3290 (Cont.),,,,,,      FORM CMS 1728-94,,,,,,,,05-07
ALLOCATION OF GENERAL SERVICE,,,,,,,,,PROVIDER NO:,,PERIOD:,,WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS,,,,,,,,,_,,FROM: ____________,,PART I,
,,,,,,,,,HOSPICE NO.:,,TO: _______________,,,
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,,,From,HOSPICE,CAPITAL RELATED,,PLANT,,,,,ALLOCATED,TOTAL,
,HOSPICE COST CENTER,,Wkst. K-4,TRIAL,COST,,OPERATION,,,ADMINIS-,,HOSPICE,HOSPICE,
,(omit cents),,"Part I,",BALANCE,BUILDINGS,MOVABLE,& MAIN-,TRANS-,SUBTOTAL,TRATIVE  &,SUB-,A&G (see,COSTS,
,,,"col. 7,",(1),& FIXTURES,EQUIPMENT,TENANCE,PORTATION,(cols. 0-4),GENERAL,TOTAL,Part II),(col 6 + col. 7),
,,,line,0,1,2,3,4,4A,5 ,6 ,7 ,8 ,
1 ,Administrative and General,,6 ,,,,,,,,,,,1 
2 ,Inpatient - General Care,,7 ,,,,,,,,,,,2 
3 ,Inpatient - Respite Care,,8 ,,,,,,,,,,,3 
4 ,Physician Services,,9 ,,,,,,,,,,,4 
5 ,Nursing Care,,10 ,,,,,,,,,,,5 
5.20,Nursing Care - Continuous Home Care,,10.20,,,,,,,,,,,5.20
6 ,Physical Therapy,,11 ,,,,,,,,,,,6 
7 ,Occupational Therapy,,12 ,,,,,,,,,,,7 
8 ,Speech/ Language Pathology,,13 ,,,,,,,,,,,8 
9 ,Medical Social Services - Direct,,14 ,,,,,,,,,,,9 
10 ,Spiritual Counseling,,15 ,,,,,,,,,,,10 
11 ,Dietary Counseling,,16 ,,,,,,,,,,,11 
12 ,Counseling - Other,,17 ,,,,,,,,,,,12 
13 ,Home Health Aide and Homemakers,,18 ,,,,,,,,,,,13 
13.20,Home Health Aide and,,18.20,,,,,,,,,,,13.20
,Homemaker-Cont Home Care,,,,,,,,,,,,,
14 ,Other,,19 ,,,,,,,,,,,14 
15 ,"Drugs, Biologicals and Infusion",,20 ,,,,,,,,,,,15 
15.30,Analgesics,,20.30,,,,,,,,,,,15.30
15.31,Sedatives/Hypnotics,,20.31,,,,,,,,,,,15.31
15.32,Other - specify,,20.32,,,,,,,,,,,15.32
16 ,Durable Medical Equipment/Oxygen,,21 ,,,,,,,,,,,16 
17 ,Patient Transportation,,22 ,,,,,,,,,,,17 
18 ,Imaging Services,,23 ,,,,,,,,,,,18 
19 ,Labs and Diagnostics,,24 ,,,,,,,,,,,19 
20 ,Medical Supplies,,25 ,,,,,,,,,,,20 
21 ,Outpatient Services (incl. E/R Dept.),,26 ,,,,,,,,,,,21 
22 ,Radiation Therapy,,27 ,,,,,,,,,,,22 
23 ,Chemotherapy,,28 ,,,,,,,,,,,23 
24 ,Other,,29 ,,,,,,,,,,,24 
25 ,Bereavement Program Costs,,30 ,,,,,,,,,,,25 
26 ,Volunteer Program Costs,,31 ,,,,,,,,,,,26 
27 ,Fundraising,,32 ,,,,,,,,,,,27 
28 ,Other Program Costs,,33 ,,,,,,,,,,,28 
29 ,Totals (sum of lines 1-28) (2),,,,,,,,,,,,,29 
30 ,"Unit Cost Multiplier: column 6, line 1 divided by the sum of column 6, line 29",,,,,,,,,,,,,30 
,"minus column 6, line 1, rounded to 6 decimal places.",,,,,,,,,,,,,
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"(1) Column 0, line 29 must agree with Wkst. A, column 10, line 25.",,,,,,,,,,,,,,
"(2) Columns 0 through 5, line 29 must agree with the corresponding columns of Wkst. B, line 25.",,,,,,,,,,,,,,
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"FORM CMS 1728-94-K-5 (5-2007)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245-3245.1)",,,,,,,,,,,,,,
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32-331.7,,,,,,,,,,,,,,Rev. 13
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