3290 (Cont.),,,,,,,FORM CMS 1728-94 ,,,,,,,,08-99 ALLOCATION OF GENERAL SERVICE,,,,,,,, PROVIDER NO.:,,, PERIOD:,, WORKSHEET J-1,, COSTS TO CORF COST CENTERS,,,,,,,, ___________________,,, FROM: _____________,, PART III,, ,,,,,,,, CORF NO.:,,, TO: ________________,,,, ,,,,,,,, ___________________,,,,,,, PART III - ALLOCATION OF GENERAL SERVICE COSTS TO CORF COST CENTERS - STATISTICAL BASIS,,,,,,,,,,,,,,, ,,,CAPITAL,,,,,,,,,,,, ,,,RELATED COSTS,,,,PLANT,,,,,,,, ,,,,,,,OPERATION,,,,,,,, ,,,BLDGS &,,MOVABLE,,& MAINTE-,,,,,,ADMINISTRATIVE,, ,,,FIXTURES,,EQUIPMENT,,NANCE,,TRANSPOR-,,,,& GENERAL,, ,CORF 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, Skilled Nursing Care,,,,,,,,,,,,,, 2 3, Physical Therapy,,,,,,,,,,,,,, 3 4, Occupational Therapy,,,,,,,,,,,,,, 4 5, Speech Pathology,,,,,,,,,,,,,, 5 6, Medical Social Services,,,,,,,,,,,,,, 6 7, Respiratory Therapy,,,,,,,,,,,,,, 7 8, Psychological Services,,,,,,,,,,,,,, 8 9, Prosthetic and Orthotic Devices,,,,,,,,,,,,,, 9 10, Drugs and Biologicals,,,,,,,,,,,,,,10 11, Medical Supplies,,,,,,,,,,,,,,11 12, Durable Medical Equipment-Rented,,,,,,,,,,,,,,12 13, Durable Medical Equipment-Sold,,,,,,,,,,,,,,13 14, Other Part B Services,,,,,,,,,,,,,,14 15, TOTALS (Sum of lines 1-14),,,,,,,,,,,,,,15 16, Total Cost to be Allocated,,,,,,,,,,,,,,16 17, Unit Cost Multiplier,,,,,,,,,,,,,,17 ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-J-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SEC. 3221.3)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, 32-328,,,,,,,,,,,,,,,Rev. 7