08-99,,,,,,,,FORM CMS 1728-94,,,,,,,3290 (Cont.) ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,, WORKSHEET RH-1, ALLOCATION OF GENERAL SERVICE,,,,,,,, ___________________,,, FROM: _______________,,, PARTS I & II, COSTS TO RHC COST CENTERS,,,,,,,, RHC NO.:,,, TO: _________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - ALLOCATION OF GENERAL SERVICE COSTS TO RHC COST CENTERS,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,NET,CAPITAL,,PLANT,,,,,ALLOCATED,, ,,,,,EXPENSES,RELATED COSTS,,OPERATION,,,A&G,,RHC,TOTAL, ,CMHC COST CENTER,,,,FOR COST,BLDGS &,MOVABLE,& MAINTE-,TRANSPOR-,SUBTOTAL,SHARED,SUB-,A&G (SEE,(SUM OF, ,(OMIT CENTS),,,,ALLOCATION (1),FIXTURES,EQUIPMENT,NANCE,TATION,(cols. 0-4),COSTS,TOTAL,PART II),COLS 6 & 7), ,,,,,0,1,2,3,4,4A,5,6,7,8, 1, Administrative and General,,,,,,,,,,,,,,1 2, Physicians,,,,,,,,,,,,,,2 3, Nurse Practitioner,,,,,,,,,,,,,,3 4, Physician Assistant,,,,,,,,,,,,,,4 5, Clinical Psychologist,,,,,,,,,,,,,,5 6, Clinical Social Worker,,,,,,,,,,,,,,6 7, Visiting Nurses,,,,,,,,,,,,,,7 8, Other Part B Services,,,,,,,,,,,,,,8 9,,,,,,,,,,,,,,,9 10, Drugs Charged to Patients,,,,,,,,,,,,,,10 11, TOTALS (Sum of lines 1-10) (2),,,,,,,,,,,,,,11 ,"(1) Column 0, line 11 must agree with Wkst. A, column 10, line 27. ",,,,,,,,,,,,,, ,"(2) Columns 0 through 5, line 11 must agree with the corresponding columns of Wkst. B, line 27.",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,0 ,0 ,0 ,0 ,0 ,,,,, PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF RHC ADMINISTRATIVE AND GENERAL COSTS,,,,,,,,,,,,,,, 1," Amount from Part I, column 6, line 11",,,,,,,,,,,,,, 1 2," Amount from Part I, column 6, line 1",,,,,,,,,,,,,, 2 3, Line 1 minus line 2,,,,,,,,,,,,,, 3 4," Unit cost multiplier for RHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,",,,,,,,,,,,,,, 4 ," lines 2 through 10, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-RH-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3229-3229.2)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, Rev. 7,,,,,,,,,,,,,,,32-337 08-99,,,,,,,,FORM CMS 1728-94,,,,,,,3290 (Cont.) ,,,,,,,, PROVIDER NO.:,,, PERIOD:,,, WORKSHEET RH-2, COMPUTATION OF RHC COSTS,,,,,,,, ___________________,,, FROM: _______________,,,, ,,,,,,,, RHC NO.:,,, TO: __________________,,,, ,,,,,,,, ___________________,,,,,,, PART I - APPORTIONMENT OF RHC COST CENTERS,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,TOTAL COSTS,,RATIO OF,,TITLE XVIII, ,RHC COST CENTER,,,,,,,,,(FROM SUPP.,TOTAL,COSTS TO,TITLE XVIII,RHC COSTS, ,(OMIT CENTS),,,,,,,,,"WKST. RH-1, PT.",RHC,CHARGES,RHC,(COL. 3 X, ,,,,,,,,,,"I, COL. 8) (1)",CHARGES (2),(COL. 1 / COL. 2),CHARGES,COL. 4), ,,,,,,,,,,1,2,3,4,5, 1, Administrative and General,,,,,,,,,,,,,,1 2, Physicians,,,,,,,,,,,,,,2 3, Nurse Practitioner,,,,,,,,,,,,,,3 4, Physician Assistant,,,,,,,,,,,,,,4 5, Clinical Psychologist,,,,,,,,,,,,,,5 6, Clinical Social Worker,,,,,,,,,,,,,,6 7, Visiting Nurses,,,,,,,,,,,,,,7 8, Other Part B Services,,,,,,,,,,,,,,8 9, Subtotal (sum of lines 1-8),,,,,,,,,,,,,,9 10," Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)",,,,,,,,,,,,,,10 11, TOTALS (Sum of lines 9 and 10),,,,,,,,,,,,,,11 ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, PART II - APPORTIONMENT OF COST OF RHC SERVICES FURNISHED BY HHA DEPARTMENTS,,,,,,,,,Fr. Wkst. B,,,,,, ,,,,,,,,,"Col 6, Line:",,,,,, 12, Physical Therapy,,,,,,,,7,,,,,,12 13, Occupational Therapy,,,,,,,,8,,,,,,13 14, Speech Pathology,,,,,,,,9,,,,,,14 15, Supplies,,,,,,,,12,,,,,,15 ,,,,,,,,,,,,,,, 17, Total (Sum of lines 12-15),,,,,,,,,,,,,,17 ,"(1) Cost for Part II, lines 12-15 are obtained from Worksheet B, column 6, lines as appropriate",,,,,,,,,,,,,, ,"(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records",,,,,,,,,,,,,, ,,,,,,,,,,,,,,, PART III - TOTAL RHC COSTS,,,,,,,,,,,,,,, 18,"Total RHC costs - Add the amount from Part I, column 5, line 9 and the amounts from Part II, column 5, line 17",,,,,,,,,,,,,,18 "Transfer the amount in Part III, column 5 to Supplemental Worksheet D, column 3, line 2",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS 1728-94-RH-2 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3230-3230.3)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, Rev. 7,,,,,,,,,,,,,,,32-339