11-00			 FORM CMS-2552-96					                3690 (Cont.)	
STATEMENT OF COSTS OF SERVICES			PROVIDER NO:	PERIOD:		WORKSHEET A-8-1			
FROM RELATED ORGANIZATIONS AND				FROM____________					
HOME OFFICE COSTS			_______________	TO_______________					
									
A. Costs incurred and adjustments required as a result of transactions with related organizations or the claiming of home office costs:									
					Amount	Net			
				Amount of	included in	Adjustments	Wkst.		
				Allowable	"Wkst. A,"	(col. 4 minus	A-7		
	Line No.	Cost Center	Expense Items	Cost	column 5	col. 5) *	Ref.		
	1	2	3	4	5	6	7		
1 	X	X	X	X	X	X	X	1 	
2 	X	X	X	X	X	X	X	2 	
3 	X	X	X	X	X	X	X	3 	
4 	X	X	X	X	X	X	X	4 	
5 	"TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet"			X	X	X		5 	
	"A-8, column 2, line 14. "								
									
" *  The amounts on lines 1-4 and subscripts as appropriate are transfered in detail to Worksheet A, column 6, lines as appropriate."									
  Positive amounts increase cost and negative amounts decrease cost.  For related organizational or home office cost which has not 									
"  been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part."									
									
B. Interrelationship to related organization(s) and/or home office:									
"The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish"									
the information requested under Part B of this worksheet.									
									
This information is used by the Health Care Financing Administration and its intermediaries in determining that the costs applicable to									
"services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs"									
"as determined under section 1861 of the Social Security Act.  If you do 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.									
									
				Related Organization(s) and/or Home Office					
			Percentage		Percentage				
	 Symbol		of		of	Type of			
	(1)	Name	Ownership	Name	Ownership	Business			
	1	2	3	4	5	6			
1 	X	X	X	X	X	X		1 	
2 	X	X	X	X	X	X		2 	
3 	X	X	X	X	X	X		3 	
4 	X	X	X	X	X	X		4 	
5 	X	X	X	X	X	X		5 	
									
	(1) Use the following symbols to indicate interrelationship to related organizations:								
									
		"A. Individual has financial interest (stockholder, partner, etc.) in both related"							
		      organization and in provider.							
		"B. Corporation, partnership, or other organization has financial interest in provider."							
		"C. Provider has financial interest in corporation, partnership, or other organization."							
		"D. Director, officer, administrator, or key person of provider or relative of such"							
		      person has financial interest in related organization.							
		"E. Individual is director, officer, administrator, or key person of provider and"							
		      related organization.							
		"F. Director, officer, administrator, or key person of related organization or relative"							
		      of such person has financial interest in provider.							
		G. Other (financial or non-financial) specify _______________________X___________________________							
									
									
									
									
									
									
									
									
									
									
									
"FORM CMS-2552-96 (9/2000)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3614)"									
									
									
Rev. 7								                        36-519