3290 (Cont.),,,,,,,,FORM CMS 1728-94,,,,,,,08-99 ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,, WORKSHEET FQ-1, ALLOCATION OF GENERAL SERVICE,,,,,,,, ___________________,,, FROM: _______________,,, PARTS I & II, COSTS TO FQHC COST CENTERS,,,,,,,, FQHC NO.:,,, TO: _________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - ALLOCATION OF GENERAL SERVICE COSTS TO FQHC COST CENTERS,,,,,,,,,,,,,,, ,,,,,NET,CAPITAL,,PLANT,,,,,ALLOCATED,, ,,,,,EXPENSES,RELATED COSTS,,OPERATION,,,A&G,,FQHC,TOTAL, ,FQHC 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, Physicians,,,,,,,,,,,,,,2 3, Nurse Practitioner,,,,,,,,,,,,,,3 4, Physician Assistant,,,,,,,,,,,,,,4 5, Clinical Psychologist,,,,,,,,,,,,,,5 6, Clinical Social Worker,,,,,,,,,,,,,,6 7, Visiting Nurses,,,,,,,,,,,,,,7 8, Preventative Primary Services,,,,,,,,,,,,,,8 9, Other Part B Services,,,,,,,,,,,,,,9 10,,,,,,,,,,,,,,,10 11, Drugs Charged to Patients,,,,,,,,,,,,,,11 12, TOTALS (Sum of lines 1-11) (2),,,,,,,,,,,,,,12 ,"(1) Column 0, line 12 must agree with Wkst. A, column 10, line 28. ",,,,,,,,,#REF!,,,,, ,"(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 28.",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,0 ,0 ,0 ,0 ,0 ,,,,, PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF FQHC 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 FQHC 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-FQ-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3231-3231.2)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, 32-340,,,,,,,,,,,,,,,Rev. 7 3290 (Cont.),,,,,,,,FORM CMS 1728-94,,,,,,,08-99 ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,, WORKSHEET FQ-2, COMPUTATION OF FQHC COSTS,,,,,,,, ___________________,,, FROM: _______________,,,, ,,,,,,,, FQHC NO.:,,, TO: __________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - APPORTIONMENT OF RHC COST CENTERS,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,TOTAL COSTS,,RATIO OF,,TITLE XVIII, ,FQHC COST CENTER,,,,,,,,,(FROM SUPP.,TOTAL,COSTS TO,TITLE XVIII,FQHC COSTS, ,(OMIT CENTS),,,,,,,,,"WKST. FQ-1, PT.",FQHC,CHARGES,FQHC,(COL. 3 X, ,,,,,,,,,,"I, COL. 8) (1)",CHARGES (2),(COL. 1 / COL. 2),CHARGES,COL. 4), ,,,,,,,,,,1,2,3,4,5, 1, Administrative and General,,,,,,,,,,,,,,1 2, Physicians,,,,,,,,,,,,,,2 3, Nurse Practitioner,,,,,,,,,,,,,,3 4, Physician Assistant,,,,,,,,,,,,,,4 5, Clinical Psychologist,,,,,,,,,,,,,,5 6, Clinical Social Worker,,,,,,,,,,,,,,6 7, Visiting Nurses,,,,,,,,,,,,,,7 8, Preventative Primary Services,,,,,,,,,,,,,,8 9, Other Part B Services,,,,,,,,,,,,,,9 10, Subtotal (sum of lines 1-9),,,,,,,,,,,,,,10 11," Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)",,,,,,,,,,,,,,11 12, TOTALS (Sum of lines 10and 11),,,,,,,,,,,,,,12 ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, PART II - APPORTIONMENT OF COST OF FQHC SERVICES FURNISHED BY HHA DEPARTMENTS,,,,,,,,,Fr. Wkst. B,,,,,, ,,,,,,,,,"Col 6, Line:",,,,,, 13, Physical Therapy,,,,,,,,7,,,,,,13 14, Occupational Therapy,,,,,,,,8,,,,,,14 15, Speech Pathology,,,,,,,,9,,,,,,15 16, Supplies,,,,,,,,12,,,,,,16 ,,,,,,,,,,,,,,, 18, Total (Sum of lines 13-16),,,,,,,,,,,,,,18 ,"(1) Cost for Part II, lines 13-16 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 FQHC COSTS,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-FQ-2 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3232-3232.3)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, 32-342,,,,,,,,,,,,,,,Rev. 7