08/02				FORM CMS-2552-96					   3690 (Cont.)																																																																												
COST ALLOCATION - HOSPICE STATISTICAL BASIS				PROVIDER NO.: _________________		PERIOD:		"WORKSHEET K-4,"																																																																													
						FROM ____________		PART II																																																																													
				HOSPICE NO.: ________________		TO _______________																																																																															
						VOLUNTEER																																																																															
		CAPITAL RELATED COST		PLANT		SERVICES		ADMINIS-																																																																													
		BUILDINGS	MOVABLE	OPERATION	TRANS-	COORDI-		TRATIVE  &																																																																													
	COST CENTER DESCRIPTIONS	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	RECONCIL-	GENERAL																																																																													
		(SQ. FT.)	($ VALUE)	(SQ. FT.)	(MILEAGE)	(HOURS)	IATION	(ACC. COST)																																																																													
		1	2	3	4 	5 	6A	6 																																																																													
	GENERAL SERVICE COST CENTERS	 	 	 	 	 	 	 																																																																													
1 	Capital Related Costs-Buildings and Fixtures	 	 	 	 	 	 	 	1 																																																																												
2 	Capital Related Costs-Movable Equipment	 	 	 	 	 	 	 	2 																																																																												
3 	Plant Operation and Maintenance				 	 	 	 	3 																																																																												
4 	Transportation-staff					 	 	 	5 																																																																												
5 	Volunteer Service Coordination						 	 	5 																																																																												
6 	Administrative and General								6 																																																																												
	INPATIENT CARE SERVICE	 	 	 	 	 	 	 																																																																													
7 	Inpatient - General Care								7 																																																																												
8 	Inpatient - Respite Care								8 																																																																												
	VISITING SERVICES	 	 	 	 	 	 	 																																																																													
9 	Physician Services								9 																																																																												
10 	Nursing Care								10 																																																																												
11 	Physical Therapy								11 																																																																												
12 	Occupational Therapy								12 																																																																												
13 	Speech/ Language Pathology								13 																																																																												
14 	Medical Social Services - Direct								14 																																																																												
15 	Spiritual Counseling	 	 						15 																																																																												
16 	Dietary Counseling								16 																																																																												
17 	Counseling - Other								17 																																																																												
18 	Home Health Aide and Homemakers								18 																																																																												
19 	Other								19 																																																																												
	OTHER HOSPICE SERVICE COSTS	 	 	 	 	 	 	 																																																																													
20 	"Drugs, Biologicals and Infusion"								20 																																																																												
21 	Durable Medical Equipment/Oxygen								21 																																																																												
22 	Patient Transportation								22 																																																																												
23 	Imaging Services								23 																																																																												
34 	Labs and Diagnostics								24 																																																																												
25 	Medical Supplies								25 																																																																												
26 	Outpatient Services (including E/R Dept.)								26 																																																																												
27 	Radiation Therapy								27 																																																																												
28 	Chemotherapy								28 																																																																												
29 	Other								29 																																																																												
	HOSPICE NONREIMBURSABLE SERVICE	 	 	 	 	 	 	 																																																																													
30 	Bereavement Program Costs								30 																																																																												
31 	Volunteer Program Costs								31 																																																																												
32 	Fundraising								32 																																																																												
33 	Other Program Costs								33 																																																																												
34 	"Cost To be Allocated (per Wkst. K-4, Part I)"	X	X	X	X	X		X	34 																																																																												
35 	Unit Cost Multiplier	X	X	X	X	X		X	35 																																																																												
"FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3634.4)"																																																																																					
Rev. 9									36-634.6