09-00,,FORM CMS-1984-99,,,,,,3890 (Cont.)
,, PROVIDER  NO.,,PERIOD:,,,,
,ADJUSTMENTS  TO  EXPENSES,,,FROM,,     WORKSHEET  A-8,,
,,,,TO,,,,
,,(2),,,EXPENSE   CLASSIFICATION   ON,,,
,(1),BASIS  FOR,,,WORKSHEET   A   TO / FROM   WHICH,,,
,Description,ADJUST-,,,THE   AMOUNT  IS  TO  BE  ADJUSTED,,,
,,MENT,AMOUNT,,COST  CENTER,,LINE  NO.,
,,1,2 ,,3 ,,4,
1 , Investment income on restricted,,,,,,,1 
, funds  (chapter 2),,,,,,,
2 , Telephone services (pay stations,,,,,,,2 
, excluded)  (chapter 21),,,,,,,
3 , Adjustment resulting from transactions,,,,,,,3 
, with Related Organizations  (chapter 10) and,Worksheet,,,,,,
, Home office costs  (chapter 21),A-8-1,,,,,,
4 ," Revenue - Employee meals, Guests",,,,,,,4 
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5 ," Income from imposition of interest,",,,,,,,5 
, finance or penalty charges  (chapter 21),,,,,,,
6 , Bad Debts Included on Trial Balance,,,,,,,6 
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7 , Patient Personal Purchases,,,,,,,7 
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8 , Miscellaneous Adjustments,,,,,,,8 
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9 , Depreciation--buildings and fixtures,,,,Buildings & Fixtures,,1,9 
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10 , Depreciation--movable equipment,,,,Movable Equipment,,2,10 
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11 , TOTAL (sum of lines 1 - 10),,,,,,,11 
," (Transfer to Worksheet A, col. 9, line 100)",,,,,,,
     (1)  Description--all chapter references in this column pertain to CMS Pub. 15-I,,,,,,,,
     (2)  Basis for adjustment,,"A.  Costs--if costs, including applicable overhead, can be determined.",,,,,,
,,B.  Amount Received--if cost cannot be determined.,,,,,,
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" FORM CMS-1984-99 (09/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3818)",,,,,,,,
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Rev. 2,,,,,,,,38-115