4290 (Cont.),,,,             FORM CMS-265-11,,,,,,,12-11
 RECLASSIFICATION  AND  ADJUSTMENT  OF  TRIAL BALANCE ,,,,,, PROVIDER CCN:,, PERIOD:,, WORKSHEET A,
 OF  EXPENSES,,,,,,,, From:   ,,,
,,,,,,,, To:   ,,,
,,,,,,,RECLASS.,,,NET EXPENSES,
,,,SALARIES,,,TOTAL,TO EXPENSES,RECLASSIFIED,ADJUSTMENTS,FOR COST,
,,FACILITY  HEALTH  CARE  COSTS,PHYSICIAN,              ,,( col. 1 through,( from,TRIAL BALANCE,TO EXPENSES,ALLOCATION,
,,,COMPENSATION,OTHER,OTHER,col. 3 ),Wkst. A-1 ),( col 4. +/- col. 5 ),( from Wkst. A-2 ),( col. 6+/-col. 7 ),
,,,1,2,3,4,5,6,7,8,
 ,,COST  CENTERS,,,,,,,,,
1 ,0100, Cap Rel Costs-Bldg & Fixt,,,,,,,,,1 
2 ,0200, Cap Rel Costs-Mvble Equip,,,,#N/A,,,,,2 
3 ,0300, Operation & Maintenance of Plant,,,,#N/A,,,,,3 
4 ,0400, Housekeeping,,,,#N/A,,,,,4 
5 ,, Subtotal (sum of lines 1 through 4)*,,,,#N/A,,,,,5 
6 ,0600, Machine Cap-Rel or Rental & Maint*,,,,#N/A,,,,,6 
7 ,0700, Salaries for Direct Patient Care*,,,,#N/A,,,,,7 
8 ,0800, EH&W Benefits for Direct Pt. Care,,,,#N/A,,,,,8 
9 ,0900, Supplies*,,,,#N/A,,,,,9 
10 ,1000, Laboratory*,,,,#N/A,,,,,10 
11 ,1100, Administrative & General,,,,#N/A,,,,,11 
12 ,1200, Drugs*,,,,#N/A,,,,,12 
13 ,1300, Interest Expense,,,,#N/A,,,,,13 
14 ,1400, Laundry and Linen,,,,#N/A,,,,,14 
15 ,1500, Medical Records,,,,#N/A,,,,,15 
16 ,1600, Phy Rout Prof Svcs-Initial Method,,,,#N/A,,,,,16 
17 ,1700, Other (Specify),,,,#N/A,,,,,17 
18 ,, Subtotal (sum of line 11 plus lines 13 through 17)*,#N/A,,,,#N/A,,#N/A,,18 
19 ,1900, Phy Rout Prof Svcs-MCP Method,,,,#N/A,,,,,19 
20 ,2000, Whole Blood & Packed Red Blood Cells*,,,,#N/A,,,,,20 
21 ,2100, Vaccines*,,,,#N/A,,,,,21 
,,NONREIMBURSABLE  COSTS  CENTERS,,,,,,,,,
22 ,2200, Physicians Private Offices*,,,,,,,,,22 
23 ,2300," ESAs (prior to January 1, 2011)",,,,,,,,,23 
24 ,2400," Method II Patients (prior to January 1, 2011)",,,,,,,,,24 
25 ,2500, Other Nonreimbursable (Specify)*,,,,,,,,,25 
26 ,2600, Other Nonreimbursable (Specify)*,,,,,,,,,26 
27 ,, Total,,,,,,,,,27 
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" * Transfer the amounts in column 8 to Worksheet B and B-1, as appropriate.",,,,,,,,,,,
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"FORM CMS-265-11 (12/2011)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4206)",,,,,,,,,,,
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42-306,,,,,,,,,,,Rev. 1