09-00,,FORM CMS 1984-99,,,3890 (Cont.)
,,PROVIDER NO:,PERIOD:,,
 STATEMENT  OF  PATIENT  REVENUES,,,FROM, WORKSHEET  G - 2,
 AND  NET  INCOME,,,TO,  PARTS  I  &  II,
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,PART I - PATIENT REVENUES,,,,
,Revenue  Center,,,,
,,,,TOTAL,
,GENERAL INPATIENT AND HOME CARE SERVICE LOCATION,,,,
1 , Skilled Nursing Facility based,,,,1 
2 , Nursing facility based,,,,2 
3 , Home care,,,,3 
4 , Other (See Instructions),,,,4 
5 , State Medicaid room & board,,,,5 
6 ," Total General Inpatient Revenues  ( Sum of lines 1, 2, 3 and 4 )",,,,6 
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,PART II - OPERATING EXPENSES,,,,
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1 ," Operating Expenses  ( Per Worksheet A, Col. 6, Line 100 )",,,,1 
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2 , Add  ( Specify ),,,,2 
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3 ,,,,,3 
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4 ,,,,,4 
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5 ,,,,,5 
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6 ,,,,,6 
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7 ,,,,,7 
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8 , Total Additions  ( Sum of lines 2 - 7 ) ,,,,8 
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9 , Deduct  ( Specify ),,,,9 
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10 ,,,,,10 
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11 ,,,,,11 
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12 ,,,,,12 
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13 ,,,,,13 
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14 , Total Deductions  ( Sum of lines 9 - 13 ),,,,14 
, Total Operating Expenses,,,,
15 ," ( Sum of lines 1 and 8,  minus line 14 )",,,,15 
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16 ,Net Income (or loss) for the period (Line 6 minus line 15),,,,16 
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" FORM CMS 1984-99 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3850.2)",,,,,
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Rev. 2,,,,,38-123