3290 (Cont.),,,,,,FORM CMS-1728-94,,,,,06-01
,,,,,,PROVIDER NO.:,,PERIOD:,,,
HOSPICE IDENTIFICATION DATA ,,,,,,_____________,,FROM: _____________,,WORKSHEET S-5,
,,,,,,HOSPICE NO.:,,TO: ________________,,,
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PART I,,,,,,,,,,,
,,,,,,,Title XVIII,,,Total,
,,,,,,,,Unduplicated,,Unduplicated,
,,,,,,,,Skilled,Other, Days,
,,,,,,,Unduplicated,Nursing,Unduplicated,(sum of,
,,,Enrollment Days,,,,Days,Facility Days,Days,cols. 1 & 3),
,,,,,,,1 ,2 ,3 ,4 ,
1 ,Continuous Home Care,,,,,,,,,,1 
2 ,Routine Home Care,,,,,,,,,,2 
3 ,Inpatient Respite Care ,,,,,,,,,,3 
4 ,General Inpatient Care,,,,,,,,,,4 
5 ,Total Hospice Days,,,,,,,,,,5 
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PART II,,,,,,,,,,,
,,,,,,,,Title XVIII,,,
,,,,,,,,Skilled,,Total,
,,,,,,,,Nursing,,(sum of,
,,Census Data,,,,,Title XVIII,Facility,Other,cols. 1 & 3),
,,,,,,,1 ,2 ,3 ,4 ,
6 ,Number of Patients Receiving,,,,,,,,,,6 
,Hospice Care,,,,,,,,,,
7 ,Total Number of Unduplicated,,,,,,,,,,7 
,Continuous Care Hours,,,,,,,,,,
,Billable to Medicare,,,,,,,,,,
8 ,Average Length of Stay (line 5 divided by line 6),,,,,,,,,,8 
9 ,Unduplicated Census Count,,,,,,,,,,9 
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"NOTE:   Parts I & II, column 1 also includes the days reported in column 2.",,,,,,,,,,,
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"FORM CMS-1728-94-S-5 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,",,,,,,,,,,,
SECTIONS 3239 - 3239.2),,,,,,,,,,,
32-306,,,,,,,,,,,Rev. 10