11-98 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO: PERIOD: "WORKSHEET B," FROM _________ PART I FROM _________ PART I FROM _________ PART I _ TO ____________ _ TO ____________ _ TO ____________ NET EXPENSES OLD CAPITAL NEW CAPITAL INTERN & FOR COST RELATED COSTS RELATED COSTS NON- INTERNS & INTERNS & PARA- RESIDENT ALLOCATION ADMINIS- MAIN- LAUNDRY MAIN- NURSING CENTRAL MEDICAL OTHER PHYSICIAN RESIDENTS RESIDENTS MEDICAL COST & POST COST CENTER DESCRIPTIONS (from Wkst. BLDGS. & MOVABLE BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE & OPERATION COST CENTER DESCRIPTIONS & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL COST CENTER DESCRIPTIONS GENERAL ANES- NURSING SALARY & PROGRAM EDUCATION STEPDOWN "A, col. 7)" FIXTURES EQUIPMENT FIXTURES EQUIPMENT BENEFITS (cols. 0-5) GENERAL REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (SPECIFY) SUBTOTAL ADJUSTMENTS TOTAL 0 1 2 3 4 5 5A 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 GENERAL SERVICE COST CENTERS GENERAL SERVICE COST CENTERS GENERAL SERVICE COST CENTERS 1 Old Capital Related Costs-Buildings and Fixtures X X 1 1 Old Capital Related Costs-Buildings and Fixtures 1 1 Old Capital Related Costs-Buildings and Fixtures 1 2 Old Capital Related Costs-Movable Equipment X X 2 2 Old Capital Related Costs-Movable Equipment 2 2 Old Capital Related Costs-Movable Equipment 2 3 New Capital Related Costs-Buildings and Fixtures X X 3 3 New Capital Related Costs-Buildings and Fixtures 3 3 New Capital Related Costs-Buildings and Fixtures 3 4 New Capital Related Costs-Movable Equipment X X 4 4 New Capital Related Costs-Movable Equipment 4 4 New Capital Related Costs-Movable Equipment 4 5 Employee Benefits X X X X X X 5 5 Employee Benefits 5 5 Employee Benefits 5 6 Administrative and General X X X X X X X X 6 6 Administrative and General 6 6 Administrative and General 6 7 Maintenance and Repairs X X X X X X X X X 7 7 Maintenance and Repairs 7 7 Maintenance and Repairs 7 8 Operation of Plant X X X X X X X X X X 8 8 Operation of Plant 8 8 Operation of Plant 8 9 Laundry and Linen Service X X X X X X X X X X 9 9 Laundry and Linen Service X 9 9 Laundry and Linen Service 9 10 Housekeeping X X X X X X X X X X 10 10 Housekeeping X X 10 10 Housekeeping 10 11 Dietary X X X X X X X X X X 11 11 Dietary X X X 11 11 Dietary 11 12 Cafeteria X X X X X X X X X X 12 12 Cafeteria X X X X 12 12 Cafeteria 12 13 Maintenance of Personnel X X X X X X X X X X 13 13 Maintenance of Personnel X X X X X 13 13 Maintenance of Personnel 13 14 Nursing Administration X X X X X X X X X X 14 14 Nursing Administration X X X X X X 14 14 Nursing Administration 14 15 Central Services and Supply X X X X X X X X X X 15 15 Central Services and Supply X X X X X X X 15 15 Central Services and Supply 15 16 Pharmacy X X X X X X X X X X 16 16 Pharmacy X X X X X X X X 16 16 Pharmacy 16 17 Medical Records & Medical Records Library X X X X X X X X X X 17 17 Medical Records & Medical Records Library X X X X X X X X X 17 17 Medical Records & Medical Records Library 17 18 Social Service X X X X X X X X X X 18 18 Social Service X X X X X X X X X X 18 18 Social Service 18 19 Other General Service (specify) X X X X X X X X X X 19 19 Other General Service (specify) X X X X X X X X X X 19 19 Other General Service (specify) X 19 20 Nonphysician Anesthetists X X X X X X X X X X 20 20 Nonphysician Anesthetists X X X X X X X X X X 20 20 Nonphysician Anesthetists X X 20 21 Nursing School X X X X X X X X X X 21 21 Nursing School X X X X X X X X X X 21 21 Nursing School X X 21 22 Intern & Res. Service-Salary & Fringes (Approved) X X X X X X X X X X 22 22 Intern & Res. Service-Salary & Fringes (Approved) X X X X X X X X X X 22 22 Intern & Res. Service-Salary & Fringes (Approved) X X 22 23 Intern & Res. Other Program Costs (Approved) X X X X X X X X X X 23 23 Intern & Res. Other Program Costs (Approved) X X X X X X X X X X 23 23 Intern & Res. Other Program Costs (Approved) X X 23 24 Paramedical Ed. Program (specify) X X X X X X X X X X 24 24 Paramedical Ed. Program (specify) X X X X X X X X X X 24 24 Paramedical Ed. Program (specify) X X 24 INPATIENT ROUTINE SERVICE COST CENTERS INPATIENT ROUTINE SERVICE COST CENTERS INPATIENT ROUTINE SERVICE COST CENTERS 25 Adults and Pediatrics (General Routine Care) X X X X X X X X X X 25 25 Adults and Pediatrics (General Routine Care) X X X X X X X X X X 25 25 Adults and Pediatrics (General Routine Care) X X X X X X X 25 26 Intensive Care Unit X X X X X X X X X X 26 26 Intensive Care Unit X X X X X X X X X X 26 26 Intensive Care Unit X X X X X X X 26 27 Coronary Care Unit X X X X X X X X X X 27 27 Coronary Care Unit X X X X X X X X X X 27 27 Coronary Care Unit X X X X X X X 27 28 Burn Intensive Care Unit X X X X X X X X X X 28 28 Burn Intensive Care Unit X X X X X X X X X X 28 28 Burn Intensive Care Unit X X X X X X X 28 29 Surgical Intensive Care Unit X X X X X X X X X X 29 29 Surgical Intensive Care Unit X X X X X X X X X X 29 29 Surgical Intensive Care Unit X X X X X X X 29 30 Other Special Care Unit (specify) X X X X X X X X X X 30 30 Other Special Care Unit (specify) X X X X X X X X X X 30 30 Other Special Care Unit (specify) X X X X X X X 30 31 Subprovider (specify) X X X X X X X X X X 31 31 Subprovider (specify) X X X X X X X X X X 31 31 Subprovider (specify) X X X X X X X 31 33 Nursery X X X X X X X X X X 33 33 Nursery X X X X X X X X X X 33 33 Nursery X X X X X X X 33 34 Skilled Nursing Facility X X X X X X X X X X 34 34 Skilled Nursing Facility X X X X X X X X X X 34 34 Skilled Nursing Facility X X X X X X X 34 35 Nursing Facility X X X X X X X X X X 35 35 Nursing Facility X X X X X X X X X X 35 35 Nursing Facility X X X X X X X 35 36 Other Long Term Care X X X X X X X X X X 36 36 Other Long Term Care X X X X X X X X X X 36 36 Other Long Term Care X X X X X X X 36 "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" Rev. 4 36-523.4 Rev. 3 36-527 Rev. 3 36-530 08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," FROM _________ PART I FROM _________ PART I FROM _________ PART I _ TO ____________ _ TO ____________ _ TO ____________ NET EXPENSES OLD CAPITAL NEW CAPITAL INTERN & FOR COST RELATED COSTS RELATED COSTS NON- INTERNS & INTERNS & PARA- RESIDENT ALLOCATION ADMINIS- MAIN- LAUNDRY MAIN- NURSING CENTRAL MEDICAL OTHER PHYSICIAN RESIDENTS RESIDENTS MEDICAL COST & POST COST CENTER DESCRIPTIONS (from Wkst. BLDGS. & MOVABLE BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE & OPERATION COST CENTER DESCRIPTIONS & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL COST CENTER DESCRIPTIONS GENERAL ANES- NURSING SALARY & PROGRAM EDUCATION STEPDOWN "A, col. 7)" FIXTURES EQUIPMENT FIXTURES EQUIPMENT BENEFITS (cols. 0-5) GENERAL REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (specify) SUBTOTAL ADJUSTMENTS TOTAL 0 1 2 3 4 5 5A 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 ANCILLARY SERVICE COST CENTERS ANCILLARY SERVICE COST CENTERS ANCILLARY SERVICE COST CENTERS 37 Operating Room X X X X X X X X X X 37 37 Operating Room X X X X X X X X X X 37 37 Operating Room X X X X X X X 37 38 Recovery Room X X X X X X X X X X 38 38 Recovery Room X X X X X X X X X X 38 38 Recovery Room X X X X X X X 38 39 Delivery Room and Labor Room X X X X X X X X X X 39 39 Delivery Room and Labor Room X X X X X X X X X X 39 39 Delivery Room and Labor Room X X X X X X X 39 40 Anesthesiology X X X X X X X X X X 40 40 Anesthesiology X X X X X X X X X X 40 40 Anesthesiology X X X X X X X 40 41 Radiology-Diagnostic X X X X X X X X X X 41 41 Radiology-Diagnostic X X X X X X X X X X 41 41 Radiology-Diagnostic X X X X X X X 41 42 Radiology-Therapeutic X X X X X X X X X X 42 42 Radiology-Therapeutic X X X X X X X X X X 42 42 Radiology-Therapeutic X X X X X X X 42 43 Radioisotope X X X X X X X X X X 43 43 Radioisotope X X X X X X X X X X 43 43 Radioisotope X X X X X X X 43 44 Laboratory X X X X X X X X X X 44 44 Laboratory X X X X X X X X X X 44 44 Laboratory X X X X X X X 44 45 PBP Clinical Laboratory Services-Program Only X X 45 45 PBP Clinical Laboratory Services-Program Only 45 45 PBP Clinical Laboratory Services-Program Only X 45 46 Whole Blood & Packed Red Blood Cells X X X X X X X X X X 46 46 Whole Blood & Packed Red Blood Cells X X X X X X X X X X 46 46 Whole Blood & Packed Red Blood Cells X X X X X X X 46 47 "Blood Storing, Processing, & Trans." X X X X X X X X X X 47 47 "Blood Storing, Processing, & Trans." X X X X X X X X X X 47 47 "Blood Storing, Processing, & Trans." X X X X X X X 47 48 Intravenous Therapy X X X X X X X X X X 48 48 Intravenous Therapy X X X X X X X X X X 48 48 Intravenous Therapy X X X X X X X 48 49 Respiratory Therapy X X X X X X X X X X 49 49 Respiratory Therapy X X X X X X X X X X 49 49 Respiratory Therapy X X X X X X X 49 50 Physical Therapy X X X X X X X X X X 50 50 Physical Therapy X X X X X X X X X X 50 50 Physical Therapy X X X X X X X 50 51 Occupational Therapy X X X X X X X X X X 51 51 Occupational Therapy X X X X X X X X X X 51 51 Occupational Therapy X X X X X X X 51 52 Speech Pathology X X X X X X X X X X 52 52 Speech Pathology X X X X X X X X X X 52 52 Speech Pathology X X X X X X X 52 53 Electrocardiology X X X X X X X X X X 53 53 Electrocardiology X X X X X X X X X X 53 53 Electrocardiology X X X X X X X 53 54 Electroencephalography X X X X X X X X X X 54 54 Electroencephalography X X X X X X X X X X 54 54 Electroencephalography X X X X X X X 54 55 Medical Supplies Charged to Patients X X X X X X X X X X 55 55 Medical Supplies Charged to Patients X X X X X X X X X X 55 55 Medical Supplies Charged to Patients X X X X X X X 55 56 Drugs Charged to Patients X X X X X X X X X X 56 56 Drugs Charged to Patients X X X X X X X X X X 56 56 Drugs Charged to Patients X X X X X X X 56 57 Renal Dialysis X X X X X X X X X X 57 57 Renal Dialysis X X X X X X X X X X 57 57 Renal Dialysis X X X X X X X 57 58 ASC (Non-Distinct Part) X X X X X X X X X X 58 58 ASC (Non-Distinct Part) X X X X X X X X X X 58 58 ASC (Non-Distinct Part) X X X X X X X 58 59 Other Ancillary (specify) X X X X X X X X X X 59 59 Other Ancillary (specify) X X X X X X X X X X 59 59 Other Ancillary (specify) X X X X X X X 59 OUTPATIENT SERVICE COST CENTERS OUTPATIENT SERVICE COST CENTERS OUTPATIENT SERVICE COST CENTERS 60 Clinic X X X X X X X X X X 60 60 Clinic X X X X X X X X X X 60 60 Clinic X X X X X X X 60 61 Emergency X X X X X X X X X X 61 61 Emergency X X X X X X X X X X 61 61 Emergency X X X X X X X 61 62 Observation Beds 62 62 Observation Beds 62 62 Observation Beds 62 63 Other Outpatient Service (specify) X X X X X X X X X X 63 63 Other Outpatient Service (specify) X X X X X X X X X X 63 63 Other Outpatient Service (specify) X X X X X X X 63 OTHER REIMBURSABLE COST CENTERS OTHER REIMBURSABLE COST CENTERS OTHER REIMBURSABLE COST CENTERS 64 Home Program Dialysis X X X X X X X X X X 64 64 Home Program Dialysis X X X X X X X X X X 64 64 Home Program Dialysis X X X X X X X 64 65 Ambulance Services X X X X X X X X X X 65 65 Ambulance Services X X X X X X X X X X 65 65 Ambulance Services X X X X X X X 65 66 Durable Medical Equipment-Rented X X X X X X X X X X 66 66 Durable Medical Equipment-Rented X X X X X X X X X X 66 66 Durable Medical Equipment-Rented X X X X X X X 66 67 Durable Medical Equipment-Sold X X X X X X X X X X 67 67 Durable Medical Equipment-Sold X X X X X X X X X X 67 67 Durable Medical Equipment-Sold X X X X X X X 67 68 Other Reimbursable (specify) X X X X X X X X X X 68 68 Other Reimbursable (specify) X X X X X X X X X X 68 68 Other Reimbursable (specify) X X X X X X X 68 69 Outpatient Rehabilitation Provider (specify) X X X X X X X X X X 69 69 Outpatient Rehabilitation Provider (specify) X X X X X X X X X X 69 69 Outpatient Rehabilitation Provider (specify) X X X X X X X 69 70 Intern-Resident Service (not appvd. tchng. prgm.) X X X X X X X X X X 70 70 Intern-Resident Service (not appvd. tchng. prgm.) X X X X X X X X X X 70 70 Intern-Resident Service (not appvd. tchng. prgm.) X X X X X X X 70 "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" Rev. 3 36-525 Rev. 3 36-528 Rev. 3 36-531 08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," COST ALLOCATION - GENERAL SERVICE COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," FROM _________ PART I FROM _________ PART I FROM _________ PART I _ TO ____________ _ TO ____________ _ TO ____________ NET EXPENSES OLD CAPITAL NEW CAPITAL INTERN & FOR COST RELATED COSTS RELATED COSTS NON- INTERNS & INTERNS & PARA- RESIDENT ALLOCATION ADMINIS- MAIN- LAUNDRY MAIN- NURSING CENTRAL MEDICAL OTHER PHYSICIAN RESIDENTS RESIDENTS MEDICAL COST & POST COST CENTER DESCRIPTIONS (from Wkst. BLDGS. & MOVABLE BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE & OPERATION COST CENTER DESCRIPTIONS & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL COST CENTER DESCRIPTIONS GENERAL ANES- NURSING SALARY & PROGRAM EDUCATION STEPDOWN "A, col. 7)" FIXTURES EQUIPMENT FIXTURES EQUIPMENT BENEFITS (cols. 0-5) GENERAL REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (specify) SUBTOTAL ADJUSTMENTS TOTAL 0 1 2 3 4 5 5A 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 71 Home Health Agency X X X X X X X X X X 71 71 Home Health Agency X X X X X X X X X X 71 71 Home Health Agency X X X X X X X 71 SPECIAL PURPOSE COST CENTERS SPECIAL PURPOSE COST CENTERS SPECIAL PURPOSE COST CENTERS 82 Lung Acquisition X X X X X X X X X X 82 82 Lung Acquisition X X X X X X X X X X 82 82 Lung Acquisition X X X X X X X 82 83 Kidney Acquisition X X X X X X X X X X 83 83 Kidney Acquisition X X X X X X X X X X 83 83 Kidney Acquisition X X X X X X X 83 84 Liver Acquisition X X X X X X X X X X 84 84 Liver Acquisition X X X X X X X X X X 84 84 Liver Acquisition X X X X X X X 84 85 Heart Acquisition X X X X X X X X X X 85 85 Heart Acquisition X X X X X X X X X X 85 85 Heart Acquisition X X X X X X X 85 86 Other Organ Acquisition (specify) X X X X X X X X X X 86 86 Other Organ Acquisition (specify) X X X X X X X X X X 86 86 Other Organ Acquisition (specify) X X X X X X X 86 92 Ambulatory Surgical Center (Distinct Part) X X X X X X X X X X 92 92 Ambulatory Surgical Center (Distinct Part) X X X X X X X X X X 92 92 Ambulatory Surgical Center (Distinct Part) X X X X X X X 92 93 Hospice X X X X X X X X X X 93 93 Hospice X X X X X X X X X X 93 93 Hospice X X X X X X X 93 94 Other Special Purpose (specify) X X X X X X X X X X 94 94 Other Special Purpose (specify) X X X X X X X X X X 94 94 Other Special Purpose (specify) X X X X X X X 94 95 SUBTOTALS (sum of lines 1-94) X X X X X X X X X X 95 95 SUBTOTALS (sum of lines 1-94) X X X X X X X X X X 95 95 SUBTOTALS (sum of lines 1-94) X X X X X X X 95 NONREIMBURSABLE COST CENTERS NONREIMBURSABLE COST CENTERS NONREIMBURSABLE COST CENTERS 96 "Gift, Flower, Coffee Shop, & Canteen" X X X X X X X X X X 96 96 "Gift, Flower, Coffee Shop, & Canteen" X X X X X X X X X X 96 96 "Gift, Flower, Coffee Shop, & Canteen" X X X X X X X 96 97 Research X X X X X X X X X X 97 97 Research X X X X X X X X X X 97 97 Research X X X X X X X 97 98 Physicians' Private Offices X X X X X X X X X X 98 98 Physicians' Private Offices X X X X X X X X X X 98 98 Physicians' Private Offices X X X X X X X 98 99 Nonpaid Workers X X X X X X X X X X 99 99 Nonpaid Workers X X X X X X X X X X 99 99 Nonpaid Workers X X X X X X X 99 100 Other Nonreimbursable (specify) X X X X X X X X X X 100 100 Other Nonreimbursable (specify) X X X X X X X X X X 100 100 Other Nonreimbursable (specify) X X X X X X X 100 101 Cross Foot Adjustments 101 101 Cross Foot Adjustments 101 101 Cross Foot Adjustments 101 102 Negative Cost Centers X X X X X X X X X 102 102 Negative Cost Centers X X X X X X X X X X 102 102 Negative Cost Centers X X X X X X X 102 103 TOTAL (sum of lines 95-102) X X X X X X X X X X 103 103 TOTAL (sum of lines 95-102) X X X X X X X X X X 103 103 TOTAL (sum of lines 95-102) X X X X X X X X 103 "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3617)" Rev. 3 36-526 Rev. 3 36-529 Rev. 3 36-532