05-07,,,,FORM CMS-1728-94,,,,,,,3290 (Cont.)
ALLOCATION OF GENERAL SERVICE,,,,,,PROVIDER NO:,,PERIOD:,,WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS,,,,,,_,,FROM: ____________,,PART II,
STATISTICAL BASIS,,,,,,HOSPICE NO.:,,TO: _______________,,,
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,,,,,CAPITAL RELATED,,PLANT,, ,,
,,,,,COST,,OPERATION,,,ADMINIS-,
,,,,,BUILDINGS,MOVABLE,& MAIN-,,,TRATIVE &,
,HOSPICE COST CENTER,,,,& FIXTURES,EQUIPMENT,TENANCE,TRANS-,,GENERAL,
,,,,,(SQUARE,(DOLLAR,(SQUARE,PORTATION,RECONCIL-,(ACCUM.,
,,,,,FEET),VALUE),FEET),(MILAGE),IATION,COST),
,,,,,1,2,3,4,5A,5 ,
1 ,Administrative and General,,,,,,,,,,1 
2 ,Inpatient - General Care,,,,,,,,,,2 
3 ,Inpatient - Respite Care,,,,,,,,,,3 
4 ,Physician Services,,,,,,,,,,4 
5 ,Nursing Care,,,,,,,,,,5 
5.20,Nursing Care - Continuous Home Care,,,,,,,,,,5.20
6 ,Physical Therapy,,,,,,,,,,6 
7 ,Occupational Therapy,,,,,,,,,,7 
8 ,Speech/ Language Pathology,,,,,,,,,,8 
9 ,Medical Social Services - Direct,,,,,,,,,,9 
10 ,Spiritual Counseling,,,,,,,,,,10 
11 ,Dietary Counseling,,,,,,,,,,11 
12 ,Counseling - Other,,,,,,,,,,12 
13 ,Home Health Aide and Homemakers,,,,,,,,,,13 
13.20,Home Health Aide and Homemaker-Cont Home Care,,,,,,,,,,13.20
14 ,Other,,,,,,,,,,14 
15 ,"Drugs, Biologicals and Infusion",,,,,,,,,,15 
15.30,Analgesics,,,,,,,,,,15.30
15.31,Sedatives/Hypnotics,,,,,,,,,,15.31
15.32,Other - specify,,,,,,,,,,15.32
16 ,Durable Medical Equipment/Oxygen,,,,,,,,,,16 
17 ,Patient Transportation,,,,,,,,,,17 
18 ,Imaging Services,,,,,,,,,,18 
19 ,Labs and Diagnostics,,,,,,,,,,19 
20 ,Medical Supplies,,,,,,,,,,20 
21 ,Outpatient Services (incl. E/R Dept.),,,,,,,,,,21 
22 ,Radiation Therapy,,,,,,,,,,22 
23 ,Chemotherapy,,,,,,,,,,23 
24 ,Other,,,,,,,,,,24 
25 ,Bereavement Program Costs,,,,,,,,,,25 
26 ,Volunteer Program Costs,,,,,,,,,,26 
27 ,Fundraising,,,,,,,,,,27 
28 ,Other Program Costs,,,,,,,,,,28 
29 ,Totals (sum of lines 1-28),,,,,,,,,,29 
30 ,Total  cost to be allocated,,,,,,,,,,30 
31 ,Unit Cost Multiplier,,,,,,,,,,31 
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"FORM CMS-1728-94-K-5 (5-2007)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245.2)",,,,,,,,,,,
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Rev. 13,,,,,,,,,,,32-331.8