09-01 FORM CMS-2552-96 3690 (Cont.) COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA PROVIDER NO.: PERIOD: WORKSHEET M-4 VACCINE COST ______________ FROM _________ COMPONENT NO.: TO: __________ _____________ Check [ ] RHC [ ] Title V [ ] Title XIX Applicable Box: [ ] FQHC [ ] Title XVIII PNEUMOCOCCAL INFLUENZA 1 2 1 "Health care staff cost (from Worksheet M-1, column 7, line 10)" X X 1 2 Ratio of pneumococcal and influenza vaccine staff time to total X X 2 health care staff time 3 Pneumoccocal and influenza vaccine health care staff cost (line 1 x line 2) X X 3 4 Medical supplies cost - pneumococcal and influenza vaccine X X 4 (from your records) 5 Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4) X X 5 6 "Total direct cost of the facility (from Worksheet M-1, column 7, line 22)" X X 6 7 "Total overhead (from Worksheet M-2, line 16)" X X 7 8 Ratio of pneumococcal and influenza vaccine direct cost to total direct X X 8 cost (line 5 divided by line 6) 9 Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8) 9 10 Total pneumococcal and influenza vaccine cost and its (their) X X 10 administration (sum of lines 5 and 9) 11 Total number of pneumococcal and influenza vaccine injections X X 11 (from your records) 12 Cost per pneumococcal and influenza vaccine injection (line 10/line 11) X X 12 13 Number of pneumococcal and influenza vaccine injections administered X X 13 to Program beneficiaries 14 Program cost of pneumococcal and influenza vaccine and its (their) X X 14 administration (line 12 x line 13) 15 "Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns 1 and 2, line 10) (transfer this amount to Worksheet M-3, line 2)" X X 15 16 "Total Program cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns 1 and 2, line 14) (transfer this amount to Worksheet M-3, line 20)" X X 16 "FORM CMS 2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3665)" Rev. 8 36-651