3890 (Cont.),,,,,,FORM CMS-1984-99,,,,,09-11 ,,,,,,PROVIDER NO.:,,PERIOD:,,, HOSPICE IDENTIFICATION DATA ,,,,,,,,FROM:,,WORKSHEET S-1, ,,,,,,,,TO:,,, PART I,,,,,,,,,,, 1 ,Name:,,,,Address:,,,City:,State:,Zip Code: ,1 2 ,County where the hospice is located,,,,,,,,,,2 ,,,,,,,,,,Date, 3 ,Hospice began operation (mm/dd/yyyy),,,,,,,,,,3 ,,,,,,,,,Dated certified,Dated certified, ,,,,,,,,,Title XVIII,Title XIX, 4 ,Certification date (mm/dd/yyyy),,,,,,,,,,4 5 ,Cost Reporting Period (mm/dd/yyyy),,,,,,From:,,To: ,,5 6 ,Provider Identification Number,,,,,,,,,,6 6.01 ,National Provider Identifier (NPI) Number,,,,,,,,,,6.01 7 ,Type of Control (see instructions),,,,,,,,,,7 PART II,,,,,,,,,,, ,,,,,Title XVIII,Title XIX,Title XVIII,Title XIX,,, ,,,,,,,Unduplicated,Unduplicated,,, ,,,Enrollment Days,,Unduplicated,Unduplicated, Skilled Nursing,Nursing,Other,Total, ,,,,,Medicare Days,Medicaid Days,Facility Days,Facility Days,Unduplicated,Unduplicated Days, ,,,,,1 ,2 ,3 ,4 ,5 ,6 , 8 ,Continuous Home Care,,,,,,,,,,8 9 ,Routine Home Care,,,,,,,,,,9 10 ,Inpatient Respite Care ,,,,,,,,,,10 11 ,Inpatient General Care,,,,,,,,,,11 12 ,Total Hospice Days,,,,,,,,,,12 PART III,,,,,,,,,,, ,,,,,,,Title XVIII,Title XIX,,, ,,,,,,,Skilled Nursing,Nursing,,, ,,,,,Title XVIII,Title XIX,Facility,Facility,Other,Total, ,,,,,1 ,2 ,3 ,4 ,5 ,6 , 13 ,Number of Patients Receiving Hospice Care,,,,,,,,,,13 ,Total Number of Unduplicated Countinuous,,,,,,,,,, 14 , Care Hours Billable to Medicare,,,,,,,,,,14 15 ,Average Length of Stay,,,,,,,,,,15 16 ,Unduplicated Census Count,,,,,,,,,,16 ,"If the hospice componentized (or fragmented) its administrative and general service costs, indicate whether option one ",,,,,,,,,, 17 ,"or two is being utilized (See PRM-II, Section 3820) (Enter ""1""for option one and ""2"" for option two)",,,,,,,,,,17 ,"Are there any related organization or home office costs as defined in CMS Pub. 15-I, chapter 10? Enter ""Y"" for yes or ""N"" for no",,,,,,,,,, 18 ,"in column 1. If yes, enter the chain home office provider number in column 2.",,,,,,,,,,18 PART IV,,,,,,,,,,, ,,,,,,,,,Durable ,, ,,,,,,,,Drug ,Medical Equipment/,Medical Supply, ,,,,,,`,, Costs,Oxygen Costs,Costs, ,,,,,,,,1 ,2 ,3 , 19 ,Inpatient General Care (see instructions),,,,,,,,,,19 ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3807)",,,,,,,,,,, ,,,,,,,,,,, 38-104,,,,,,,,,,,Rev. 9