3690 (Cont.)			                    FORM CMS-2552-96					05-04																																										
COMPUTATION OF ORGAN ACQUISITION				PROVIDER NO.:		PERIOD:	"WORKSHEET D-6,"																																											
COSTS AND CHARGES				_______________		FROM ___________	PART I																																											
				OPO NO.: 		TO ______________																																												
				_______________																																														
Check		  [ ] HEART	  [ ] LIVER	 [  ] PANCREAS		 [  ] OTHER (specify)																																												
Applicable Box		  [ ] KIDNEY	  [ ] LUNG	 [  ] INTESTINE																																														
PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)																																																		
    Computation of Inpatient																																																		
     Routine Service Costs			Inpatient			Organ																																												
      Applicable to Organ			Routine Organ		Per Diem Costs	Acquisition	Cost																																											
          Acquistion			Charges		(from Wkst. D-1)	Days	(col. 2 x col. 3)																																											
			1	D	2	3	4																																											
1 	 Adults and Pediatrics			38 		X		1 																																										
2 	 Intensive Care			43 		X		2 																																										
3 	 Coronary Care			44 		X		3 																																										
4 	 Burn Intensive Care Unit			45 		X		4 																																										
5 	 Surgical Intensive Care Unit			46 		X		5 																																										
6 	 Other Special Care (specify)			47 		X		6 																																										
7 	TOTAL (sum of lines 1-6)					X		7 																																										
																																																		
    Computation of Ancillary					Ratio of Cost/	Organ	Organ																																											
     Service Cost Applicable					Charges	Acquisition	Acquisition																																											
      to Organ Acquisition					(from	Ancillary	Ancillary																																											
					"Wkst. C, Part I)"	Charges	Costs																																											
				C	1	2	3																																											
8 	 Operating Room			37 				8 																																										
9 	 Recovery Room			38 				9 																																										
10 	 Delivery Room & Labor Room			39 				10 																																										
11 	 Anesthesiology			40 				11 																																										
12 	 Radiology-Diagnostic			41 				12 																																										
13 	 Radiology-Theraputic			42 				13 																																										
14 	 Radioisotope			43 				14 																																										
15 	 Laboratory			44 				15 																																										
16 	 PBP Clinical Laboratory Services-Program Only			45 				16 																																										
17 	 Whole Blood & Packed Red Blood Cells			46 				17 																																										
18 	" Blood Storage, Processing, & Transfusing"			47 				18 																																										
19 	 IV Therapy			48 				19 																																										
20 	 Respiratory Therapy			49 				20 																																										
21 	 Physical Therapy			50 				21 																																										
22 	 Occupational Therapy			51 				22 																																										
23 	 Speech Pathology			52 				23 																																										
24 	 Electrocardiology			53 				24 																																										
25 	 Electroencephalography			54 				25 																																										
26 	 Medical Supplies Charged to Patients			55 				26 																																										
27 	 Drugs Charged to Patients			56 				27 																																										
28 	 Renal Dialysis			57 				28 																																										
29 	 ASC (non-distinct part)			58 				29 																																										
30 	 Other Ancillary (specify)			59 				30 																																										
31 	 Clinic			60 				31 																																										
32 	 Emergency Room			61 				32 																																										
33 	 Observation Beds			62 				33 																																										
34 	 Other Outpatient Service (specify)			63 				34 																																										
35 	 TOTAL (sum of lines 8-34)							35 																																										
	C = Worksheet C line numbers		D = Worksheet D-1 line numbers																																															
																																																		
																																																		
																																																		
																																																		
																																																		
"FORM CMS-2552-96 (9/2000)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3625 & 3625.1)"																																																		
																																																		
36-582								                   Rev. 12