3290 (Cont.),,,FORM CMS 1728-94 ,,,,01-10 ALLOCATION OF OVERHEAD,,PROVIDER NO.:,,PERIOD:,,WORKSHEET RF-2, TO RHC/FQHC SERVICES,,_______________,,FROM: ____________,,, ,,COMPONENT NO.:,,TO: ____________,,, ,,_______________,,,,, Check ,, [ ] RHC,,,,, Applicable Box:,, [ ] FQHC,,,,, VISITS AND PRODUCTIVITY,,,,,,, ,,,,,,, ,,Number,,,Minimum,Greater of, ,,of FTE,Total,Productivity,Visits,Col. 2 or, ,,Personnel,Visits,Standard (1),(col. 1x col. 3),Col. 4, , Positions,1,2,3,4,5, 1 ,Physicians,,,,,,1 2 ,Physician Assistants,,,,,,2 3 ,Nurse Practitioners,,,,,,3 4 ,Subtotal (sum of lines 1-3),,,,,,4 5 ,Visiting Nurse,,,,,,5 6 ,Clinical Psychologist,,,,,,6 7 ,Clinical Social Worker,,,,,,7 8 ,Total FTEs and Visits (sum of lines 4-7),,,,,,8 9 ,Physician Services Under Agreements,,,,,,9 ,(1) Productivity standards established by CMS are: 4200 visits for each physician and 2100 visits for each nonphysician,,,,,, ,"practitioner. If an exception to the productivity standard has been granted, (Worksheet S-4, line 13 equals ""Y""), then input",,,,,, ,"in column 3, lines 1-3, the productivity standards derived by the fiscal intermediary.",,,,,, ,,,,,,, DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES,,,,,,, 10 ,"Total costs of health care services (from Worksheet RF-1, column 10, line 22 less the amount",,,,,,10 ,"from Worksheet RF-1, column 10, line 20)",,,,,, 11 ,"Total nonreimbursable costs (from Worksheet RF-1, column 10, line 28)",,,,,,11 12 ,Cost of all services (excluding overhead) (sum of lines 10 and 11),,,,,,12 13 ,Ratio of RHC/FQHC services (line 10 divided by line 12),,,,,,13 14 ,"Total facility overhead - (from Worksheet RF-1, column 10, line 31) (see instructions)",,,,,,14 15 ,Allowable GME Overhead (see instructions),,,,,,15 16 ,Net Facility Overhead (line 14 minus line 15),,,,,,16 17 ,Parent provider overhead allocated to facility (see instructions),,,,,,17 18 ,Total overhead (sum of lines 14 and 17),,,,,,18 19 ,Overhead applicable to RHC/FQHC services (line 13 x line 18),,,,,,19 20 ,Total allowable cost of RHC/FQHC services (sum of lines 10 and 19),,,,,,20 ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, FORM CMS-1728-94-RF-2 (3-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.,,,,,,, "15-II, SECTION 3235 - 3235.2)",,,,,,, ,,,,,,, 32-344,,,,,,,Rev. 15