09-11,,,,,,FORM CMS-1984-99,,,,,3890 (Cont.) This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Completion of this report is viewed as a condition,,,,,,,,, FORM APPROVED,, of your provider agreement.,,,,,,,,, OMB NO. 0938-0758,, ,,,,,,PROVIDER NO.:,PERIOD:,,,, HOSPICE COST AND DATA REPORT,,,,,,,FROM ,, WORKSHEET S,, ,,,,,,,TO ,,,, Intermediary ,, [ ] Audited,,,,Date Received:,,[ ] Initial [ ] Reopening,,, use only,, [ ] Desk Reviewed,,,,Intermediary No.,,[ ] Final,,, ,,,,,,,,,,, CERTIFICATION,,,,,,,,,,, ,,,,,,,,,,, MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE,,,,,,,,,,, "PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER",,,,,,,,,,, "FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PRODUCED",,,,,,,,,,, "THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL",,,,,,,,,,, "CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.",,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,, CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S),,,,,,,,, ,,,,,,,,,,, ,I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or,,,,,,,,,, ,manually submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by,,,,,,,,,, ,____________________________________________(Provider Names(s) and Number(s)) for the cost reporting ,,,,,,,,,, ,"period beginning and ending and that to the best of my knowledge and belief,",,,,,,,,,, ,"it is a true, correct and complete statement prepared from the books and records of the provider in accordance with applicable",,,,,,,,,, ,"instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health ",,,,,,,,,, ,care services and that the services identified in this cost report were provided in compliance with such laws and regulations.,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,(Signed)________________________________________________,,,,,, ,,,,,,Officer or Administrator of Provider(s),,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,Title,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,Date,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,Phone Number: Area Code,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, "According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB",,,,,,,,,,, control number. The valid OMB control number for this information collection is 0938-0758. The time required to complete this information,,,,,,,,,,, "collection is estimated to average 176 hours per response, including the time to review instructions, search existing data resources, gather the data needed,",,,,,,,,,,, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions,,,,,,,,,,, "for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850 and to the Office of Information",,,,,,,,,,, "and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503",,,,,,,,,,, ,,,,,,,,,,, "FORM CMS-1984-99 (4/1999) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3806)",,,,,,,,,,, ,,,,,,,,,,, Rev. 9,,,,,,,,,,,38-103