11-96		                        FORM CMS-2552-96				         3690 (Cont.)					
REASONABLE COST DETERMINATION FOR THERAPY			PROVIDER NO.	PERIOD	"WORKSHEET A-8-3,"						
SERVICES FURNISHED BY OUTSIDE SUPPLIERS				FROM:________________	"PARTS II, III, & IV"						
			____________________	TO: __________________							
Check applicable box:		( ) Physical Therapy  ( ) Respiratory Therapy									
											
PART II (Continued) - SALARY EQUIVALENCY COMPUTATION											
23 	" Certified Therapists (column 6, line 12 time column 6, line 13)"				X	23 					
24 	" Non-registered, non-certified therapists (column 7, line 12 times column 7, line 13)"				X	24 					
25 	" Assistants (column 9, line 12 times column 9, line 13)"				X	25 					
26 	 Subtotal allowance amount (see instructions)				X	26 					
27 	" Aides (column 10, line 12 times column 10, line 13)"				X	27 					
28 	" Trainees (column 11, line 12 times column 11, line 13)"				X	28 					
29 	 Total allowance amount (see instructions)				X	29 					
	" If the sum of columns 1-3 and 5-7 for respiratory therapy or columns 4, 8, and 9 for physical therapy is greater than line 2, make"										
	 no entries on lines 30 and 31 and enter on line 32 the amount from line 29.  Otherwise complete lines 30-32.										
30 	 Weighted average rate excluding aides and trainees				X	30 					
31 	 Weighted allowance excluding aides and trainees				X	31 					
32 	 Total salary equivalency (see instructions)				X	32 					
											
PART III - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION - PROVIDER SITE											
   Standard Travel Allowance											
33 	" Therapists total (line 3 times column 4, line 14)"					33 					
34 	" Registered Therapists (line 5 times column 1, line 14)"					34 					
35 	" Certified Therapists (line 6 times column 2, line 14)"					35 					
36 	" Non-registered, non-certified therapists (line 7 times column 3, line 14)"					36 					
37 	" Assistants (line 4 times column 9, line 14)"					37 					
38 	 Subtotal (see instructions)					38 					
39 	 Standard travel expense (see instructions)					39 					
40 	Total standard travel allowance and travel expense (sum of lines 38 and 39)				X	40 					
											
PART IV - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION - HHA SERVICES OUTSIDE PROVIDER SITE											
   Standard Travel Expense											
41 	" Therapists (line 8 times column 8, line 14)"					41 					
42 	" Assistants (line 9 times column 9, line 14)"					42 					
43 	 Subtotal (sum of lines 41 and 42)					43 					
44 	 Standard Travel Expense (line 10 times the sum of lines 8 and 9)					44 					
   Optional Travel Allowance and Optional Travel Expense											
45 	" Therapists (sum of columns 4 and 8, line 15 times column 8, line 13)"					45 					
46 	" Assistants (column 9, line 15 times column 9, line 13)"					46 					
47 	 Subtotal (sum of lines 45 and 46)					47 					
48 	" Optional Travel Expense (line 11 times the sum of columns 4, 8, and 9, line 16)"					48 					
"   Total Travel Allowance and Travel Expense - HHA Services.  Complete one of the following three lines (49, 50, or 51, as appropriate)."											
49 	 Standard Travel Allowance and Standard Travel Expense (sum of lines 43 and 44) (see instructions)					49 					
50 	 Optional Travel Allowance and Standard Travel Expense (sum of lines 47 and 44)  (see instructions)					50 					
51 	 Optional Travel Allowance and Optional Travel Expense (sum of lines 47 and 48)  (see instructions)					51 					
											
"FORM CMS-2552-96 (9/96)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3616.2-3616.4)"											
Rev. 2						                36-522