3290 (Cont.),,,,,FORM CMS 1728-94,,,,,,05-07
COST ALLOCATION - HOSPICE GENERAL SERVICE COST,,,,,,PROVIDER NO:,,PERIOD:,,WORKSHEET K-4,
,,,,,,_,,FROM: ____________,,PART I,
,,,,,,HOSPICE NO.:,,TO: _______________,,,
,,,,,,_,,,,,
,,NET,,,,,,,,,
,,EXPENSES,,,,,,,,,
,,FOR COST,CAPITAL RELATED,,,,VOLUNTEER,,,,
,COST CENTER DESCRIPTIONS,ALLOC.,COST,,PLANT,,SERVICES,,ADMINIS-,,
,,"(FR. WKST K,",BUILDINGS,MOVABLE,OPERATION,TRANS-,COORDI-,SUBTOTAL,TRATIVE &,,
,,COL. 10),& FIXTURES,EQUIPMENT,& MAINT.,PORTATION,NATOR,(col. 0 - 5),GENERAL,TOTAL,
,,0,1,2,3,4 ,5 ,5A,6 ,7 ,
,GENERAL SERVICE COST CENTERS,, , ,,,,,,,
1 ,Capital Related Costs-Bldg and Fixt.,, , ,,,,,,,1 
2 ,Capital Related Costs-Movable Equip.,, , ,,,,,,,2 
3 ,Plant Operation and Maintenance,,,,,,,,,,3 
4 ,Transportation - Staff,,,,,,,,,,4 
5 ,Volunteer Service Coordination,,,,,,,,,,5 
6 ,Administrative and General,,,,,,,,,,6 
,INPATIENT CARE SERVICE,,,,,,,,,,
7 ,Inpatient - General Care,,,,,,,,,,7 
8 ,Inpatient - Respite Care,,,,,,,,,,8 
,VISITING SERVICES,,,,,,,,,,
9 ,Physician Services,,,,,,,,,,9 
10 ,Nursing Care,,,,,,,,,,10 
10.20,Nursing Care - Continuous Home Care,,,,,,,,,,10.20
11 ,Physical Therapy,,,,,,,,,,11 
12 ,Occupational Therapy,,,,,,,,,,12 
13 ,Speech/ Language Pathology,,,,,,,,,,13 
14 ,Medical Social Services - Direct,,,,,,,,,,14 
15 ,Spiritual Counseling,, , ,,,,,,,15 
16 ,Dietary Counseling,,,,,,,,,,16 
17 ,Counseling - Other,,,,,,,,,,17 
18 ,Home Health Aide and Homemakers,,,,,,,,,,18 
18.20,Home Health Aide and Homemaker-Cont Home Care,,,,,,,,,,18.20
19 ,Other,,,,,,,,,,19 
,OTHER HOSPICE SERVICE COSTS,,,,,,,,,,
20 ,"Drugs, Biologicals and Infusion",,,,,,,,,,20 
20.30,Analgesics,,,,,,,,,,20.30
20.31,Sedatives/Hypnotics,,,,,,,,,,20.31
20.32,Other - specify,,,,,,,,,,20.32
21 ,Durable Medical Equipment/Oxygen,,,,,,,,,,21 
22 ,Patient Transportation,,,,,,,,,,22 
23 ,Imaging Services,,,,,,,,,,23 
24 ,Labs and Diagnostics,,,,,,,,,,24 
25 ,Medical Supplies,,,,,,,,,,25 
26 ,Outpatient Services (incl. E/R Dept.),,,,,,,,,,26 
27 ,Radiation Therapy,,,,,,,,,,27 
28 ,Chemotherapy,,,,,,,,,,28 
29 ,Other,,,,,,,,,,29 
,HOSPICE NONREIMBURSABLE SERV.,,,,,,,,,,
30 ,Bereavement Program Costs,,,,,,,,,,30 
31 ,Volunteer Program Costs,,,,,,,,,,31 
32 ,Fundraising,,,,,,,,,,32 
33 ,Other Program Costs,,,,,,,,,,33 
34 ,Total (sum of line 1 thru 33),,,,,,,,,,34 
"FORM CMS-1728-94-K-4 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3244)",,,,,,,,,,,
,,,,,,,,,,,
32-331.5,,,,,,,,,,,Rev. 13