3290 (Cont.),,,,FORM CMS 1728-94 ,,,01-10 COMPUTATION OF PNEUMOCOCCAL AND,,,,PROVIDER NO.:,PERIOD:,WORKSHEET RF-4, INFLUENZA VACCINE COST,,,,_______________,FROM: _______,, ,,,,COMPONENT NO.:,TO: __________,, ,,,,_______________,,, Check ,, [ ] RHC,,,,, Applicable Box:,, [ ] FQHC,,,,, ,,,,,,, ,,,,SEASONAL,,INFLUENZA, ,,,,INFLUENZA,H1N1,& H1N1, ,,,PNEUMOCOCCAL,ONLY,ONLY,(See instructions), ,CALCULATION OF COST,,1 ,2 ,2.01 ,2.02 , 1 ,Health care staff cost ,,,,,,1 ,"(Worksheet RF-1, column 10, line 10)",,,,,, 2 ,Ratio of pneumococcal and influenza vaccine ,,,,,,2 ,staff time to total health care staff time ,,,,,, 3 ,Pneumococcal and influenza vaccine ,,,,,,3 ,health care staff cost (line 1 x line 2),,,,,, 4 ,Medical supplies cost - pneumococcal and influenza ,,,,,,4 ,vaccine (from your records),,,,,, 5 ,Direct cost of pneumococcal and influenza ,,,,,,5 ,vaccine (line 3 plus line 4),,,,,, 6 ,Total direct cost of the facility ,,,,,,6 ,"(Worksheet RF-1, column 10, line 22)",,,,,, 7 ,Total facility overhead ,,,,,,7 ,"(Worksheet RF-2, line 18)",,,,,, 8 ,Ratio of pneumococcal and influenza vaccine ,,,,,,8 ,direct cost to total direct cost (line 5 divided by line 6),,,,,, 9 ,Overhead cost - pneumococcal and influenza ,,,,,,9 ,vaccine (line 7 x line 8),,,,,, 10 ,Total pneumococcal and influenza vaccine cost and ,,,,,,10 ,its (their) administration (sum of lines 5 and 9),,,,,, 11 ,Total number of pneumococcal and influenza ,,,,,,11 ,vaccine injections (from your records),,,,,, 12 ,Cost per pneumococcal and influenza ,,,,,,12 ,vaccine injection (line 10/ line 11),,,,,, 13 ,Number of pneumococcal and influenza vaccine ,,,,,,13 ,injections administered to Medicare beneficiaries,,,,,, 14 ,Medicare cost of pneumococcal and influenza vaccine ,,,,,,14 ,and its (their) administration (line 12 x line 13),,,,,, ,,,,,,, 15 ,Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns,,,,,,15 ,"1, 2, 2.01 and 2.02, line 10) (transfer this amount to Worksheet RF-3, line 2)",,,,,, 16 ,Total Medicare cost of pneumococcal and influenza vaccine and its (their) administration (sum,,,,,,16 ,"of columns 1, 2, 2.01 and 2.02, line 14) (transfer this amount to Worksheet RF-3, line 20)",,,,,, ,,,,, ,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, "FORM CMS-1728-94-RF-4 (1-2010) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3237)",,,,,,, ,,,,,,, ,,,,,,, 32-346,,,,,,,Rev. 14