08-99,,,,FORM CMS 1728-94,,,,3290 (Cont.)
STATEMENT OF,,,,   PROVIDER NO.:,, PERIOD,,
REVENUE AND EXPENSES,,,,,,From:  ___________, WORKSHEET F-1,
,,,, ___________,,To: ___________,,
 1, Total patient revenues,,,,,,, 1
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 2, Less:  Allowances and discounts on patients' accounts,,,,,,, 2
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 3, Net patient revenues (Line 1 minus line 2),,,,,,, 3
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 4," Operating expenses (From Worksheet A, column 6, line 29)",,,,,,, 4
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 5, Additions to operating expenses (Specify),,,,,,, 5
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 6,,,,,,,, 6
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 7,,,,,,,, 7
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 8,,,,,,,, 8
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 9,,,,,,,, 9
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10,,,,,,,,10
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11, Subtractions from operating expenses (Specify),,,,,,,11
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12,,,,,,,,12
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13,,,,,,,,13
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14,,,,,,,,14
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15,,,,,,,,15
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16,,,,,,,,16
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17, Less total operating expenses (net of lines 4 thru 16),,,,,,,17
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18, Net income from service to patients (Line 3 minus line 17),,,,,,,18
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, Other income:,,,,,,,
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19 ," Contributions, donations, bequests, etc.",,,,,,,19 
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20 , Income from investments,,,,,,,20 
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21 , Purchase discounts,,,,,,,21 
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22 , Rebates and refunds of expenses,,,,,,,22 
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23 , Sale of Medical and Nursing Supplies to other than patients,,,,,,,23 
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24 , Sale of durable medical equipment to other than patients,,,,,,,24 
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25 , Sale of drugs to other than patients,,,,,,,25 
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26 , Sale of medical records and abstracts,,,,,,,26 
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27 ,Other revenues (Specify),,,,,,,27 
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28 ,,,,,,,,28 
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29 ,,,,,,,,29 
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30 ,,,,,,,,30 
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31 ,,,,,,,,31 
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32 , Total Other Income (Sum of lines 19 thru 31),,,,,,,32 
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33 , Net Income or Loss for the period (Line 18 plus line 32),,,,,,,33 
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FORM CMS-1728-94  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SEC. 3218),,,,,,,,
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Rev. 7,,,,,,,,32-325