3290 (Cont.),,,,,,,FORM CMS 1728-94,,,,,,05-07
,,,,,,,,    PROVIDER NO.:,,  PERIOD:,,,
,COST ALLOCATION - GENERAL SERVICE COST,,,,,,,,,From:  ___________,,WORKSHEET B,
,,,,,,,,    _____________,,To: ___________,,,
,,,,,NET EXPENSES,CAPITAL,,,,,,,
,,,,,FOR COST,RELATED COSTS,,PLANT,,,,,
,,,,,ALLOCATION,,,OPERATION,,,ADMINISTRA-,,
,,,,,(FR.WKST,BLDGS &,MOVABLE,&,TRANS-,SUBTOTAL,TIVE ,,
,,,,,"A, COL10)",& FIXTURES,EQUIPMENT,MAINTENANCE,PORTATION,(cols. 0-4),& GENERAL,TOTAL,
,,,,,0,1,2,3,4 ,4A,5 ,6 ,
,GENERAL SERVICE COST CENTERS,,,,,,,,,,,,
 1, Capital Related - Bldg. and Fixtures,,,,,0 ,,,,,,, 1
 2, Capital Related - Movable Equipment,,,,,0 ,0 ,,,,,, 2
 3, Plant Operation & Maintenance,,,,,0 ,0 ,0 ,,,,, 3
 4, Transportation (See Instructions),,,,,0 ,0 ,0 ,,,,, 4
 5, Administrative and General ,,,,,,,,,,,, 5
,   HHA REIMBURSABLE SERVICES,,,,,,,,,,,,
 6, Skilled Nursing Care,,,,,0 ,0 ,0 ,,,0 ,, 6
 7, Physical Therapy,,,,,0 ,0 ,0 ,,,0 ,, 7
 8, Occupational Therapy,,,,,0 ,0 ,0 ,,,0 ,, 8
 9, Speech Pathology,,,,,0 ,0 ,0 ,,,0 ,, 9
10, Medical Social Services,,,,,0 ,0 ,0 ,,,0 ,,10
11, Home Health Aide,,,,,0 ,0 ,0 ,,,0 ,,11
12, Supplies (See Instructions),,,,,0 ,0 ,0 ,,,0 ,,12
13, Drugs,,,,,0 ,0 ,0 ,,,0 ,,13
13.20,Cost of Administering Vaccines,,,,,,,,,,,,13.20
14, DME,,,,,0 ,0 ,0 ,,,0 ,,14
,   HHA NONREIMBURSABLE SERVICES,,,,,,,,,,,,
15, Home Dialysis Aide Services,,,,,,,,,,,,15
16, Respiratory Therapy,,,,,,,,,,,,16
17, Private Duty Nursing,,,,,,,,,,,,17
18, Clinic,,,,,,,,,,,,18
19, Health Promotion Activities,,,,,,,,,,,,19
20, Day Care Program,,,,,,,,,,,,20
21, Home Delivered Meals Program,,,,,,,,,,,,21
22,Homemaker Services,,,,,,,,,,,,22
23,Other,,,,,,,,,,,,23
,   SPECIAL PURPOSE COST CENTER,,,,,,,,,,,,
24,CORF,,,,,,,,,,,,24
25,Hospice,,,,,,,,,,,,25
26,CMHC,,,,,,,,,,,,26
27,RHC,,,,,,,,,,,,27
28,FQHC,,,,,,,,,,,,28
29, Total,,,,,0 ,0 ,0 ,,,0 ,,29
,,,,,,,,,,,,,
,,,,,,,,,,,,,
,,,,,,,,,,,,,
,,,,,,,,,,,,,
"FORM CMS-1728-94-B  (5-2007)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3214)",,,,,,,,,,,,,
,,,,,,,,,,,,,
32-318,,,,,,,,,,,,,Rev. 13
05-07,,,,,,,FORM CMS 1728-94,,,,,,3290 (Cont.)
,,,,,,,,    PROVIDER NO.:,,  PERIOD:,,,
,,COST ALLOCATION - STATISTICAL BASIS,,,,,,,,From:  ___________,,WORKSHEET B-1,
 ,,,,,,,,    _____________,,To: ___________,,,
,,,,,,CAPITAL,,,,,,,
,,,,,,RELATED COSTS,,PLANT,,,ADMINISTRA-,,
,,,,,,BLDGS &,MOVABLE,OPERATION,,,TIVE ,,
,,,,,,& FIXTURES,EQUIPMENT,MAINTENANCE,TRANS-,,& GENERAL ,,
,,COST CENTER,,,,(SQUARE,(DOLLAR,(SQUARE,PORTATION,RECONCIL-,(ACCUMU-,,
,,,,,,FEET),VALUE),FEET),(MILEAGE),IATION,LATED COST),TOTAL,
,,,,,,1 ,2 ,3,4,5A,5 ,6 , 
,   GENERAL SERVICE COST CENTER,,,,,,,,,,,,
 1, Capital Related - Bldg. and Fixtures,,,,,,,,,,,, 1
 2, Capital Related - Movable Equipment,,,,,,,,,,,, 2
 3, Plant Operation & Maintenance,,,,,,,,,,,, 3
 4, Transportation (See Instructions),,,,,,,,,,,, 4
 5, Administrative and General ,,,,,,,,,,,, 5
,   HHA REIMBURSABLE SERVICES,,,,,,,,,,,,
 6, Skilled Nursing Care,,,,,,,,,,,, 6
 7, Physical Therapy,,,,,,,,,,,, 7
 8, Occupational Therapy,,,,,,,,,,,, 8
 9, Speech Pathology,,,,,,,,,,,, 9
10, Medical Social Services,,,,,,,,,,,,10
11, Home Health Aide,,,,,,,,,,,,11
12, Supplies (See Instructions),,,,,,,,,,,,12
13, Drugs,,,,,,,,,,,,13
13.20,Cost of Administering Vaccines,,,,,,,,,,,,13.20
14,DME,,,,,,,,,,,,14
,   HHA NONREIMBURSABLE SERVICES,,,,,,,,,,,,
15, Home Dialysis Aide Services,,,,,,,,,,,,15
16, Respiratory Therapy,,,,,,,,,,,,16
17, Private Duty Nursing,,,,,,,,,,,,17
18, Clinic,,,,,,,,,,,,18
19, Health Promotion Activities,,,,,,,,,,,,19
20, Day Care Program,,,,,,,,,,,,20
21, Home Delivered Meals Program,,,,,,,,,,,,21
22,Homemaker Services,,,,,,,,,,,,22
23,Other,,,,,,,,,,,,23
,   SPECIAL PURPOSE COST CENTER,,,,,,,,,,,,
24,CORF,,,,,,,,,,,,24
25,Hospice,,,,,,,,,,,,25
26,CMHC,,,,,,,,,,,,26
27,RHC,,,,,,,,,,,,27
28,FQHC,,,,,,,,,,,,28
29, Total,,,,,,,,,,,,29
30, Cost To Be Allocated (Per Wkst B),,,,,,,,,,,,30
31, Unit Cost Multiplier,,, ,,,,,,,,,31
"FORM CMS-1728-94-B-1 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3214)",,,,,,,,,,,,,
,,,,,,,,,,,,,
Rev. 13,,,,,,,,,,,,,32-319