05-13,,,Form CMS-222-92,,,,,,,2990 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL,,,,PROVIDER CCN:,,PERIOD:,,WORKSHEET A,,
BALANCE OF EXPENSES,,,,,,FROM: ,,Page 1,,
,,,,,,TO:,,,,
,,,,,,,Reclassified,Adjustments,Net,
,,COST CENTER,Compen-,Other,Total,Reclassi-,Trial Balance,Increases,Expenses,
,,,sation,,(Col. 1 + 2),fications,(Col. 3 +/- 4),(Decreases),(Col. 5 +/- 6),
,,,1,2,3,4,5,6,7,
 ,,FACILITY HEALTH CARE STAFF COSTS,,,,,,,,
1 ,0100,  Physician,,,,,,,,1 
2 ,0200,  Physician Assistant,,,,,,,,2 
3 ,0300,  Nurse Practitioner,,,,,,,,3 
4 ,0400,  Visiting Nurse,,,,,,,,4 
5 ,0500,  Other Nurse,,,,,,,,5 
6 ,0600,  Clinical Psychologist,,,,,,,,6 
7 ,0700,  Clinical Social Worker,,,,,,,,7 
8 ,0800,  Laboratory Technician,,,,,,,,8 
9 ,0900,  Other (Specify) ,,,,,,,,9 
10 ,1000, ,,,,,,,,10 
11 ,1100,,,,,,,,,11 
12 ,,Subtotal-Facility Health Care Staff Costs,,,,,,,,12 
 ,,COSTS UNDER AGREEMENT,,,,,,,, 
13 ,1300,  Physician Services Under Agreement,,,,,,,,13 
14 ,1400,  Physician Supervision Under Agreement,,,,,,,,14 
15 ,1500,,,,,,,,,15 
16 ,,Subtotal Under Agreement (Lines 13-15),,,,,,,,16 
 ,,OTHER HEALTH CARE COSTS,,,,,,,, 
17 ,1700,  Medical Supplies,,,,,,,,17 
18 ,1800,  Transportation (Health Care Staff),,,,,,,,18 
19 ,1900,  Depreciation-Medical Equipment,,,,,,,,19 
20 ,2000,  Professional Liability Insurance,,,,,,,,20 
20.50,2050,  Allowable GME Pass Through Costs,,,,,,,,20.50
21 ,2100, Other (Specify),,,,,,,,21 
22 ,2200, ,,,,,,,,22 
23 ,2300, ,,,,,,,,23 
24 ,,Subtotal-Other Health Care Costs (Lines 17-23),,,,,,,,24 
25 ,,Total Cost of Services (Other Than,,,,,,,,25 
,,Overhead And Other RHC/FQHC Services),,,,,,,,
 ,,"Sum of Lines 12, 16, And 24",,,,,,,, 
 ,,FACILITY OVERHEAD-FACILITY COST,,,,,,,, 
26 ,2600,  Rent,,,,,,,,26 
27 ,2700,  Insurance,,,,,,,,27 
28 ,2800,  Interest On Mortgage Or Loans,,,,,,,,28 
29 ,2900,  Utilities,,,,,,,,29 
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"FORM CMS-222-92 (05-2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 2904)",,,,,,,,,,
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Rev. 11,,,,,,,,,,29-305