3290 (Cont.),,,,,,,,FORM CMS 1728-94,,,,,,,05-07
,,,,,,,,,,   PROVIDER NO.:,,     PERIOD:,,,
,,   RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES,,,,,,,,    _______________,,From:  ___________,,  WORKSHEET A,
,,,,,,,,,, ,,To: ___________,,,
,,,,,,,,CONTRACTED,,,,RECLASSI-,,EXPENSES,
,,,,,,EMPLOYEE,  TRANSPOR-,PURCHASED,,,RECLASSI-,FIED TRIAL,,FOR COST,
,,,,,SALARIES,BENEFITS, TATION (See,SERVICES,OTHER,,FICATION,BALANCE,ADJUST-,ALLOCATION,
,,,,,(Fr Wks A-1),(Fr Wks A-2),Instructions),(Fr Wks A-3),COSTS,TOTAL,(Fr Wks A-4),(Cols 6 + 7),MENTS,(Col 8 + 9),
,,,,,1,2,3,4,5,6,7,8,9,10,
,,   GENERAL SERVICE COST CENTER,,,,,,,,,,,,,
 1,0100, Capital Related - Bldg. & Fix.,,,,,,,,,,,,, 1
 2,0200, Capital Related - Movable Equip,,,,,,,,,,,,, 2
 3,0300, Plant Operation & Maintenance,,,,,,,,,,,,, 3
 4,0400, Transportation (See Instructions),,,,,,,,,,,,, 4
 5,0500, Administrative and General,,,,,,,,,,,,, 5
,,   HHA REIMBURSABLE SERVICES,,,,,,,,,,,,,
 6,0600, Skilled Nursing Care,,,,,,,,,,,,, 6
 7,0700, Physical Therapy,,,,,,,,,,,,, 7
 8,0800, Occupational Therapy,,,,,,,,,,,,, 8
 9,0900, Speech Pathology,,,,,,,,,,,,, 9
10,1000, Medical Social Services,,,,,,,,,,,,,10
11,1100, Home Health Aide,,,,,,,,,,,,,11
12,1200, Supplies (See Instructions),,,,,,,,,,,,,12
13,1300,Drugs,,,,,,,,,,,,,13
13.20,1320 ,Cost of Administering Vaccines,,,,,,,,,,,,,13.20
14,1400, DME,,,,,,,,,,,,,14
,,   HHA NONREIMBURSABLE SERVICES,,,,,,,,,,,,,
15,1500, Home Dialysis Aide Services,,,,,,,,,,,,,15
16,1600, Respiratory Therapy,,,,,,,,,,,,,16
17,1700, Private Duty Nursing,,,,,,,,,,,,,17
18,1800, Clinic,,,,,,,,,,,,,18
19,1900, Health Promotion Activities,,,,,,,,,,,,,19
20,2000, Day Care Program,,,,,,,,,,,,,20
21,2100, Home Delivered Meals Program,,,,,,,,,,,,,21
22,2200,Homemaker,,,,,,,,,,,,,22
23,,Other,,,,,,,,,,,,,23
,,   SPECIAL PURPOSE COST CENTERS,,,,,,,,,,,,,
24,2400,CORF,,,,,,,,,,,,,24
25,2500,Hospice,,,,,,,,,,,,,25
26,2600,CMHC,,,,,,,,,,,,,26
27,2700,RHC,,,,,,,,,,,,,27
28,2800,FQHC,,,,,,,,,,,,,28
29,, Total,,,,,,,,,,,,,29
"FORM CMS-1728-94 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3206)",,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
32-308,,,,,,,,,,,,,,,Rev. 13