09-01 FORM CMS-2552-96 3690 (Cont.) 09-01 FORM CMS-2552-96 3690 (Cont.) 09-01 FORM CMS-2552-96 3690 (Cont.) ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ___________ PERIOD: "WORKSHEET K-5," ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ___________ PERIOD: "WORKSHEET K-5," ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ___________ PERIOD: "WORKSHEET K-5," COSTS TO HOSPICE COST CENTERS FROM__________________ PART I COSTS TO HOSPICE COST CENTERS FROM__________________ PART I (Cont.) COSTS TO HOSPICE COST CENTERS FROM__________________ PART I (Cont.) HOSPICE NO.: _____________ TO ___________________ HOSPICE NO.: _____________ TO ___________________ HOSPICE NO.: _____________ TO ___________________ INTERN & From HOSPICE OLD CAPITAL NEW CAPITAL NON- PARA- RESIDENT ALLOCATED TOTAL HOSPICE COST CENTER Wkst. K-4 TRIAL RELATED COSTS RELATED COSTS ADMINIS- MAIN- CORF COST CENTER LAUNDRY MAIN- NURSING CENTRAL MEDICAL HHA COST CENTER OTHER PHYSICIAN INTERNS & RESIDENTS MEDICAL COST & POST HOSPICE HOSPICE (omit cents) "Part I," BALANCE BLDGS. & MOVABLE BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE & OPERATION (omit cents) & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL (omit cents) GENERAL ANES- NURSING SALARY & PROGRAM EDUCATION SUBTOTAL STEPDOWN SUBTOTAL A&G (see COSTS "col. 7," (1) 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) ADJUST. (cols. 25 ± 26) Part II) (cols. 27 ± 28) line 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 6 X X X X X X X X X 1 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 1 2 Inpatient - General Care 7 X X X X X X X X X X 2 2 Inpatient - General Care X X X X X X X X X X 2 2 Inpatient - General Care X X X X X X X X X X 2 3 Inpatient - Respite Care 8 X X X X X X X X X X 3 3 Inpatient - Respite Care X X X X X X X X X X 3 3 Inpatient - Respite Care X X X X X X X X X X 3 4 Physician Services 9 X X X X X X X X X X 4 4 Physician Services X X X X X X X X X X 4 4 Physician Services X X X X X X X X X X 4 5 Nursing Care 10 X X X X X X X X X X 5 5 Nursing Care X X X X X X X X X X 5 5 Nursing Care X X X X X X X X X X 5 6 Physical Therapy 11 X X X X X X X X X X 6 6 Physical Therapy X X X X X X X X X X 6 6 Physical Therapy X X X X X X X X X X 6 7 Occupational Therapy 12 X X X X X X X X X X 7 7 Occupational Therapy X X X X X X X X X X 7 7 Occupational Therapy X X X X X X X X X X 7 8 Speech/ Language Pathology 13 X X X X X X X X X X 8 8 Speech/ Language Pathology X X X X X X X X X X 8 8 Speech/ Language Pathology X X X X X X X X X X 8 9 Medical Social Services - Direct 14 X X X X X X X X X X 9 9 Medical Social Services - Direct X X X X X X X X X X 9 9 Medical Social Services - Direct X X X X X X X X X X 9 10 Spiritual Counseling 15 X X X X X X X X X X 10 10 Spiritual Counseling X X X X X X X X X X 10 10 Spiritual Counseling X X X X X X X X X X 10 11 Dietary Counseling 16 X X X X X X X X X X 11 11 Dietary Counseling X X X X X X X X X X 11 11 Dietary Counseling X X X X X X X X X X 11 12 Counseling - Other 17 X X X X X X X X X X 12 12 Counseling - Other X X X X X X X X X X 12 12 Counseling - Other X X X X X X X X X X 12 13 Home Health Aide and Homemakers 18 X X X X X X X X X X 13 13 Home Health Aide and Homemakers X X X X X X X X X X 13 13 Home Health Aide and Homemakers X X X X X X X X X X 13 14 Other 19 X X X X X X X X X X 14 14 Other X X X X X X X X X X 14 14 Other X X X X X X X X X X 14 15 "Drugs, Biologicals and Infusion" 20 X X X X X X X X X X 15 15 "Drugs, Biologicals and Infusion" X X X X X X X X X X 15 15 "Drugs, Biologicals and Infusion" X X X X X X X X X X 15 16 Durable Medical Equipment/Oxygen 21 X X X X X X X X X X 16 16 Durable Medical Equipment/Oxygen X X X X X X X X X X 16 16 Durable Medical Equipment/Oxygen X X X X X X X X X X 16 17 Patient Transportation 22 X X X X X X X X X X 17 17 Patient Transportation X X X X X X X X X X 17 17 Patient Transportation X X X X X X X X X X 17 18 Imaging Services 23 X X X X X X X X X X 18 18 Imaging Services X X X X X X X X X X 18 18 Imaging Services X X X X X X X X X X 18 19 Labs and Diagnostics 24 X X X X X X X X X X 19 19 Labs and Diagnostics X X X X X X X X X X 19 19 Labs and Diagnostics X X X X X X X X X X 19 20 Medical Supplies 25 X X X X X X X X X X 20 20 Medical Supplies X X X X X X X X X X 20 20 Medical Supplies X X X X X X X X X X 20 21 Outpatient Services (including E/R Dept.) 26 X X X X X X X X X X 21 21 Outpatient Services (including E/R Dept.) X X X X X X X X X X 21 21 Outpatient Services (including E/R Dept.) X X X X X X X X X X 21 22 Radiation Therapy 27 X X X X X X X X X X 22 22 Radiation Therapy X X X X X X X X X X 22 22 Radiation Therapy X X X X X X X X X X 22 23 Chemotherapy 28 X X X X X X X X X X 23 23 Chemotherapy X X X X X X X X X X 23 23 Chemotherapy X X X X X X X X X X 23 24 Other 29 X X X X X X X X X X 24 24 Other X X X X X X X X X X 24 24 Other X X X X X X X X X X 24 25 Bereavement Program Costs 30 X X X X X X X X X X 25 25 Bereavement Program Costs X X X X X X X X X X 25 25 Bereavement Program Costs X X X X X X X X X X 25 26 Volunteer Program Costs 31 X X X X X X X X X X 26 26 Volunteer Program Costs X X X X X X X X X X 26 26 Volunteer Program Costs X X X X X X X X X X 26 27 Fundraising 32 X X X X X X X X X X 27 27 Fundraising X X X X X X X X X X 27 27 Fundraising X X X X X X X X X X 27 28 Other Program Costs 33 X X X X X X X X X X 28 28 Other Program Costs X X X X X X X X X X 28 28 Other Program Costs X X X X X X X X X X 28 29 Totals (sum of lines 1-28) (2) X X X X X X X X X X 29 29 Totals (sum of lines 1-28) (2) X X X X X X X X X X 29 29 Totals (sum of lines 1-28) (2) X X X X X X X X X X 29 30 Unit Cost Multiplier (see instructions) 30 30 Unit Cost Multiplier (see instructions) 30 30 Unit Cost Multiplier (see instructions) 30 "(1) Column 0, line 29 must agree with Wkst. A, column 7, line 93." "(1) Column 0, line 29 must agree with Wkst. A, column 7, line 93." "(1) Column 0, line 29 must agree with Wkst. A, column 7, line 93." "(2) Columns 0 through 27, line 29 must agree with the corresponding columns of Wkst. B, Part I, line 93." "(2) Columns 0 through 27, line 29 must agree with the corresponding columns of Wkst. B, Part I, line 93." "(2) Columns 0 through 27, line 29 must agree with the corresponding columns of Wkst. B, Part I, line 93." "FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3634.5-3634.8)" "FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3634.5-3634.8)" "FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3634.5-3634.8)" Rev. 8 36-634.7 Rev. 8 36-634.8 Rev. 8 36-634.9