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 COSTS TO PROVIDER NO.: ______________ PERIOD: "WORKSHEET J-1," ALLOCATION OF GENERAL SERVICE COSTS TO PROVIDER NO.: ________________ PERIOD: "WORKSHEET J-1," ALLOCATION OF GENERAL SERVICE COSTS TO PROVIDER NO.: ________________ PERIOD: "WORKSHEET J-1," OUTPATIENT REHABILITATION PROVIDER COST CENTERS COMPONENT NO.: ___________ FROM______________ PART I OUTPATIENT REHABILITATION PROVIDER COST CENTERS COMPONENT NO.: _____________ FROM_______________ PART I (CONT.) OUTPATIENT REHABILITATION PROVIDER COST CENTERS COMPONENT NO.: _____________ FROM________________ PART I (CONT.) TO _________________ TO __________________ TO ___________________ Check [ ] CMHC [ ] OPT [ ] OSP Check [ ] CMHC [ ] OPT [ ] OSP Check [ ] CMHC [ ] OPT [ ] OSP Applicable Box: [ ] CORF [ ] OOT Applicable Box: [ ] CORF [ ] OOT Applicable Box: [ ] CORF [ ] OOT NET INTERN & EXPENSES OLD CAPITAL NEW CAPITAL MAIN- CENTRAL MEDICAL NON- PARA- RESIDENT ALLOCATED COMPONENT COST CENTER FOR COST RELATED COSTS RELATED COSTS ADMINIS- MAIN- LAUNDRY COMPONENT COST CENTER TENANCE NURSING SERVICES RECORDS OTHER PHYSICIAN COMPONENT COST CENTER INTERNS & RESIDENTS MEDICAL SUBTOTAL COST & POST SUBTOTAL COMPONENT TOTAL (omit cents) ALLOCATION BLDGS. & MOVABLE BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE OPERATION & LINEN (omit cents) HOUSE- OF ADMINIS- & & SOCIAL GENERAL ANES- (omit cents) NURSING SALARY & PROGRAM EDUCATION (sum of STEPDOWN (sum of cols. A&G (see (sum of cols. (see instru.) FIXTURES EQUIPMENT FIXTURES EQUIPMENT BENEFITS (cols. 0-5) GENERAL & REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (SPECIFY) cols. 5a-24) ADJ. 25 ± 26) Part II) (2) 27 ± 28) 0 1 2 3 4 5 5A 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 1 Administrative and General X X X X X X X X X X 1 1 Administrative and General X X X X X X X X X X X 1 1 Administrative and General X X X X X X X 1 2 Skilled Nursing Care X X X X X X X X X X 2 2 Skilled Nursing Care X X X X X X X X X X X 2 2 Skilled Nursing Care X X X X X X X X 2 3 Physical Therapy X X X X X X X X X X 3 3 Physical Therapy X X X X X X X X X X X 3 3 Physical Therapy X X X X X X X X 3 4 Occupational Therapy X X X X X X X X X X 4 4 Occupational Therapy X X X X X X X X X X X 4 4 Occupational Therapy X X X X X X X X 4 5 Speech Pathology X X X X X X X X X X 5 5 Speech Pathology X X X X X X X X X X X 5 5 Speech Pathology X X X X X X X X 5 6 Medical Social Services X X X X X X X X X X 6 6 Medical Social Services X X X X X X X X X X X 6 6 Medical Social Services X X X X X X X X 6 7 Respiratory Therapy X X X X X X X X X X 7 7 Respiratory Therapy X X X X X X X X X X X 7 7 Respiratory Therapy X X X X X X X X 7 8 Psychiatric/Psychological Services X X X X X X X X X X 8 8 Psychiatric/Psychological Services X X X X X X X X X X X 8 8 Psychiatric/Psychological Services X X X X X X X X 8 9 Individual Therapy X X X X X X X X X X 9 9 Individual Therapy X X X X X X X X X X X 9 9 Individual Therapy X X X X X X X X 9 10 Group Therapy X X X X X X X X X X 10 10 Group Therapy X X X X X X X X X X X 10 10 Group Therapy X X X X X X X X 10 11 Individualized Activity Therapies X X X X X X X X X X 11 11 Individualized Activity Therapies X X X X X X X X X X X 11 11 Individualized Activity Therapies X X X X X X X X 11 12 Family Counseling X X X X X X X X X X 12 12 Family Counseling X X X X X X X X X X X 12 12 Family Counseling X X X X X X X X 12 13 Diagnostic Services X X X X X X X X X X 13 13 Diagnostic Services X X X X X X X X X X X 13 13 Diagnostic Services X X X X X X X X 13 14 Approved Patient Training & Education X X X X X X X X X X 14 14 Approved Patient Training & Education X X X X X X X X X X X 14 14 Approved Patient Training & Education X X X X X X X X 14 15 Prosthetic and Orthotic Devices X X X X X X X X X X 15 15 Prosthetic and Orthotic Devices X X X X X X X X X X X 15 15 Prosthetic and Orthotic Devices X X X X X X X X 15 16 Drugs and Biologicals X X X X X X X X X X 16 16 Drugs and Biologicals X X X X X X X X X X X 16 16 Drugs and Biologicals X X X X X X X X 16 17 Medical Supplies X X X X X X X X X X 17 17 Medical Supplies X X X X X X X X X X X 17 17 Medical Supplies X X X X X X X X 17 18 Medical Appliances X X X X X X X X X X 18 18 Medical Appliances X X X X X X X X X X X 18 18 Medical Appliances X X X X X X X X 18 19 Durable Medical Equipment-Rented X X X X X X X X X X 19 19 Durable Medical Equipment-Rented X X X X X X X X X X X 19 19 Durable Medical Equipment-Rented X X X X X X X X 19 20 Durable Medical Equipment-Sold X X X X X X X X X X 20 20 Durable Medical Equipment-Sold X X X X X X X X X X X 20 20 Durable Medical Equipment-Sold X X X X X X X X 20 21 All Others X X X X X X X X X X 21 21 All Others X X X X X X X X X X X 21 21 All Others X X X X X X X X 21 22 Totals (sum of lines 1-21)(1) X X X X X X X X X X 22 22 Totals (sum of lines 1-21)(1) X X X X X X X X X X X 22 22 Totals (sum of lines 1-21)(1) X X X X X X X X 22 23 Unit Cost Multiplier (see instructions) 23 23 Unit Cost Multiplier (see instructions) 23 23 Unit Cost Multiplier (see instructions) X 23 "(1) Columns 0 through 27, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions." "(1) Columns 0 through 27, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions." "(1) Columns 0 through 27, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions." "(2) The sum of lines 2-21 must equal the amount in column 27, line 1." "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3656.1)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3656.1)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3656.1)" Rev. 3 36-625 Rev. 3 36-626 Rev. 3 36-627