05-07,,,,FORM CMS-1728-94,,,,,3290 (Cont.)
COST ALLOCATION - HOSPICE STATISTICAL BASIS,,,,PROVIDER NO:,,PERIOD:,,WORKSHEET K-4,
,,,,_,,FROM: ____________,,PART II,
,,,,HOSPICE NO.:,,TO: _______________,,,
,,,,_,,,,,
,,CAPITAL RELATED,,,,,,,
,,COST,,,,VOLUNTEER,,,
,,BUILDINGS,MOVABLE,PLANT,,SERVICES,,ADMINIS-,
,,& FIXTURES,EQUIPMENT,OPERATION,TRANS-,COORDI-,,TRATIVE  &,
,COST CENTER DESCRIPTIONS,(SQUARE,(DOLLAR,& MAINT.,PORTATION,NATOR,RECON-,GENERAL,
,,FEET),VALUE),(SQ. FT.),(MILEAGE),(HOURS),CILIATION,(ACC. COST),
,,1,2,3,4 ,5 ,6A,6 ,
,GENERAL SERVICE COST CENTERS, , ,,,,,,
1 ,Capital Related Costs-Buildings and Fixtures, , ,,,,,,1 
2 ,Capital Related Costs-Movable Equipment, , ,,,,,,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 
34 ,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 ,"Cost To be Allocated (per Wkst K-4, Part I)",,,,,,,,34 
35 ,Unit Cost Multiplier,,,,,,,,35 
,,,,,,,,,
"FORM CMS-1728-94-K-4 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3244)",,,,,,,,,
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Rev. 13,,,,,,,,,32-331.6