09-11,,,,FORM CMS-1984-99,,,,,,,,3890 (Cont.) COST ALLOCATION - STATISTICAL BASIS,,,,PROVIDER NO:,,PERIOD:,,,,,, ,,,,,,FROM,,,,,WORKSHEET B-1, ,,,,,,TO,,,,,, ,,,CAPITAL,,,,,,,,, ,,CAPITAL,RELATED,,,VOLUNTEER,,,,,, ,,RELATED,COST,PLANT,,SERVICE,,ADMINIS-,A & G,A & G,A & G, ,,COST BLDG ,MOVABLE,OPERATION,TRANS-,COORDI-,,TRATIVE &,SHARED,REIMB.,NON-REIMB., ,COST CENTER DESCRIPTIONS,& FIXTURES,EQUIPMENT,& MAINT.,PORTATION,NATOR,RECONCI-,GENERAL,COSTS,COSTS,COSTS, ,,(SQ. FT.),$ VALUE),(SQ. FT.),(MILEAGE),(HOURS),LIATION,(ACC. COST),(ACC. COST),(ACC. COST),(ACC. COST), ,,1 ,2 ,3 ,4 ,5 ,6A,6 ,6.01 ,6.02 ,6.03 , ,GENERAL SERVICE COST CENTERS, , ,,,,,,, ,, 1 ,Capital Related Costs-Buildings and Fixtures, , ,,,,,,,,,1 2 ,Capital Related Costs-Movable Equipment, , ,,,,,,,,,2 3 ,Plant Operation and Maintenance,,,,,,,,,,,3 4 ,Transportation-staff,,,,,,,,,,,5 5 ,Volunteer Service Coordination,,,,,,,,,,,5 6 ,Administrative and General,,,,,,,,,,,6 6.01 ,A & G Shared Costs,,,,,,,,,,,6.01 6.02 ,A & G Reimbursable Costs,,,,,,,,,,,6.02 6.03 ,A & G Nonreimbursable Costs,,,,,,,,,,,6.03 ,INPATIENT CARE SERVICE,,,,,,,,,,, 10 ,Inpatient - General Care,,,,,,,,,,,10 11 ,Inpatient - Respite Care,,,,,,,,,,,11 ,VISITING SERVICES,,,,,,,,,,, 15 ,Physician Services,,,,,,,,,,,15 16 ,Nursing Care,,,,,,,,,,,16 16.20 ,Nursing Care -- Continuous Home Care,,,,,,,,,,,16.20 17 ,Physical Therapy,,,,,,,,,,,17 18 ,Occupational Therapy,,,,,,,,,,,18 19 ,Speech/ Language Pathology,,,,,,,,,,,19 20 ,Medical Social Services ,,,,,,,,,,,20 21 ,Spiritual Counseling, , ,,,,,,, ,,21 22 ,Dietary Counseling,,,,,,,,,,,22 23 ,Counseling - Other,,,,,,,,,,,23 24 ,Home Health Aide and Homemaker,,,,,,,,,,,24 24.20 ,HH Aide & Homemaker -- Cont Home Care,,,,,,,,,,,24.20 25 ,Other,,,,,,,,,,,25 ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3820)",,,,,,,,,,,, ,,,,,,,,,,,, Rev. 9,,,,,,,,,,,,38-117.2 3890 (Cont.),,,,FORM CMS-1984-99,,,,,,,,09-11 COST ALLOCATION - STATISTICAL BASIS,,,,PROVIDER NO:,,PERIOD:,,,,,, ,,,,,,FROM,,,,,WORKSHEET B-1, ,,,,,,TO,,,,,, ,,,CAPITAL,,,,,,,,, ,,CAPITAL,RELATED,,,VOLUNTEER,,,,,, ,,RELATED,COST,PLANT,,SERVICE,,ADMINIS-,A & G,A & G,A & G, ,,COST BLDG ,MOVABLE,OPERATION,TRANS-,COORDI-,,TRATIVE &,SHARED,REIMB.,NON-REIMB., ,COST CENTER DESCRIPTIONS,& FIXTURES,EQUIPMENT,& MAINT.,PORTATION,NATOR,RECONCI-,GENERAL,COSTS,COSTS,COSTS, ,,(SQ. FT.),$ VALUE),(SQ. FT.),MILEAGE,(HOURS),LIATION,(ACC. COST),(ACC. COST),(ACC. COST),(ACC. COST), ,,1 ,2 ,3 ,4 ,5 ,6A,6 ,6.01 ,6.02 ,6.03 , ,OTHER HOSPICE SERVICE COSTS,,,,,,,,,,, 30 ,"Drugs, Biologicals and Infusion",,,,,,,,,,,30 30.30 ,Analgesics,,,,,,,,,,,30.30 30.31 ,Sedatives / Hypnotics,,,,,,,,,,,30.31 30.32 ,Other -- Specify,,,,,,,,,,,30.32 31 ,Durable Medical Equipment/Oxygen,,,,,,,,,,,31 32 ,Patient Transportation,,,,,,,,,,,32 33 ,Imaging Services,,,,,,,,,,,33 34 ,Labs and Diagnostics,,,,,,,,,,,34 35 ,Medical Supplies,,,,,,,,,,,35 36 ,Outpatient Services (incl. E/R Dept.),,,,,,,,,,,36 37 ,Radiation Therapy,,,,,,,,,,,37 38 ,Chemotherapy,,,,,,,,,,,38 39 ,Other,,,,,,,,,,,39 ,HOSPICE NONREIMBURSABLE SERV.,,,,,,,,,,, 50 ,Bereavement Program Costs,,,,,,,,,,,50 51 ,Volunteer Program Costs,,,,,,,,,,,51 52 ,Fundraising,,,,,,,,,,,52 53 ,Other Program Costs,,,,,,,,,,,53 100 ,Cost To be Allocated (per Wkst B),,,,,,,,,,,100 101 ,Unit Cost Multiplier,,,,,,,,,,,101 ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3820)",,,,,,,,,,,, ,,,,,,,,,,,, ,,,,,,,,,,,, 38-118,,,,,,,,,,,,Rev. 9