulls":8},14.01]
[14.02," Home Program-Hemo Pediatric",{"$nulls":8},14.02]
[15," Home Program-IPD",{"$nulls":8},15]
[15.01," Home Program-IPD Adult",{"$nulls":8},15.01]
[15.02," Home Program-IPD Pediatric",{"$nulls":8},15.02]
[16," Home Program-CAPD",{"$nulls":8},16]
[16.01," Home Program-CAPD Adult",{"$nulls":8},16.01]
[16.02," Home Program-CAPD Pediatric",{"$nulls":8},16.02]
[17," Home Program-CCPD",{"$nulls":8},17]
[17.01," Home Program-CCPD Adult",{"$nulls":8},17.01]
[17.02," Home Program-CCPD Pediatric",{"$nulls":8},17.02]
[18," Subtotal (lines 2-16.02)",{"$nulls":8},18]
[null,"NONREIMBURSABLE  COST  CENTERS"]
[19," Physicians' Private Offices",{"$nulls":8},19]
[20," Method II Patients prior to 1/1/2011",{"$nulls":8},20]
[21," Other Nonreimbursable ",{"$nulls":8},21]
[22," Other Nonreimbursable ",{"$nulls":8},22]
[23," Total (see instructions) ",{"$nulls":8},23]
[24," Total Costs to be Allocated",{"$nulls":8},24]
[25," Unit Cost Multiplier (Line 24 div. by Line 23)",{"$nulls":8},25]
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4211)"]
["42-313.1",{"$nulls":9},"Rev. 2"]
["06-13",null,null,null,"    FORM CMS-265-11",{"$nulls":5},"4290 (Cont.)"]
{"$rows_empty":22}
[{"$nulls":4},"This page intentionally left blank."]
{"$rows_empty":32}
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[]
["Rev. 2",{"$nulls":9},"42-313.2"]

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["4290 (Cont.)",null,null,null,"      FORM CMS-265-11     ",{"$nulls":4},"06-13"]
[" COMPUTATION  OF  AVERAGE  COST  PER  TREATMENT",{"$nulls":6}," PROVIDER CCN:"," PERIOD:"," WORKSHEET C"]
[" ESRD  PPS  BUNDLED PAYMENT",{"$nulls":7}," From:   "]
[{"$nulls":8}," To:   "]
[]
[{"$nulls":4},"TOTAL"]
[null,null,null,"NUMBER","COSTS","AVERAGE COST"]
[null,null,null,"OF","(Transferred from","OF TREATMENT"]
[null,null,null,"TREATMENTS","Wkst. B, col. 13A)","(col. 2 divided by col. 1)"]
[null,null,null,1,2,3]
[8.01," Maintenance-Hemo Adult",{"$nulls":4},8.01]
[8.02," Maintenance-Hemo Pediatric",{"$nulls":4},8.02]
[9.01," Maintenance-IPD Adult",{"$nulls":4},9.01]
[9.02," Maintenance-IPD Pediatric",{"$nulls":4},9.02]
[10.01," Training-Hemo Adult",{"$nulls":4},10.01]
[10.02," Training-Hemo Pediatric",{"$nulls":4},10.02]
[11.01," Training-IPD Adult",{"$nulls":4},11.01]
[11.02," Training-IPD Pediatric",{"$nulls":4},11.02]
[12.01," Training-CAPD Adult",{"$nulls":4},12.01]
[12.02," Training-CAPD Pediatric",{"$nulls":4},12.02]
[13.01," Training-CCPD Adult",{"$nulls":4},13.01]
[13.02," Training-CCPD Pediatric",{"$nulls":4},13.02]
[14.01," Home Program-Hemodialysis Adult",{"$nulls":4},14.01]
[14.02," Home Program-Hemodialysis Pediatric",{"$nulls":4},14.02]
[15.01," Home Program-IPD Adult",{"$nulls":4},15.01]
[15.02," Home Program-IPD Pediatric",{"$nulls":4},15.02]
[16.01," Home Program-CAPD Adult",null,"Patient Weeks",null,null,16.01]
[]
[16.02," Home Program-CAPD Pediatric",null,"Patient Weeks",null,null,16.02]
[]
[17.01," Home Program-CCPD Adult",null,"Patient Weeks",null,null,17.01]
[]
[17.02," Home Program-CCPD Pediatric",null,"Patient Weeks",null,null,17.02]
[]
[18," Totals","(Column 1 - Sum of Lines 8.01 through 15.02)",null,null,null,18]
[null,null,"(Column 2 - Sum of Lines 8.01 through 17.02)"]
[19," Total provider treatments ",{"$nulls":4},19]
[null," (informational only)"]
{"$rows_empty":15}
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[]
["42-314",{"$nulls":8},"Rev. 2"]

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["06-13",{"$nulls":5},"              FORM CMS-265-11",{"$nulls":9},"4290 (Cont.)"]
[" COMPUTATION  OF  AVERAGE  COST  PER  TREATMENT",{"$nulls":10}," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET D"]
[" BASIC  COMPOSITE  COST",{"$nulls":12}," From:   "]
[{"$nulls":13}," To:   "]
[]
[null,null,"TOTAL",null,null,"MEDICARE"]
[{"$nulls":5},"NUMBER","NUMBER","NUMBER"]
[null,null,"TOTAL",null,"AVERAGE","OF","OF","OF",null,"AVERAGE","AVERAGE","AVERAGE","TOTAL","TOTAL","TOTAL"]
[null,null,"NUMBER","COSTS","COST OF","TREAT-","TREAT-","TREAT-","TOTAL","PAYMENT","PAYMENT","PAYMENT","PAYMENT","PAYMENT","PAYMENT"]
[null,null,"OF","( transfer from","TREAT-","MENTS","MENTS","MENTS","EXPENSES","RATE","RATE","RATE","DUE","DUE","DUE","TOTAL"]
[null,null,"TREAT-","Wkst. B,","MENT","( see","( see","( see","( see","( see","( see","( see","( col. 4 x","( col. 4.01 x","( col. 4.02 x","PAYMENT"]
[null,null,"MENTS","col. 11A )","( col 2 / col. 1 )","instructions )","instructions )","instructions )","instructions )","instructions )","instructions )","instructions )","col. 6 )","col. 6.01 )","col. 6.02 )","DUE"]
[null,null,1,2,3,4,4.01,4.02,5,6,6.01,6.02,7,7.01,7.02,8]
[1," Maintenance-Hemodialysis",null,"(line 8.01 and",{"$nulls":12},1]
[null,null,null,"line 8.02)"]
[]
[2," Maintenance-IPD",null,"(line 9.01 and",{"$nulls":12},2]
[null,null,null,"line 9.02)"]
[null,null,null,0,0]
[3," Training-Hemodialysis",null,"(line 10.01 and",{"$nulls":12},3]
[null,null,null,"line 10.02)"]
[{"$nulls":4},0]
[4," Training-IPD",null,"(line 11.01 and",{"$nulls":12},4]
[null,null,null,"line 11.02)"]
[null,null,null,0,0]
[5," Training-CAPD",null,"(line 12.01 and",{"$nulls":12},5]
[null,null,null,"line 12.02)"]
[null,null,null,0,0]
[6," Training-CCPD",null,"(line 13.01 and",{"$nulls":12},6]
[null,null,null,"line 13.02)"]
[{"$nulls":4},0]
[7," Home Program-Hemodialysis",null,"(line 14.01 and",{"$nulls":12},7]
[null,null,null,"line 14.02)"]
[{"$nulls":4},0]
[8," Home Program-IPD",{"$nulls":14},8]
[null,null,null,"line 15.02)"]
[null,null,null,0,0]
[9," Home Program-CAPD","Patient","(line 16.01 and",{"$nulls":12},9]
[null,null,"Weeks","line 16.02)"]
[null,null,null,0,0]
[10," Home Program-CCPD","Patient","(line 17.01 and",{"$nulls":12},10]
[null,null,"Weeks","line 17.02)"]
[null,null,null,0,0]
[11," Total ",{"$nulls":6},0,{"$nulls":4},0,null,0,11]
[null," (see instructions)",{"$nulls":6},0,{"$nulls":4},0,null,0]
{"$rows_empty":8}
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[]
["Rev. 2",{"$nulls":15},"42-315"]

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["4290 (Cont.)",null,"FORM CMS-265-11",{"$nulls":5},"06-13"]
[" CALCULATION  OF  BAD  DEBT  REIMBURSEMENT",null,null," PROVIDER CCN:",null," PERIOD:",null," WORKSHEET E,"]
[{"$nulls":5}," From:   ",null," PARTS I & II"]
[{"$nulls":5}," To:   "]
[]
["  PART  I  -  CALCULATION  OF  REIMBURSABLE  BAD  DEBTS  TITLE  XVIII  -  PART  B"]
[1," Total Expenses Related to Care of Medicare Beneficiaries (from Wkst. D, col. 5, line 11)",{"$nulls":6},1]
[]
[{"$nulls":4},"Column 1",null,"Column 2"]
[2," Total payment due net of Part B deductibles (from Wkst. D, col. 7, line 11)  (see instructions)",{"$nulls":6},2]
[2.01," Total payment due net of Part B deductibles (from Wkst. D. col. 7.01, line 11)  (see instr.)",{"$nulls":6},2.01]
[2.02," Total payment due net of Part B deductibles (from Wkst. D. col. 7.02, line 11)  (see instr.)",{"$nulls":6},2.02]
[2.03," Total payment due net of Part B deductibles  (see instructions)",{"$nulls":6},2.03]
[3," Outlier payments",{"$nulls":6},3]
[4,{"$nulls":7},4]
[5," Program payments (80% of line 2.03, column 2)",{"$nulls":6},5]
[6," Amount of cost to be recovered from Medicare patients (line 1 minus line 5)",{"$nulls":6},6]
[7," Deductibles and coinsurance billed to Medicare Part B patients  (see instructions)",{"$nulls":6},7]
[7.01," Deductibles and coinsurance billed to Medicare Part B patients  (see instructions)",{"$nulls":6},7.01]
[7.02," Deductibles and coinsurance billed to Medicare Part B patients  (see instructions)",{"$nulls":6},7.02]
[7.03," Total deductibles and coinsurance billed to Medicare Part B patients for comparison  (see instructions)",{"$nulls":6},7.03]
[8," Bad debts for deductibles and coinsurance net of bad debt recoveries for services rendered prior to 1/1/2011",{"$nulls":6},8]
[9," Transition period 1 (75-25%) bad debts for deductibles and coinsurance net of bad debt recoveries for",{"$nulls":6},9]
[null," services rendered on or after 1/1/2011 but before 1/1/2012"]
[10," Transition period 2 (50-50%) bad debts for deductibles and coinsurance net of bad debt recoveries for",{"$nulls":6},10]
[null," services rendered on or after 1/1/2012 but before 1/1/2013"]
[11," Transition period 3 (25-75%) bad debts for deductibles and coinsurance net of bad debt recoveries for",{"$nulls":6},11]
[null," services rendered on or after 1/1/2013 but before 1/1/2014"]
[12," 100% PPS bad debts for deductibles and coinsurance net of bad debt recoveries for",{"$nulls":6},12]
[null," services rendered on or after 1/1/2014"]
[13," Total bad debts (sum of line 8 through line 12)",{"$nulls":6},13]
[14," Net deductibles and coinsurance billed to Medicare Part B patients (line 7.03 minus line 13, col. 2)",{"$nulls":6},14]
[15," Unrecovered from Medicare Part B patients (line 6 minus line 14)  (If line 14 exceeds line 6, do not complete line 16)",{"$nulls":6},15]
[16," Reimbursable bad debts (see instructions)",{"$nulls":6},16]
[17," Reimbursable bad debts for dual eligible beneficiaries  (see instructions--informational only)",{"$nulls":6},17]
[18," Tentative adjustment",{"$nulls":6},18]
[19," Sequestration adjustment amount",{"$nulls":6},19]
[20," Balance due provider/program (line 16 minus lines 18 and 19) (Indicate overpayment in parentheses) (see instructions)",{"$nulls":6},20]
[]
[]
[" PART  II  -  CALCULATION  OF  FACILITY  SPECIFIC  COMPOSITE  COST  PERCENTAGE"]
[1," Total allowable expenses (from Wkst. C, col. 2, line 18)",{"$nulls":4},1]
[2," Total composite costs (from Wkst. D, col. 2, line 11)",{"$nulls":4},2]
[3," Facility specific composite cost percentage (line 2 divided by line 1)",{"$nulls":4},3]
{"$rows_empty":28}
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4214)"]
[]
["42-316",{"$nulls":7},"Rev. 2"]

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["06-13",null,"FORM CMS-265-11   ",{"$nulls":4},"4290 (Cont.)"]
["ANALYSIS  OF  PAYMENTS  TO  PROVIDERS",null,null,"  PROVIDER CCN:  "," PERIOD: ",null," WORKSHEET E-1"]
["FOR  SERVICES  RENDERED ",null,null,null," From:   "]
[{"$nulls":4}," To:   "]
[]
[" PART  I  -  TO  BE  COMPLETED  BY  CONTRACTOR"]
[{"$nulls":5},"Part B"]
[{"$nulls":5},"mm/dd/yyyy","Amount"]
[null,"Description",null,null,null,"1"]
[1," List separately each tentative settlement",null,"Program"," .01",null,null,1.01]
[null," payment after desk review. Also show",null,"to"," .02",null,null,1.02]
[null," date of each payment.",null,"Provider"," .03",null,null,1.03]
[null," If none, write \"NONE,\" or enter a zero. (1)",null,"Provider"," .50",null,null,1.5]
[null,null,null,"to"," .51",null,null,1.51]
[null,null,null,"Program"," .52",null,null,1.52]
[null," SUBTOTAL (sum of lines 1.01 - 1.49 minus sum of lines 1.50 - 1.98)",null,null," .99",null,null,1.99]
[null," (Transfer to Wkst E, Part I, line 18)"]
[2," Determine net settlement amount (balance",null,"Program to provider"," .01",null,null,2.01]
[null," due) based on the cost report. (1)",null,"Provider to program"," .50",null,null,2.5]
[3," Name of Contractor",null,null,"Contractor Number",null,null,3]
[]
[]
[" (1) On line 2.50, 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."]
[]
[]
[]
[" PART  II  -  TO  BE  COMPLETED  BY  PROVIDER"]
[4,"Low volume payment amount  (see instructions)",{"$nulls":5},4]
{"$rows_empty":43}
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4215)"]
[]
["Rev 2",{"$nulls":6},"42-317"]

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["4290 (Cont.)",null,"            FORM CMS-265-11             ",{"$nulls":5},"06-13"]
[" BALANCE  SHEET",null,null,null," PROVIDER CCN:",null," PERIOD:"," WORKSHEET F"]
[{"$nulls":6}," From:   "]
[{"$nulls":6}," To:   "]
[]
[null,"ASSETS  (omit cents)"]
[null,"     CURRENT  ASSETS",null,"Amount"]
[1," Cash on hand and in banks",null,null,1]
[2," Temporary investments",null,null,2]
[3," Notes receivable",null,null,3]
[4," Accounts receivable",null,null,4]
[5," Other receivables",null,null,5]
[6," Less: allowances for uncollectible notes and accounts receivable",null,null,6]
[7," Inventory",null,null,7]
[8," Prepaid expenses",null,null,8]
[9," Other current assets",null,null,9]
[10," Due from other funds",null,null,10]
[11," TOTAL  CURRENT  ASSETS  (Sum of lines 1 through 10)",null,null,11]
[null,"     FIXED  ASSETS"]
[12," Land",null,null,12]
[13," Land improvements",null,null,13]
[14," Less: Accumulated depreciation",null,null,14]
[15," Buildings",null,null,15]
[16," Less Accumulated depreciation",null,null,16]
[17," Leasehold improvements",null,null,17]
[18," Less: Accumulated Amortization",null,null,18]
[19," Fixed equipment",null,null,19]
[20," Less: Accumulated depreciation",null,null,20]
[21," Automobiles and trucks",null,null,21]
[22," Less: Accumulated depreciation",null,null,22]
[23," Major movable equipment",null,null,23]
[24," Less: Accumulated depreciation",null,null,24]
[25," Minor equipment nondepreciable",null,null,25]
[26," Other fixed assets",null,null,26]
[27," TOTAL  FIXED  ASSETS  (Sum of lines 12 through 26)",null,null,27]
[null,"     OTHER  ASSETS"]
[28," Investments",null,null,28]
[29," Deposits on leases",null,null,29]
[30," Due from owners/officers",null,null,30]
[31," Other assets",null,null,31]
[32," TOTAL  OTHER  ASSETS  (Sum of lines 28 through 31)",null,null,32]
[33," TOTAL  ASSETS  (Sum of lines 11, 27, and 32)",null,null,33]
[]
[null,"LIABILITIES  AND  FUND  BALANCES  (omit cents)"]
[null,"     CURRENT  LIABILITIES"]
[34," Accounts payable",null,null,34]
[35," Salaries, wages & fees payable",null,null,35]
[36," Payroll taxes payable",null,null,36]
[37," Notes & loans payable (Short term)",null,null,37]
[38," Deferred income",null,null,38]
[39," Accelerated payments",null,null,39]
[40," Due to other funds",null,null,40]
[41," Other current liabilities",null,null,41]
[42," TOTAL  CURRENT  LIABILITIES  (Sum of lines 34 through 41)",null,null,42]
[null,"     LONG  TERM  LIABILITIES"]
[43," Mortgage payable",null,null,43]
[44," Notes payable",null,null,44]
[45," Unsecured loans",null,null,45]
[46," Other long term liabilities",null,null,46]
[47,null,null,null,47]
[48," TOTAL  LONG  TERM  LIABILITIES  (Sum of lines 43 through 47)",null,null,48]
[49," TOTAL  LIABILITIES  (Sum of lines 42 and 48)",null,null,49]
[null,"     CAPITAL  ACCOUNTS"]
[50," FUND BALANCES",null,null,50]
[51," TOTAL  LIABILITIES  AND  FUND  BALANCES  (Sum of lines 49 and 50)",null,null,51]
[]
[null,"(         ) = contra amount"]
[]
[]
[]
[]
[]
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)"]
[]
["Rev. 2",{"$nulls":7},"42-318"]

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["06-13",null,"            FORM CMS-265-11       ",null,null,null,"4290 (Cont.)"]
[" STATEMENT  OF  REVENUES  AND  EXPENSES",null,null," PROVIDER CCN:"," PERIOD:"," WORKSHEET F-1"]
[{"$nulls":4}," From:   "]
[{"$nulls":4}," To:  "]
[]
[null,null,null,"Amount","Amount"]
[1," Total patient revenues",null,null,null,1]
[2," Less:  Allowances and discounts on patients' accounts",null,null,null,2]
[3," Net patient revenues (Line 1 minus line 2)",null,null,null,3]
[4," Operating expenses (From Worksheet A, column 6, line 27)",null,null,null,4]
[5," Additions to operating expenses (Specify)",null,null,null,5]
[6,{"$nulls":4},6]
[7,{"$nulls":4},7]
[8,{"$nulls":4},8]
[9,{"$nulls":4},9]
[10,{"$nulls":4},10]
[11," Subtractions from operating expenses (Specify)",null,null,null,11]
[12,{"$nulls":4},12]
[13,{"$nulls":4},13]
[14,{"$nulls":4},14]
[15,{"$nulls":4},15]
[16,{"$nulls":4},16]
[17," Less total operating expenses (net of lines 4 through 16)",null,null,null,17]
[18," Net income from services to patients (Line 3 minus line 17)",null,null,null,18]
[null," Other income:"]
[19," Contributions, donations, bequests, etc.",null,null,null,19]
[20," Income from investments",null,null,null,20]
[21," Purchase discounts",null,null,null,21]
[22," Rebates and refunds of expenses",null,null,null,22]
[23," Sale of medical and nursing supplies to other than patients",null,null,null,23]
[24," Sale of durable medical equipment to other than patients",null,null,null,24]
[25," Sale of drugs to other than patients",null,null,null,25]
[26," Sale of medical records and abstracts",null,null,null,26]
[27," Other revenues (Specify)",null,null,null,27]
[28,{"$nulls":4},28]
[29,{"$nulls":4},29]
[30,{"$nulls":4},30]
[31,{"$nulls":4},31]
[32," Total Other Income (Sum of lines 19 through 31)",null,null,null,32]
[33," Net Income or Loss for the period (Line 18 plus line 32)",null,null,null,33]
{"$rows_empty":32}
["FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)"]
[]
["Rev. 2",{"$nulls":5},"42-319"]