4290 (Cont.),,FORM CMS-265-11,,,,,,,06-13
 ADJUSTMENTS  TO  EXPENSES,,, PROVIDER CCN:,, PERIOD:,, WORKSHEET A-2,,
,,,,, From:   ,,,,
,,,,, To:   ,,,,
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,,,,, Expense classification on Worksheet A from which,,,,
,,,BASIS FOR,, amount is to be deducted or to which the amount is,,,,
,,,ADJUSTMENT,, to be added,,,,
,DESCRIPTION (1),,(2),AMOUNT,COST CENTER,,,LINE NO.,
,,,1,2,3,,,4,
1 , Investment income on commingled restricted and unrestricted funds  (Chapter 2),,,,,,,,1 
2 ," Trade, quantity and time discounts on purchases  (Chapter 8)",,,,,,,,2 
3 , Rebates and refunds of expenses  (Chapter 8),,,,,,,,3 
4 , Rental of building or office space to others,,,,,,,,4 
5 , Physician non-routine professional patient care services,,,,,,,,5 
6 , Home office costs  (Chapter 21),,,,,,,,6 
7 , Adjustment resulting from transactions with related organizations  (Chapter 10),,From Wkst. A-3,,,,,,7 
8 , Vending machines,,,,,,,,8 
9 , Meals served to patients,,,,,,,,9 
10 , Physicians' professional services--MCP Method,,A ,, Physicians' professional services--MCP Method,,,19,10 
11 , Services under arrangement,,,,,,,,11 
12 , Provision for doubtful accounts,,,,,,,,12 
13 , Capital Related--Buildings & Fixtures,,,, Capital Related--Buildings & Fixtures,,,1,13 
14 , Capital Related--Moveable Equipment,,,, Capital Related--Moveable Equipment,,,2,14 
15 ," Rebates on Epoetin prior to January 1, 2011",,,, Epoetin,,,23,15 
16 , Epoetin,,A ,, Epoetin,,,23,16 
17 ," Rebates on Aranesp prior to January 1, 2011",,,, Aranesp,,,23,17 
18 , Aranesp,,A ,, Aranesp,,,23,18 
19 ," Rebates on Epoetin on or after January 1, 2011",,,, Epoetin,,,12,19 
20 ," Rebates on Aranesp on or after January 1, 2011",,,, Aranesp,,,12,20 
20.01," Rebates on ESA drugs on or after January 1, 2012",,,, Drugs,,,12,20.01
21 , Physician malpractice premiums,,,,,,,,21 
22 , Other (specify)   ,,,,,,,,22 
23 , Other (specify) ,,,,,,,,23 
24 , Other (specify) ,,,,,,,,24 
100 ," Total  (transfer to Wkst. A, col. 7, line 27)",,,,,,,,100 
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,(1) Description-all chapter references in this column pertain to CMS Pub. 15-1,,,,,,,,
,(2) Basis for adjustment (see instructions),,,,,,,,
,"       A. Costs-if cost, including applicable overhead, can be determined",,,,,,,,
,       B. Amount Received-if cost cannot be determined,,,,,,,,
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"FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4208)",,,,,,,,,
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42-308,,,,,,,,,Rev. 2