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 COSTS TO PROVIDER NO.: ___________ PERIOD: "WORKSHEET K-5," ALLOCATION OF GENERAL SERVICE COSTS TO PROVIDER NO.: ______________ PERIOD: "WORKSHEET K-5," ALLOCATION OF GENERAL SERVICE COSTS TO PROVIDER NO.: __________ PERIOD: "WORKSHEET K-5," HOSPICE COST CENTERS STATISTICAL BASIS FROM__________________ PART II HOSPICE COST CENTERS STATISTICAL BASIS FROM__________________ PART II (Cont.) HOSPICE COST CENTERS STATISTICAL BASIS FROM__________________ PART II (Cont.) HOSPICE NO.: _____________ TO ___________________ HOSPICE NO.: _____________ TO ___________________ HOSPICE NO.: _____________ 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 HOSPICE 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 Inpatient - General Care 2 2 Inpatient - General Care 2 2 Inpatient - General Care 2 3 Inpatient - Respite Care 3 3 Inpatient - Respite Care 3 3 Inpatient - Respite Care 3 4 Physician Services 4 4 Physician Services 4 4 Physician Services 4 5 Nursing Care 5 5 Nursing Care 5 5 Nursing Care 5 6 Physical Therapy 6 6 Physical Therapy 6 6 Physical Therapy 6 7 Occupational Therapy 7 7 Occupational Therapy 7 7 Occupational Therapy 7 8 Speech/ Language Pathology 8 8 Speech/ Language Pathology 8 8 Speech/ Language Pathology 8 9 Medical Social Services - Direct 9 9 Medical Social Services - Direct 9 9 Medical Social Services - Direct 9 10 Spiritual Counseling 10 10 Spiritual Counseling 10 10 Spiritual Counseling 10 11 Dietary Counseling 11 11 Dietary Counseling 11 11 Dietary Counseling 11 12 Counseling - Other 12 12 Counseling - Other 12 12 Counseling - Other 12 13 Home Health Aide and Homemakers 13 13 Home Health Aide and Homemakers 13 13 Home Health Aide and Homemakers 13 14 Other 14 14 Other 14 14 Other 14 15 "Drugs, Biologicals and Infusion" 15 15 "Drugs, Biologicals and Infusion" 15 15 "Drugs, Biologicals and Infusion" 15 16 Durable Medical Equipment/Oxygen 16 16 Durable Medical Equipment/Oxygen 16 16 Durable Medical Equipment/Oxygen 16 17 Patient Transportation 17 17 Patient Transportation 17 17 Patient Transportation 17 18 Imaging Services 18 18 Imaging Services 18 18 Imaging Services 18 19 Labs and Diagnostics 19 19 Labs and Diagnostics 19 19 Labs and Diagnostics 19 20 Medical Supplies 20 20 Medical Supplies 20 20 Medical Supplies 20 21 Outpatient Services (including E/R Dept.) 21 21 Outpatient Services (including E/R Dept.) 21 21 Outpatient Services (including E/R Dept.) 21 22 Radiation Therapy 22 22 Radiation Therapy 22 22 Radiation Therapy 22 23 Chemotherapy 23 23 Chemotherapy 23 23 Chemotherapy 23 24 Other 24 24 Other 24 24 Other 24 25 Bereavement Program Costs 25 25 Bereavement Program Costs 25 25 Bereavement Program Costs 25 26 Volunteer Program Costs 26 26 Volunteer Program Costs 26 26 Volunteer Program Costs 26 27 Fundraising 27 27 Fundraising 27 27 Fundraising 27 28 Other Program Costs 28 28 Other Program Costs 28 28 Other Program Costs 28 29 Total (sum of lines 1 thru 28) 29 29 Total (sum of lines 1 thru 28) 29 29 Total (sum of lines 1 thru 28) 29 30 Total cost to be allocated X X X X X X X X 30 30 Total cost to be allocated X X X X X X X X X 30 30 Total cost to be allocated X X X X X X X 30 31 Unit Cost Multiplier (see instructions) X X X X X X X X 31 31 Unit Cost Multiplier (see instructions) X X X X X X X X X 31 31 Unit Cost Multiplier (see instructions) X X X X X X X 31 "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 36-634.10 Rev. 8 36-634.11 Rev. 8 36-634.12