06-13,,            FORM CMS-265-11       ,,,,4290 (Cont.)
 STATEMENT  OF  REVENUES  AND  EXPENSES,,, PROVIDER CCN:, PERIOD:, WORKSHEET F-1,
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,,,Amount,Amount,,
1 , Total patient revenues,,,,1 ,
2 , Less:  Allowances and discounts on patients' accounts,,,,2 ,
3 , Net patient revenues (Line 1 minus line 2),,,,3 ,
4 ," Operating expenses (From Worksheet A, column 6, line 27)",,,,4 ,
5 , Additions to operating expenses (Specify),,,,5 ,
6 ,,,,,6 ,
7 ,,,,,7 ,
8 ,,,,,8 ,
9 ,,,,,9 ,
10 ,,,,,10 ,
11 , Subtractions from operating expenses (Specify),,,,11 ,
12 ,,,,,12 ,
13 ,,,,,13 ,
14 ,,,,,14 ,
15 ,,,,,15 ,
16 ,,,,,16 ,
17 , Less total operating expenses (net of lines 4 through 16),,,,17 ,
18 , Net income from services to patients (Line 3 minus line 17),,,,18 ,
, Other income:,,,,,
19 ," Contributions, donations, bequests, etc.",,,,19 ,
20 , Income from investments,,,,20 ,
21 , Purchase discounts,,,,21 ,
22 , Rebates and refunds of expenses,,,,22 ,
23 , Sale of medical and nursing supplies to other than patients,,,,23 ,
24 , Sale of durable medical equipment to other than patients,,,,24 ,
25 , Sale of drugs to other than patients,,,,25 ,
26 , Sale of medical records and abstracts,,,,26 ,
27 , Other revenues (Specify),,,,27 ,
28 ,,,,,28 ,
29 ,,,,,29 ,
30 ,,,,,30 ,
31 ,,,,,31 ,
32 , Total Other Income (Sum of lines 19 through 31),,,,32 ,
33 , Net Income or Loss for the period (Line 18 plus line 32),,,,33 ,
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"FORM CMS-265-11 (06/2013)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)",,,,,,
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Rev. 2,,,,,,42-319