01-10,,,,FORM CMS 1728-94,,,,,3290 (Cont.) This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result,,,,,,,,, in all interim payments made since the beginning of the cost reporting period being deemed,,,,,,, FORM APPROVED,, as overpayments (42 USC 1395g).,,,,,,, OMB NO. 0938-0022,, HOME HEALTH AGENCY COST REPORT,,,, PROVIDER NO.:,, PERIOD:,,, CERTIFICATION AND SETTLEMENT SUMMARY,,,,,,From: ___________,,WORKSHEET S, ,,,, _______________,,To: ___________,,, , Intermediary Use Only:,,,,,,,, ,,,,,,,,, ,[ ] Audited,Date Received,,____________,[ ],Initial,,[ ] Re-opened, ,[ ] Desk Reviewed,Intermediary No.,,____________,[ ],Final,,, ,,,,,,,,, PART I - CERTIFICATION,,,,,,,,, ,,,,,,,,, Check ,,[ ],Electronically filed cost report,,,Date: ___________,,, applicable box,,[ ],Manually submitted cost report,,,Time: ___________,,, MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY,,,,,,,,, "BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT",,,,,,,,, "UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED",,,,,,,,, OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE,,,,,,,,, "ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.",,,,,,,,, ,,,,,,,,, ,,,CERTIFICATION BY OFFICER OR DIRECTOR OF THE AGENCY,,,,,, ,,,,,,,,, ,I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying,,,,,,,, ,Home Health Agency Cost Report and the Balance Sheet and Statement of Revenue and Expenses,,,,,,,, ,prepared by _________________________________________(Provider name(s) and number(s)) for the cost,,,,,,,, ,"report beginning _____________________and ending __________________________, and that to the",,,,,,,, ,"best of my knowledge and belief, it is a true, correct and complete report prepared from the",,,,,,,, ,"books and records of the provider in accordance with applicable instructions, except as noted. ",,,,,,,, ,I further certify that I am familiar with the laws and regulations regarding the provision of ,,,,,,,, ,"health care services, and that the services identified in this cost report were provided in",,,,,,,, ,compliance with such laws and regulations.,,,,,,,, ,,,,,,,,, ,,(Signed),__________________________________________,,,,,, ,,, Officer or Director,,,,,, ,,,__________________________________________,,,,,, ,,, Title,,,,,, ,,,__________________________________________,,,,,, ,,, Date,,,,,, ,,,,,,,,, ,,,,,,,,, ,,,,,,,,, PART II - SETTLEMENT SUMMARY,,,,,,,,, ,,,,,,,,, ,,,,, TITLE XVIII,,,, ,,,,PART A,,,PART B,, ,,,,1,,,2,, ,,,,,,,,, 1,HOME HEALTH AGENCY,,,,,,,,1 ,,,,,,,,, 2,HOME HEALTH-BASED CORF,,,,,,,,2 ,,,,,,,,, 3,HOME HEALTH-BASED CMHC,,,,,,,,3 3.5 ,HOME HEALTH-BASED RHC/FQHC,,,,,,,,3.5 ,(specify),,,,,,,, ,,,,,,,,, 4 ,TOTAL,,,,,,,,4 ,,,,,,,,, """According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid",,,,,,,,, OMB control number. The valid OMB control number for this information collection is 0938-0022. The time required to complete this,,,,,,,,, "information collection is estimated to average 226 hours per response, including the time to review instructions, search existing data resources,",,,,,,,,, "gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time",,,,,,,,, "estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail",,,,,,,,, "Stop C4-26-05, Baltimore, Maryland 21244-1850.""",,,,,,,,, ,,,,,,,,, ,,,,,,,,, "FORM CMS-1728-94-S (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS. 3203-3203.2)",,,,,,,,, ,,,,,,,,, Rev. 14,,,,,,,,,32-303