08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ___________ PERIOD: "WORKSHEET H-5," ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ______________ PERIOD: "WORKSHEET H-5," ALLOCATION OF GENERAL SERVICE PROVIDER NO.: __________ PERIOD: "WORKSHEET H-5," COSTS TO HHA COST CENTERS HHA NO.: _____________ FROM__________________ PART II COSTS TO HHA COST CENTERS HHA NO.: _____________ FROM__________________ PART II (CONT.) COSTS TO HHA COST CENTERS HHA NO.: _____________ FROM__________________ PART II (CONT.) STATISTICAL BASIS TO ___________________ STATISTICAL BASIS TO ___________________ STATISTICAL BASIS TO ___________________ OLD CAPITAL NEW CAPITAL NON- PARA- RELATED COST RELATED COST ADMINIS- MAIN- LAUNDRY MAIN- NURSING CENTRAL MEDICAL PHYSICIAN INTERNS & RESIDENTS MEDICAL BLDGS. & MOVABLE BLDGS. & MOVABLE EMPLOYEE TRATIVE & TENANCE & OPERATION & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL OTHER ANES- NURSING SALARY & PROGRAM EDUCATION HHA COST CENTER FIXTURES EQUIPMENT FIXTURES EQUIPMENT BENEFITS GENERAL REPAIRS OF PLANT HHA COST CENTER SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY HHA COST CENTER SERVICE GENERAL THETISTS SCHOOL FRINGES COSTS (SPECIFY) (SQUARE (DOLLAR (SQUARE (DOLLAR (GROSS RECONCIL- (ACCUM. (SQUARE (SQUARE (POUNDS OF (HOURS OF (MEALS (MEALS (NUMBER (DIRECT (COSTED (COSTED (TIME (TIME SERVICE (ASSIGNED (ASSIGNED (ASSIGNED (ASSIGNED (ASSIGNED FEET) VALUE) FEET) VALUE) SALARIES) IATION COST) FEET) FEET) LAUNDRY) SERVICE) SERVED) SERVED) HOUSED) NURS. HRS) REQUIS.) REQUIS.) SPENT) SPENT) (SPECIFY) TIME) TIME) TIME) TIME) TIME) 1 2 3 4 5 6A 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 Administrative and General 1 1 Administrative and General 1 1 Administrative and General 1 2 Skilled Nursing Care 2 2 Skilled Nursing Care 2 2 Skilled Nursing Care 2 3 Physical Therapy 3 3 Physical Therapy 3 3 Physical Therapy 3 4 Occupational Therapy 4 4 Occupational Therapy 4 4 Occupational Therapy 4 5 Speech Pathology 5 5 Speech Pathology 5 5 Speech Pathology 5 6 Medical Social Services 6 6 Medical Social Services 6 6 Medical Social Services 6 7 Home Health Aide 7 7 Home Health Aide 7 7 Home Health Aide 7 8 Supplies 8 8 Supplies 8 8 Supplies 8 9 Drugs 9 9 Drugs 9 9 Drugs 9 10 DME 10 10 DME 10 10 DME 10 11 Home Dialysis Aide Services 11 11 Home Dialysis Aide Services 11 11 Home Dialysis Aide Services 11 12 Respiratory Therapy 12 12 Respiratory Therapy 12 12 Respiratory Therapy 12 13 Private Duty Nursing 13 13 Private Duty Nursing 13 13 Private Duty Nursing 13 14 Clinic 14 14 Clinic 14 14 Clinic 14 15 Health Promotion Activities 15 15 Health Promotion Activities 15 15 Health Promotion Activities 15 16 Day Care Program 16 16 Day Care Program 16 16 Day Care Program 16 17 Home Delivered Meals Program 17 17 Home Delivered Meals Program 17 17 Home Delivered Meals Program 17 18 Homemaker Service 18 18 Homemaker Service 18 18 Homemaker Service 18 19 All Others 19 19 All Others 19 19 All Others 19 20 Totals (sum of lines 1-19) 20 20 Totals (sum of lines 1-19) 20 20 Totals (sum of lines 1-19) 20 21 Total cost to be allocated X X X X X X X X 21 21 Total cost to be allocated X X X X X X X X X 21 21 Total cost to be allocated X X X X X X X 21 22 Unit Cost Multiplier X X X X X X X X 22 22 Unit Cost Multiplier X X X X X X X X X 22 22 Unit Cost Multiplier X X X X X X X 22 "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3646.2)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3646.2)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3646.2)" Rev. 3 36-614 Rev. 3 36-615 Rev. 3 36-616