3290 (Cont.),,,,,FORM CMS-1728-94,,,,,,05-07
ALLOCATION OF GENERAL SERVICE,,,,,PROVIDER NO.: _____________,,,PERIOD:,,WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS,,,,,HOSPICE NO.: ____________,,,FROM: ___________,,Part III,
COMPUTATION OF TOTAL HOSPICE SHARED COSTS,,,,,,,,TO: ___________,,,
Hospice shared cost computation,,,,,,,,,Total,Hospice,
,,,,,,,Total HHA,Cost to,Hospice,Shared,
,,,,,,,Charges,Charge,Charges,Ancillary ,
,,,,,"From Wkst B, ",Total HHA,(from Provider,Ratio,(from Provider,Costs,
,COST CENTER ,,,,"col. 6, line:",Costs,Records),(col. 2/col.3),Records),(col. 4 x col. 5),
,,,,,1 ,2 ,3 ,4 ,5 ,6 ,
ANCILLARY SERVICE COST CENTERS,,,,,,,,,,,
1 ,Physical Therapy,,,,7 ,,,,,,1 
2 ,Occupational Therapy,,,,8 ,,,,,,2 
3 ,Speech/ Language Pathology,,,,9 ,,,,,,3 
4 ,Medical Social Services - Direct,,,,10 ,,,,,,4 
5 ,Durable Medical Equipment/Oxygen,,,,14 ,,,,,,5 
6 ,Medical Supplies,,,,12 ,,,,,,6 
7 ,Totals (sum of lines 1-7) ,,,,,,,,,,7 
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"FORM CMS-1728-94-K-5  (6-2001)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245.3)",,,,,,,,,,,
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32-331.9,,,,,,,,,,,Rev. 13