09-01						FORM CMS-2552-96				           3690 (Cont.)				
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)).  Failure to report can result in all interim									FORM APPROVED					
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).									OMB NO. 0938-0050					
HOSPITAL AND HOSPITAL HEALTH CARE					PROVIDER NO.:		PERIOD:		"WORKSHEET S,"					
COMPLEX COST REPORT CERTIFICATION							FROM _____________		PARTS  I & II					
AND SETTLEMENT SUMMARY					_____________		TO ________________							
Intermediary 		  [  ]  Audited			Date Received: ____X_____			[  ] Initial     [  ] Reopening						
use only		  [  ]  Desk Reviewed			Intermediary No._________			[  ] Final						
PART I - CERTIFICATION														
Check 			  [  ]  Electronically filed cost report				      Date:____________		Time:________					
applicable box			  [  ]  Manually submitted cost report											
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE														
"BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW.  FURTHERMORE,"														
IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY														
"OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR"														
IMPRISONMENT MAY RESULT.														
										
		     CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)								
										
	I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or									
	manually submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by									
	______________________________________________________ (Provider Names(s) and Number(s)) for the cost reporting period									
	"beginning __________________ and ending ___________________  and that to the best of my knowledge and belief, it is a true,"									
	"correct and complete statement prepared from the books and records of the provider in accordance with applicable instructions,"									
	except as noted.  I further certify that I am familiar with the laws and regulations regarding the provision of health care services									
	and that the services identified in this cost report were provided in compliance with such laws and regulations.									
										
					(Signed)________________________________________________					
						         Officer or Administrator of Provider(s)				
						  ______________________________________________				
						     Title				
						  ______________________________________________				
						     Date				
										
PART II - SETTLEMENT SUMMARY										
							                TITLE XVIII			
						TITLE V	PART A	PART B	TITLE XIX	
						1	2	3	4	
							X	X	X	
1 	HOSPITAL									1 
							X	X	X	
2 	SUBPROVIDER									2 
							X	X	X	
3 	SWING BED - SNF									3 
									X	
4 	SWING BED - NF									4 
							X	X	X	
5 	SKILLED NURSING FACILITY									5 
									X	
6 	NURSING FACILITY									6 
							X	X	X	
7 	HOME HEALTH AGENCY									7 
8 	OUTPATIENT REHABILITATION							X	X	8 
	PROVIDER (specify)									
								X	X	
9 	HEALTH CLINIC (specify)									9 
						X	X	X	X	
100 	TOTAL									100 
"The above amounts represent ""due to"" or ""due from"" the applicable program for the element of the above complex indicated."										
"According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control"										
"number for this information collection is 0938-0050.  The time required to complete this information collection is estimated 657 hours per response, including the time to review instructions,"										
"search existing resources, gather the data needed, and complete and review the information collection.  If you have any comments concerning the accuracy of the time estimate(s) or suggestions"										
"for improving this form, please write to:  Health Care Financing Administration, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850, and to the Office of the Information and"										
"Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503."										
"FORM CMS-2552-96 (5/1999)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 3603-3603.2)"										
										
										
										
										
										
										
Rev. 8										                     36-503