3690 (Cont.)		                            FORM CMS-2552-96				08/02																							
APPORTIONMENT OF COST FOR THE			PROVIDER NO.:	PERIOD:	"WORKSHEET D-9,"																								  .
SERVICES OF TEACHING PHYSICIANS				FROM________	PART II																								
			________________	TO___________																									
Check		  [ ]  Hospital																											
Applicable Box:		  [ ] Subprovider 																											
				Medical School	Total																								
			Hospital Staff	Faculty	(col 1 + col 2)																								
			1	2	3																								
1 	 Adjusted Cost of Physician's Direct Medical and Surgical Services					1 																							
2 	 Total Inpatient Days and Outpatient Visit Days					2 																							
3 	 Average Per Diem (line 1 ÷ line 2)					3 																							
																													
	 HEALTH CARE PROGRAM REIMBURSABLE DAYS																												
																													
4 	 Title  V - Inpatient					4 																							
5 	 Title  V - Outpatient					5 																							
6 	 Title  XVIII - Part A					6 																							
7 	 Title  XVIII - Part B					7 																							
8 	 Title  XIX - Inpatient					8 																							
9 	 Title  XIX - Outpatient					9 																							
10 	 Inpatient and Outpatient Kidney Acquisition					10 																							
11 	 Inpatient and Outpatient Liver Acquisition					11 																							
12 	 Inpatient and Outpatient Heart Acquisition					12 																							
13 	 Inpatient and Outpatient Lung Acquisition					13 																							
13.01 	 Inpatient and Outpatient Pancreas Acquisition					13.0113 																							
13.02 	 Inpatient and Outpatient Intestine Acquisition					13.02 																							
																													
	 HEALTH CARE PROGRAM REIMBURSABLE COST																												
																													
14 	 Title  V - Inpatient (line 3 x line 4)					14 																							
15 	 Title  V - Outpatient (line 3 x line 5)					15 																							
16 	 Title  XVIII - Part A (line 3 x line 6)					16 																							
17 	 Title  XVIII - Part B (line 3 x line 7)					17 																							
18 	 Title  XIX - Inpatient (line 3 x line 8)					18 																							
19 	 Title  XIX - Outpatient (line 3 x line 9)					19 																							
20 	 Inpatient and Outpatient Kidney Acquisition (line 3 x line 10)					20 																							
21 	 Inpatient and Outpatient Liver Acquisition (line 3 x line 11)					21 																							
22 	 Inpatient and Outpatient Heart Acquisition (line 3 x line 12)					22 																							
23 	 Inpatient and Outpatient Lung Acquisition (line 3 x line 13)					23 																							
23.01 	 Inpatient and Outpatient Pancreas Acquisition (line 3 x line 13.01)					23.01 																							
23.02 	 Inpatient and Outpatient Intestine Acquisition (line 3 x line 13.02)					23.02 																							
																													
																													
	  Transfer the amounts in column 3 as follows:																												
	"     Add lines 14 and 15, and transfer to Worksheet E-3, Part III"																												
	"     Line 16 to Worksheet E, Part A, or Worksheet E-3, Part I or II as appropriate"																												
	"     Line 17 to Worksheet E, Part B"																												
	"     Add lines 18 and 19, and transfer to Worksheet E-3, Part III, as appropriate"																												
	"     Sum of lines 20 through  23.02 to Worksheet D-6, Part III, line 51"																												
																													
																													
																													
																													
																													
																													
																													
																													
																													
																													
																													
																													
																													
																													
																													
																													
"FORM CMS-2552-96 (8/2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3626 & 3626.2)"																													
																													
36-586						              Rev. 9