3690 (Cont.)		FORM CMS-2552-96						04-05		
HOSPITAL WAGE INDEX INFORMATION			PROVIDER NO.:		PERIOD:		"WORKSHEET S-3,"			
					FROM __________		PART II			
			______________		TO _____________					
PART II - WAGE DATA										
			Reclass.	Adjusted	Paid Hours	Average				
			of Salaries	Salaries	Related	Hourly Wage				
		Amount	(from 	(col. 1 ±	to Salaries	(col. 3 ÷	Data			
		Reported	Wkst. A-6)	col. 2)	in col. 3	col. 4)	Source			
		1	2	3	4	5	6			
	SALARIES									
1 	Total salaries (see instructions)							1 		
2 	Non-physician anesthetist Part A							2 		
3 	Non-physician anesthetist Part B							3 		
4 	Physician-Part A							4 		
4.01 	 Teaching physician salaries (see instructions)							4.01 		
5 	Physician-Part B							5 		
5.01 	Non-physician-Part B							5.01 		
6 	Interns & residents (in an approved program)							6 		
6.01 	"Contract services, I&R (see instructions)"							6.01 		
7 	Home office personnel							7 		
8 	SNF							8 		
8.01 	Excluded area salaries (see instructions)							8.01 		
	OTHER WAGES & RELATED COSTS									
9 	Contract labor (see instructions)							9 		
9.01 	 Pharmacy services under contract							9.01 		
9.02 	 Laboratory services under contract							9.02 		
9.03 	Management and administrative services							9.03 		
10 	Contract labor: physician-Part A							10 		
 10.01 	 Teaching physician under contract (see instru.)							 10.01 		
11 	Home office salaries & wage-related costs							11 		
12 	Home office: physician Part A							12 		
 12.01 	 Teaching physician salaries (see instructions)							 12.01 		
 	WAGE-RELATED COSTS							 		
13 	Wage-related costs (core)						CMS 339	13 		
14 	Wage-related costs (other)						CMS 339	14 		
15 	Excluded areas						CMS 339	15 		
16 	Non-physician anesthetist Part A						CMS 339	16 		
17 	Non-physician anesthetist Part B						CMS 339	17 		
18 	Physician Part A						CMS 339	18 		
18.01 	Part A teaching physicians (see instructions)						CMS 339	18.01 		
19 	Physician Part B						CMS 339	19 		
19.01 	Wage-related costs (RHC/FQHC)						CMS 339	19.01 		
20 	Interns & residents (in an approved program)						CMS 339	20 		
										
										
										
										
										
										
										
										
										
										
										
										
										
										
										
										
										
"FORM CMS-2552-96 (5/2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.2)"										
										
36-506.2								Rev. 14		
06-03		FORM CMS-2552-96						3690 (Cont.)		
HOSPITAL WAGE INDEX INFORMATION			PROVIDER NO.:		PERIOD:		"WORKSHEET S-3,"			
					FROM __________		PART III			
			______________		TO _____________					
PART II - WAGE DATA										
			Reclass.	Adjusted	Paid Hours	Average				
			of Salaries	Salaries	Related	Hourly Wage				
		Amount	(from 	(col. 1 ±	to Salaries	(col. 3 ÷	Data			
		Reported	Wkst. A-6)	col. 2)	in col. 3	col. 4)	Source			
		1	2	3	4	5	6			
	OVERHEAD COSTS - DIRECT SALARIES									
21 	Employee Benefits	X	X	X	X	X		21 		
22 	Administrative & General	X	X	X	X	X		22 		
22.01 	Administrative & General under contract (see inst.)	X	X	X	X	X		22.01 		
23 	Maintenance & Repairs	X	X	X	X	X		23 		
24 	Operation of Plant	X	X	X	X	X		24 		
25 	Laundry & Linen Service	X	X	X	X	X		25 		
26 	Housekeeping	X	X	X	X	X		26 		
26.01 	Housekeeping under contract (see instructions)	X	X	X	X	X		26.01 		
27 	Dietary	X	X	X	X	X		27 		
27.01 	Dietary under contract (see instructions)	X	X	X	X	X		27.01 		
28 	Cafeteria	X	X	X	X	X		28 		
29 	Maintenance of Personnel	X	X	X	X	X		29 		
30 	Nursing Administration	X	X	X	X	X		30 		
31 	Central Services and Supply	X	X	X	X	X		31 		
32 	Pharmacy	X	X	X	X	X		32 		
33 	Medical Records & Medical Records Library	X	X	X	X	X		33 		
34 	Social Service	X	X	X	X	X		34 		
35 	Other General Service 	X	X	X	X	X		35 		
										
PART III - HOSPITAL WAGE INDEX SUMMARY										
1 	Net salaries (see instructions)	X	X	X	X	X		1 		
2 	Excluded area salaries (see instructions)	X	X	X	X	X		2 		
3 	Subtotal salaries (line 1 minus line 2)	X	X	X	X	X		3 		
4 	Subtotal other wages & related costs (see inst.)	X	X	X	X	X		4 		
5 	Subtotal wage-related costs (see inst.)	X	X	X	X	X		5 		
6 	Total (sum of lines 3 thru 5)	X	X	X	X	X		6 		
7 	Net salaries (see instructions)							7 		
8 	Excluded area salaries							8 		
9 	Subtotal salaries (line 7 minus line 8)							9 		
10 	Subtotal other wages & related costs (see inst.)							10 		
11 	Subtotal wage-related costs (see inst.)							11 		
12 	Total (sum of lines 9 thru 11)							12 		
13 	Total overhead costs (see inst.)	X	X	X	X	X		13 		
										
										
										
										
										
										
										
										
										
										
										
										
										
										
										
										
										
										
"FORM CMS-2552-96 (6/2003) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.2)"										
										
Rev. 10								36-506.3