3290 (Cont.),,,,,,FORM CMS 1728-94,,,,08-99 This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result,,,,,,,,,, in all interim payments made since the beginning of the cost reporting period being deemed,,,,,,,,,, as overpayments (42 USC 1395g).,,,,,,,,,, , STATEMENT OF COSTS OF ,,,,, PROVIDER NO.:,, PERIOD:,, WORKSHEET A-6 , SERVICES FROM,,,,,,,From: ___________,, , RELATED ORGANIZATIONS,,,,, ____________,,To: ___________,, A. Are there any costs included on Worksheet A which resulted from transactions,,,,,,,,,, " with related organizations as defined in CMS Pub. 15-I, chapter 10?",,,,,,,,,, ,,,,,,,,,, ,," [ ] Yes [ ] No (If ""Yes,"" complete Parts B and C)",,,,,,,, B. Costs incurred and adjustment required as result of transactions with related organizations,,,,,,,,,, ,,," LOCATION AND AMOUNT INCLUDED ON WKST A, COL. 8",,,,,,AMOUNT,NET ,,,,,,,,,ALLOWABLE,ADJUSTMENT ,LINE NO.,,COST CENTER,,EXPENSE ITEMS,,,AMOUNT,IN COST,(col 4 -5) ,1 ,,2 ,,3 ,,,4,5,6 1,,,,,,,,,, 2,,,,,,,,,,0 3,,,,,,,,,,0 4," TOTALS (Sum of lines 1-3)(Transfer col. 6, lines 1-3 to Wkst A, Col. 9,",,,,,,,,, ," lines as appropriate)(Transfer col. 6, line 4 to Wkst A-5, col. 2, line 5)",,,,,,,,, C. Interrelationship of provider to related organization(s):,,,,,,,,,, ,,,,,,,,,, "The Secretary, by virtue of authority granted under section 1814(b)(1) of the Social Security Act,",,,,,,,,,, requires the provider to furnish the information requested on Part C of this worksheet.,,,,,,,,,, ,,,,,,,,,, "The information will be used by the CMS and its intermediaries in determining that the costs applicable to services,",,,,,,,,,, "facilities and supplies furnished by organizations related to the provider by common ownership or control,",,,,,,,,,, represent reasonable costs as determined under section 1861 of the Social Security Act.,,,,,,,,,, "If the provider does not provide all or any part of the requested information, the cost report will be considered",,,,,,,,,, incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,Percent,Percent, ,,,,,,,,Owned,Ownership, SYMBOL,,,,,,,,by,of,Type of , (1),Name,,,Address,,,Provider,Provider,Business ,1,2 ,,,3 ,,,4 ,5,6 1,,,,,,,,,, 2,,,,,,,,,, 3,,,,,,,,,, 4,,,,,,,,,, 5,,,,,,,,,, ,,,,,,,,,, ,(1) Use the following symbols to indicate the interrelationship of the provider to related organizations:,,,,,,,,, ,,,,,,,,,, ,,"A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.",,,,,,,, ,,"B. Corporation, partnership or other organization has financial interest in provider.",,,,,,,, ,,"C. Provider has financial interest in corporation, partnership or other organization.",,,,,,,, ,,"D. Director, officer, administrator or key person of provider or relative of such person has financial interest in",,,,,,,, ,, related organization.,,,,,,,, ,,"E. Individual is director, officer, administrator or key person of provider and related organization.",,,,,,,, ,,"F. Director, officer, administrator or key person of related organization or relative of such person has financial",,,,,,,, ,, interest in provider.,,,,,,,, ,,G. Other (financial or nonfinancial) specify.,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, "FORM CMS-1728-94-A-6 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3212)",,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, 32-314,,,,,,,,,,Rev. 7