3290 (Cont.),,,,,,,,FORM CMS 1728-94,,,,,,,06-01 ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,,WORKSHEET CM-1, ALLOCATION OF GENERAL SERVICE,,,,,,,, ___________________,,, FROM: _______________,,,PARTS I & II, COSTS TO CMHC COST CENTERS,,,,,,,, CMHC NO.:,,, TO: _________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CMHC COST CENTERS,,,,,,,,,,,,,,, ,,,,,NET,CAPITAL,,PLANT,,,,,ALLOCATED,, ,,,,,EXPENSES,RELATED COSTS,,OPERATION,,,A&G,,CMHC,TOTAL, ,CMHC COST CENTER,,,,FOR COST,BLDGS &,MOVABLE,& MAINTE-,TRANSPOR-,SUBTOTAL,SHARED,SUB-,A&G (SEE,(SUM OF, ,(OMIT CENTS),,,,ALLOCATION (1),FIXTURES,EQUIPMENT,NANCE,TATION,(cols. 0-4),COSTS,TOTAL,PART II),COLS 6 & 7), ,,,,,0,1,2,3,4,4A,5,6,7,8, 1, Administrative and General,,,,,,,,,,,,,, 1 2, Drugs and Biologicals,,,,,#REF!,,,,,,,,, 2 3, Occupational Therapy,,,,,#REF!,,,,,,,,, 3 4, Psychiatric/Psychological Services,,,,,#REF!,,,,,,,,, 4 5, Individual Therapy,,,,,#REF!,,,,,,,,, 5 6, Group Therapy,,,,,#REF!,,,,,,,,, 6 7, Family Counseling,,,,,#REF!,,,,,,,,, 7 8, Individualized Activity Therapy,,,,,#REF!,,,,,,,,, 8 9, Diagnostic Therapy,,,,,#REF!,,,,,,,,, 9 10, Patient Training and Education,,,,,#REF!,,,,,,,,,10 11 , Other Part B Services,,,,,,,,,,,,,,11 12 , TOTALS (Sum of lines 1-11) (2),,,,,#REF!,,,,,,,,,12 ,"(1) Column 0, line 12 must agree with Wkst. A, column 10, line 26.",,,,,,,,,#REF!,,,,, ,"(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 26.",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,#REF!,0 ,0 ,0 ,0 ,,,,, PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF CMHC ADMINISTRATIVE AND GENERAL COSTS,,,,,,,,,,,,,,, 1," Amount from Part I, column 6, line 12",,,,,,,,,,,,,, 1 2," Amount from Part I, column 6, line 1",,,,,,,,,,,,,, 2 3, Line 1 minus line 2,,,,,,,,,,,,,, 3 4," Unit cost multiplier for CMHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,",,,,,,,,,,,,,, 4 ," lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-CM-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3225-3225.2)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, 32-332,,,,,,,,,,,,,,,Rev. 10 ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, 3290 (Cont.),,,,,,,,FORM CMS 1728-94,,,,,,,03-04 ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,,WORKSHEET CM-2, COMPUTATION OF CMHC COSTS,,,,,,,, ___________________,,, FROM: _______________,,,, ,,,,,,,, CMHC NO.:,,, TO: __________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - APPORTIONMENT OF CMHC COST CENTERS ,,,,,,,,,,,,,,, ,,,,,,,,,RATIO OF,,TOTAL,TITLE XVIII,TITLE XVIII,, ,,,,,,,TOTAL COSTS,,COSTS TO,TOTAL,TITLE XVIII,CMHC,CMHC COSTS,TITLE XVIII, ,,,,,,,(FROM SUPP.,TOTAL,CHARGES,TITLE XVIII,CMHC COSTS,CHARGES ON,ON OR AFTER,CMHC, ,CMHC COST CENTER,,,,,,"WKST. CM-1, PT.",CMHC,(COL. 1 /,CMHC,(COL. 3 x,OR AFTER,"8/1/00, 1/1/02,",COSTS PRIOR, ,(OMIT CENTS),,,,,,"I, COL. 8) (1)",CHARGES (2), COL. 2),CHARGES,COL. 3.01),"8/1/00, 1/1/02,","1/1/03, or 1/1/04","8/1/00, 1/1/02,", ,,,,,,,,,,,,"1/1/03, or 1/1/04",(COL 3 xCOL. 4),"1/1/03, or 1/1/04", ,,,,,,,1,2,3,3.01 ,3.02 ,4,5,6, 1, Administrative and General,,,,,,,,,,,,,, 1 2, Drugs and Biologicals,,,,,,"100,000 ","120,000 ",0.833333 ,75000 ,"62,500",0,0,"62,500", 2 3, Occupational Therapy,,,,,,,,,,,,,, 3 4, Psychiatric/Psychological Services,,,,,,"47,000 ","59,000 ",0.796610 ,,,,,, 4 5, Individual Therapy,,,,,,"52,000 ","65,000 ",0.800000 ,,,,,, 5 6, Group Therapy,,,,,,"26,000 ","37,000 ",0.702703 ,,,,,, 6 7, Family Counseling,,,,,,,,,,,,,, 7 8, Individualized Activity Therapy,,,,,,,,,,,,,, 8 9, Diagnostic Therapy,,,,,,,,,,,,,, 9 10, Patient Training and Education,,,,,,,,,,,,,,10 11, Other Part B Services,,,,,,,,,,,,,,11 12, TOTALS (Sum of lines 2-11),,,,,,,,,,,,,,12 ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, PART II - APPORTIONMENT OF COST OF CMHC,,,,,,,,,,,,,,, SERVICES FURNISHED SHARED BY HHA DEPARTMENTS,,,,,,"Fr. Wkst. B,",,,,,,,,, ,,,,,,"Col 6, Line:",,,,,,,,, 13 , Occupational Therapy,,,,,8 ,,,,,,,,,13 14 , Medical Social Services,,,,,10 ,,,,,,,,,14 15 , Supplies,,,,,12 ,,,,,,,,,15 16 , Total (Sum of lines 13-15),,,,,,,,,,,,,,16 ,"(1) Cost for Part II, lines 13-15 are obtained from Worksheet B, column 6, lines as appropriate",,,,,,,,,,,,,, ,"(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, PART III - TOTAL CMHC COSTS,,,,,,,,,,3.01 ,3.02 ,4 ,5 ,6 , 17 ,"Total CMHC costs - Add the amount from Part I, column 6, line 12 and the amount from Part II, column 6, line 16.",,,,,,,,,,,,,,17 ," Add the amounts from Part I, line 12 and Part II, line 16 for columns 3.01, 3.02 and 4 through 6, respectively.",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "Transfer the amount in Part III, column 6 to Worksheet CM-3, line 1, column 1. (see instructions)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-CM-2 (3-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3226-3226.3)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, 32-334,,,,,,,,,,,,,,,Rev. 12