3690 (Cont.)			FORM CMS-2552-96						08-06																																																																																																
HOSPITAL RENAL DIALYSIS DEPARTMENT				PROVIDER NO.:		PERIOD:		WORKSHEET S-5																																																																																																	{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1
STATISTICAL DATA				 ________________		FROM ___________																																																																																																			
						TO ______________																																																																																																			
	RENAL DIALYSIS STATISTICS																																																																																																								
			           Outpatient		              Training		              Home																																																																																																		
					Hemo-	CAPD	Hemo-	CAPD																																																																																																	
		DESCRIPTION	Regular	High Flux	dialysis	CCPD	dialysis	CCPD																																																																																																	
			1	2	3	4	5	6																																																																																																	
1 	 Number of patients in program at								1 																																																																																																
	 end of cost reporting period		X	X	X	X	X	X																																																																																																	
2 	 Number of times per week patient								2 																																																																																																
	  receives dialysis		X	X	X	X	X	X																																																																																																	
3 	 Average patient dialysis time including setup		X	X	X	X			3 																																																																																																
4 	 CAPD exchanges per day					X		X	4 																																																																																																
5 	 Number of days in year dialysis furnished		X	X					5 																																																																																																
6 	 Number of stations		X	X	X	X			6 																																																																																																
7 	 Treatment capacity per day per station		X	X					7 																																																																																																
8 	 Utilization (see instructions)		X	X					8 																																																																																																
9 	 Average times dialyzers re-used		X	X					9 																																																																																																
10 	 Percentage of patients re-using dialyzers		X	X					10 																																																																																																
																																																																																																									
	TRANSPLANT INFORMATION																																																																																																								
11 	 Number of patients on transplant list							X	11 																																																																																																
12 	 Number of patients transplanted during the cost reporting period							X	12 																																																																																																
																																																																																																									
	EPOIETIN																																																																																																								
13 	 Net costs of Epoietin furnished to all maintenance dialysis patients by the provider.							X	13 																																																																																																
13.01 	Epoietin amount from Worksheet A for Home Dialysis program							X	13.01 																																																																																																
14 	 Number of EPO units furnished relating to the renal dialysis department							X	14 																																																																																																
14.01 	 Number of EPO units furnished relating to the home dialysis department							X	14.01 																																																																																																
																																																																																																									
	"PHYSICIAN PAYMENT METHOD (enter ""X"" if method(s) is applicable)"																																																																																																								
15 	 MCP_________	X	INITIAL METHOD__________		X				15 																																																																																																
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
"FORM CMS-2552-96 (08/2006)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3607)"																																																																																																									
																																																																																																									
																																																																																																									
																																																																																																									
36-508									           Rev. 16