3890 (Cont.),,,,,,FORM CMS-1984-99,,,,,,,,09-00 STATEMENT OF COSTS OF SERVICES,,,,,,PROVIDER NO:,,PERIOD:,,,,WORKSHEET A-8-1,, FROM RELATED ORGANIZATIONS AND,,,,,,,,FROM,,,,,, HOME OFFICE COSTS,,,,,,,,TO,,,,,, ,,,,,,,,,,,,,, "A. Costs incurred and adjustments required as a result of transactions with related organizations or the claiming of home office costs,",,,,,,,,,,,,,, and/or related organization:,,,,,,,,,,,,,, ,,,,,,,,,Amount,,,,Net, ,,,,,,,Amount,,(from,,,,Adjustments, ,,,,,,,Allowable,,"Worksheet A,",,,,(col. 4 minus, ,Line No.,Cost Center,Expense Items,,,,In Cost,,col. 5),,,,col. 5) *, ,1 ,2 ,3 ,,,,4 ,,5 ,,,,, 1 ,,,,,,,,,,,,,,1 2 ,,,,,,,,,,,,,,2 3 ,,,,,,,,,,,,,,3 4 ,,,,,,,,,,,,,,4 5 ,"TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet",,,,,,,,,,,,,5 ,"A-8, column 2, line 3. ",,,,,,,,,,,,, ,,,,,,,,,,,,,, B. Interrelationship to related organization(s) and/or home office:,,,,,,,,,,,,,, "The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish",,,,,,,,,,,,,, the information requested under Part B of this worksheet.,,,,,,,,,,,,,, ,,,,,,,,,,,,,, This information is used by the Centers for Medicare and Medicare Services and its intermediaries in determining that the costs applicable to,,,,,,,,,,,,,, "services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs",,,,,,,,,,,,,, "as determined under section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost ",,,,,,,,,,,,,, report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.,,,,,,,,,,,,,, ,,,,,,,,,,,,,, " * The amounts on lines 1-4 and subscripts as appropriate are transferred in detail to Worksheet A, column 9, lines as appropriate.",,,,,,,,,,,,,, Positive amounts increase cost and negative amounts decrease cost. For related organizational or home office cost which has not ,,,,,,,,,,,,,, " been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.",,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,Related Organization(s) and/or Home Office,,,,,,,,, ,,,Percentage,,,,,Percentage,,,,Type of,, ,Symbol,,of,,,,,of,,,,,, ,(1),Name,Ownership,,Name,,,Ownership,,,,Business,, ,1 ,2 ,3 ,,4 ,,,5 ,,,,6 ,, 1 ,,,,,,,,,,,,,,1 2 ,,,,,,,,,,,,,,2 3 ,,,,,,,,,,,,,,3 4 ,,,,,,,,,,,,,,4 5 ,,,,,,,,,,,,,,5 ,,,,,,,,,,,,,, ,(1) Use the following symbols to indicate interrelationship to related organizations:,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,"A. Individual has financial interest (stockholder, partner, etc.) in both related",,,,,,,,,,,, ,, organization and in provider.,,,,,,,,,,,, ,,"B. Corporation, partnership, or other organization has financial interest in provider.",,,,,,,,,,,, ,,"C. Provider has financial interest in corporation, partnership, or other organization.",,,,,,,,,,,, ,,"D. Director, officer, administrator, or key person of provider or relative of such",,,,,,,,,,,, ,, person has financial interest in related organization.,,,,,,,,,,,, ,,"E. Individual is director, officer, administrator, or key person of provider and",,,,,,,,,,,, ,, related organization.,,,,,,,,,,,, ,,"F. Director, officer, administrator, or key person of related organization or relative",,,,,,,,,,,, ,, of such person has financial interest in provider.,,,,,,,,,,,, ,,G. Other (financial or non-financial) specify __________________________________________________,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, ,,,,,,,,,,,,,, "FORM CMS-1984-99 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN PUB. 15-II, SECTION 3818.1)",,,,,,,,,,,,,, ,,,,,,,,,,,,,, 38-116,,,,,,,,,,,,,,Rev. 2