09-11,,,,,FORM CMS 1984-99,,,,,,,,,, 3890 (Cont.) COST ALLOCATION BASED ON SERVICE COST CENTERS,,,,,PROVIDER NO:,,PERIOD:,,,,,,,, ,,,,,,,FROM,,,,,,,WORKSHEET B, ,,,,,,,TO,,,,,,,, ,,,,,,,,,,,,,,, ,,,,CAPITAL,,,,,,,,,,, ,,NET,CAPITAL,RELATED,,,VOLUNTEER,,,,,,,, ,,EXPENSES,RELATED,COST,PLANT,,SERVICE,,A & G,,A & G,,A & G,, ,COST CENTER DESCRIPTIONS,FOR COST,COST BLDG,MOVABLE,OPERATION,TRANS-,COORDI-,SUBTOTAL,SHARED,SUBTOTAL,REIMB.,SUBTOTAL,NON-REIMB.,, ,,ALLOC.,& FIXTURES,EQUIPMENT,& MAINT.,PORTATION,NATOR,(col. 0 - 5),COSTS,(col. 0 - 6.01,COSTS,(col. 0 - 6.02),COSTS,TOTAL, ,,0 ,1 ,2 ,3 ,4 ,5 ,5A,6.01 ,6A.01,6.02 ,6A.02,6.03 ,7 , ,GENERAL SERVICE COST CENTERS,, , ,,,,,,, ,,,, 1 ,Capital Related Costs-Bldg and Fixtures,, , ,,,,,,,,,,,1 2 ,Capital Related Costs-Movable Equipment,, , ,,,,,,,,,,,2 3 ,Plant Operation and Maintenance,,,,,,,,,,,,,,3 4 ,Transportation - Staff,,,,,,,,,,,,,,4 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,,,,,,,,,,,,,,12 ,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 3890 (Cont.),,,,FORM CMS-1984-99,,,,,,,,,,,09-11 COST ALLOCATION BASED ON SERVICE COST CENTERS,,,,,PROVIDER NO:,,PERIOD:,,,,,,,, ,,,,,,,FROM,,,,,,,WORKSHEET B, ,,,,,,,TO,,,,,,,, ,,,,,,,,,,,,,,, ,,,,CAPITAL,,,,,,,,,,, ,,NET,CAPITAL,RELATED,,,VOLUNTEER,,,,,,,, ,,EXPENSES,RELATED,COST,PLANT,,SERVICE,,A & G,,A & G,,A & G,, ,COST CENTER DESCRIPTIONS,FOR COST,COST BLDG,MOVABLE,OPERATION,TRANS-,COORDI-,SUBTOTAL,SHARED,SUBTOTAL,REIMB.,SUBTOTAL,NON-REIMB.,, ,,ALLOC.,& FIXTURES,EQUIPMENT,& MAINT.,PORTATION,NATOR,(col. 0 - 5),COSTS,(col. 0 - 6.01,COSTS,(col. 0 - 6.02),COSTS,TOTAL, ,,0 ,1 ,2 ,3 ,4 ,5 ,5A,6.01 ,6A.01,6.02 ,6A.02,6.03 ,7 , ,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 ,Total,,,,,,,,,,,,,,100 ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3820)",,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, 38-117.1,,,,,,,,,,,,,,,Rev. 9