3690 (Cont.)			FORM CMS-2552-96				11-00																	
ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS				PROVIDER NO.	PERIOD:	WORKSHEET I-1																		
				______________	FROM__________																			
					TO____________																			
Check applicable box:		 [ ] Renal Dialysis Department     [ ] Home Program Dialysis																						
			TOTAL			FTEs per																		
			COSTS	BASIS	STATISTICS	2080 Hours																		
			1	2	3	4																		
1 	Registered Nurses		X	Hours of Service	X	X	1 																	
2 	Licensed Practical Nurses		X	Hours of Service	X	X	2 																	
3 	Nurses Aides		X	Hours of Service	X	X	3 																	
4 	Technicians		X	Hours of Service	X	X	4 																	
5 	Social Workers		X	Hours of Service	X	X	5 																	
6 	Dieticians		X	Hours of Service	X	X	6 																	
7 	Physicians		X	Accumulated Cost			7 																	
8 	Non-patient Care Salary		X	Accumulated Cost			8 																	
9 	Subtotal (sum of lines 1-8)		X				9 																	
10 	Employee Benefits		X	Salary			10 																	
11 	Old & New Capital Related Costs-Bldgs. & Fixtures		X	Square Feet			11 																	
12 	Old & New Capital Related Costs-Mov. Equip.		X	Percentage of Time			12 																	
13 	Machine Costs & Repairs		X	Percentage of Time			13 																	
14 	Supplies		X	Requisitions			14 																	
15 	Drugs		X	Requisitions			15 																	
16 	Other 		X	Accumulated Cost			16 																	
17 	Subtotal (sum of lines 9-16)*		X				17 																	
18 	Old Capital Related Costs-Bldgs. & Fixtures		X	Square Feet			18 																	
19 	Old Capital Related Costs-Mov. Equip.		X	Percentage of Time			19 																	
20 	New Capital Related Costs-Bldgs. & Fixtures		X	Square Feet			20 																	
21 	New Capital Related Costs-Mov. Equip.		X	Percentage of Time			21 																	
22 	Employee Benefits		X	Salary			22 																	
23 	Administrative and General		X	Accumulated Cost			23 																	
24 	Maint./Repairs-Operation-Housekeeping		X	Square Feet			24 																	
25 	Medical Education Program Costs		X				25 																	
26 	Central Services & Supplies		X	Requisitions			26 																	
27 	Pharmacy		X	Requisitions			27 																	
28 	Other Allocated Costs		X	Accumulated Cost			28 																	
29 	Subtotal (sum of lines 17-28)*		X				29 																	
30 	Laboratory (see instructions)		X	Charges	X		30 																	
31 	Respiratory Therapy (see instructions)		X	Charges	X		31 																	
32 	Other (see instructions)		X	Charges	X		32 																	
33 	Total costs (sum of lines 29-32)		X				33 																	
																								
	"*  Line 17, column 1 should agree with Worksheet A, column 7 for line 57 or line 64 as appropriate,"																							
	"     and line 29, column 1 should agree with Worksheet B, Part I, column 27 for line 57 or line 64 as appropriate."																							
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
"FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3651)"																								
																								
																								
																								
																								
36-620							           Rev. 7																	
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
																								
ALLOCATION METHOD																								
																								
Statistics	Exception Requests																							
																								
Charges	No S/W I-2 Part II																							
																								
Weighted Treatments	I/P = 2																							
	O/P & Home = 1																							
	Training = 3