03-10,,,,,FORM CMS 1728-94,,,,,,,3290 (Cont.)
ANALYSIS OF HHA-BASED RURAL HEALTH CLINIC/,,,,,,,PROVIDER NO.:,,PERIOD:,,WORKSHEET RF-1,
FEDERALLY QUALIFIED HEALTH CENTER COSTS,,,,,,,_______________,,FROM: ____________,,,
,,,,,,,COMPONENT NO.:,,TO: ____________,,,
,,,,,,,_______________,,,,,
Check ,,  [  ]  RHC,,,,,,,,,,
Applicable Box:,,  [  ]  FQHC,,,,,,,,,,
,,,,,,,,,RECLASSIFIED,,NET EXPENSES,
,,,,,CONTRACTED/,,TOTAL,,TRIAL,,FOR,
,,,EMPLOYEE,TRANSPOR-,PURCHASED,,(sum of col. 1,RECLASSIFI-,BALANCE,,ALLOCATION,
,,SALARIES,BENEFITS,TATION,SERVICES,OTHER COSTS,thru col. 5),CATIONS,(col. 6 + col. 7),ADJUSTMENTS,(col. 8 + col. 9),
,,1,2,3,4,5,6,7,8 ,9 ,10 ,
 ,FACILITY HEALTH CARE STAFF COSTS,,,,,,,,,,, 
1 ,Physician,,,,,,,,,,,1 
2 ,Physician Assistant,,,,,,,,,,,2 
3 ,Nurse Practitioner,,,,,,,,,,,3 
4 ,Visiting Nurse,,,,,,,,,,,4 
5 ,Other Nurse,,,,,,,,,,,5 
6 ,Clinical Psychologist,,,,,,,,,,,6 
7 ,Clinical Social Worker,,,,,,,,,,,7 
8 ,Laboratory Technician,,,,,,,,,,,8 
9 ,Other Facility Health Care Staff Costs,,,,,,,,,,,9 
10 ,Subtotal (sum of lines 1-9),,,,,,,,,,,10 
 ,COSTS UNDER AGREEMENT,,,,,,,,,,, 
11 ,Physician Services Under Agreement,,,,,,,,,,,11 
12 ,Physician Supervision Under Agreement,,,,,,,,,,,12 
13 ,Other Costs Under Agreement,,,,,,,,,,,13 
14 ,Subtotal (sum of lines 11-13),,,,,,,,,,,14 
 ,OTHER HEALTH CARE COSTS,,,,,,,,,,, 
15 ,Medical Supplies,,,,,,,,,,,15 
16 ,Transportation (Health Care Staff),,,,,,,,,,,16 
17 ,Depreciation-Medical Equipment,,,,,,,,,,,17 
18 ,Professional Liability Insurance,,,,,,,,,,,18 
19 ,Other Health Care Costs,,,,,,,,,,,19 
20 ,Allowable GME Pass Through Costs,,,,,,,,,,,20 
21 ,Subtotal (sum of lines 15-20),,,,,,,,,,,21 
22 ,Total Cost of Health Care Services (sum of,,,,,,,,,,,22 
,"lines 10, 14, and 21)",,,,,,,,,,,
,COSTS OTHER THAN RHC/FQHC SERVICES,,,,,,,,,,,
23 ,Pharmacy,,,,,,,,,,,23 
24 ,Dental,,,,,,,,,,,24 
25 ,Optometry,,,,,,,,,,,25 
26 ,All other nonreimbursable costs,,,,,,,,,,,26 
27 ,Non-allowable GME Pass Through Costs,,,,,,,,,,,27 
28 ,Total Nonreimbursable Costs (sum of lines 23-27),,,,,,,,,,,28 
,FACILITY OVERHEAD,,,,,,,,,,,
29 ,Facility Costs,,,,,,,,,,,29 
30 ,Administrative Costs,,,,,,,,,,,30 
31 ,Total Facility Overhead (sum of lines 29 and 30),,,,,,,,,,,31 
32 ,"Total facility costs (sum of lines 22, 28 and 31)",,,,,,,,,,,32 
,"The net expenses for cost allocation on Worksheet A for the applicable RHC/FQHC cost center line must equal the total facility costs in column 10, line 30 of this worksheet for cost reporting",,,,,,,,,,,
,"periods beginning on or after January 1, 1998.",,,,,,,,,,,
,,,,,,,,,,,,
"FORM CMS-1728-94-RF-1  (3-2010)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3234)",,,,,,,,,,,,
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Rev. 15,,,,,,,,,,,,32-343