03-04,,,,,,FORM CMS 1728-94,,,,,,,,,3290 (Cont.)
ALLOCATION OF GENERAL SERVICE,,,,,,,,  PROVIDER NO.:,,,  PERIOD:,,   WORKSHEET CM-1,,
COSTS TO CMHC COST CENTERS,,,,,,,,  ___________________,,,  FROM:  _____________,,   PART III,,
,,,,,,,,  CMHC NO.:,,,  TO:  ______________,,,,
,,,,,,,,  ___________________,,,,,,,
PART III - ALLOCATION OF GENERAL SERVICE COSTS TO CMHC COST CENTERS - STATISTICAL BASIS,,,,,,,,,,,,,,,
,,,CAPITAL,,,,,,,,,,,,
,,,RELATED COSTS,,,,PLANT,,,,,,,,
,,,,,,,OPERATION,,,,,,,,
,,,BLDGS &,,MOVABLE,,& MAINTE-,,,,,,ADMINISTRATIVE,,
,,,FIXTURES,,EQUIPMENT,,NANCE,,TRANSPOR-,,,,& GENERAL,,
,CMHC COST CENTER,,(SQUARE,,(SQUARE,,(SQUARE,, TATION,,RECONCIL-,,(ACCUMULATED,,
,(OMIT CENTS),,FEET),,FEET),,FEET),,(MILEAGE),,IATION,,COST),,
,,,1 ,,2 ,,3 ,,4 ,,5A,,5 ,,
 1, Administrative and General,,,,,,,,,,,,,, 1
 2, Drugs and Biologicals,,,,,,,,,,,,,, 2
 3, Occupational Therapy,,,,,,,,,,,,,, 3
 4, Psychiatric/Psychological Services,,,,,,,,,,,,,, 4
 5, Individual Therapy,,,,,,,,,,,,,, 5
 6, Group Therapy,,,,,,,,,,,,,, 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 1-11),,,,,,,,,,,,,,12
13, Total Cost to be Allocated,,,,,,,,,,,,,,13
14, Unit Cost Multiplier,,,,,,,,,,,,,,14
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
"FORM CMS 1728-94-CM-1  (11-1998)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SEC. 3225.3)",,,,,,,,,,,,,,,
,,,,,,,,,,,,,,,
Rev. 12,,,,,,,,,,,,,,,32-333