01-05,,,Form CMS-222-92,,,,2990 (Cont.) INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING,,,,PROVIDER CCN:,PERIOD:,WORKSHEET, FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET,,,,,FROM: ,S, STATISTICAL DATA AND CERTIFICATION STATEMENT,,,,CLINIC CCN:,TO:,PART III, ,,,,,,, ,,,,,,, PART III - STATISTICAL DATA FOR CLINICS FILING UNDER CONSOLIDATED COST REPORTING ,,,,,,, 1 ,Name:,,,,,,1 2 ,Street:,,,,P.O. Box:,,2 3 ,City:,,State:,,Zip Code:,,3 4 ,County:,,,,,,4 5 ,Provider Number:,,,,,,5 6 ,Designation:,,,Date Certified:,,,6 ,,,,,,, 7 ,Names of physicians furnishing services at the health facility or under agreement,,,,,,7 ,(as described in instructions) and Medicare billing numbers (include all Part B billing numbers),,,,,, ,,Name,,,,Billing Number, ,,1 ,,,,2 , 7.01 ,,,,,,,7.01 7.02 ,,,,,,,7.02 7.03 ,,,,,,,7.03 7.04 ,,,,,,,7.04 7.05 ,,,,,,,7.05 ,,,,,,, 8 ,, Supervisory Physicians,,,,,8 ,,,,,Hours of Supervision,, ,,Name,,,For Reporting Period,, ,,1 ,,,2 ,, 8.01 ,,,,,,,8.01 8.02 ,,,,,,,8.02 8.03 ,,,,,,,8.03 8.04 ,,,,,,,8.04 8.05 ,,,,,,,8.05 ,,,,,,, 9,"Does the facility operate as other than a RHC or FQHC? Enter ""Y"" for yes or ""N"" for no.",,,,,,9 10,"If yes, specify what type of operation. (i.e., physicians office, independent laboratory, etc.)",,,,,,10 11,Identify days and hours by listing the time the facility operates as a RHC or FQHC next to the applicable day,,,,,,11 ,,Days,,,Hours of Operation,, ,,,,,From ,To, 11.01,,Sunday,,,,,11.01 11.02,,Monday,,,,,11.02 11.03,,Tuesday,,,,,11.03 11.04,,Wednesday,,,,,11.04 11.05,,Thursday,,,,,11.05 11.06,,Friday,,,,,11.06 11.07,,Saturday,,,,,11.07 12,Identify days and hours by listing the time the facility operates as other than a RHC or FQHC next to the applicable day.,,,,,,12 ,,Days,,,Hours of Operation,, ,,,,,From ,To, 12.01,,Sunday,,,,,12.01 12.02,,Monday,,,,,12.02 12.03,,Tuesday,,,,,12.03 12.04,,Wednesday,,,,,12.04 12.05,,Thursday,,,,,12.05 12.06,,Friday,,,,,12.06 12.07,,Saturday,,,,,12.07 ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, "FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 2903.2)",,,,,,, ,,,,,,, Rev. 7,,,,,,,29-304.1 ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, Rev. 7,,,,,,,29-303