12-11,,,, FORM CMS-265-11,,,,,,,,,,,,,,,,,,4290 (Cont.) INDEPENDENT RENAL DIALYSIS FACILITY,,,,, PROVIDER CCN:, PERIOD:,,,,,,,, WORKSHEET S-2,,,,,,,, REIMBURSEMENT QUESTIONNAIRE,,,,,, From: ,,,,,,,,,,,,,,,, ,,,,,, To: ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,Y/N,,,,,DATE,,,,,V/I,,,,, PROVIDER ORGANIZATION AND OPERATION,,,,,,,,,1 ,,,,,2 ,,,,,3 ,,, 1 , Has the provider changed ownership immediately prior to the beginning of the cost reporting period? ,,,,,,,,,,,,,,,,,,,,,1 ," Enter ""Y"" for yes or ""N"" for no in column 1. If yes, enter the date (mm/dd/yyyy) of the change in column 2. ",,,,,,,,,,,,,,,,,,,,, , (see instructions),,,,,,,,,,,,,,,,,,,,, 2 ," Has the provider terminated participation in the Medicare Program? Enter ""Y"" for yes or ""N"" for no in column 1. ",,,,,,,,,,,,,,,,,,,,,2 ," If yes, enter in column 2 the termination date (mm/dd/yyyy); and, enter in column 3, ""V"" for voluntary or ""I""",,,,,,,,,,,,,,,,,,,,, , for involuntary.,,,,,,,,,,,,,,,,,,,,, 3 ," Is the provider involved in business transactions, including management contracts, with individuals or entities",,,,,,,,,,,,,,,,,,,,,3 ," (e.g., chain home offices, drug or medical supply companies) that were related to the provider or its officers,",,,,,,,,,,,,,,,,,,,,, ," medical staff, management personnel, or members of the board of directors through ownership, control, or",,,,,,,,,,,,,,,,,,,,, ," family and other similar relationships? Enter ""Y"" for yes or ""N"" for no in column 1. (see instructions)",,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,Y/N,,,,,A/C/R,,,,,DATE,,,,, FINANCIAL DATA AND REPORTS,,,,,,,,,1 ,,,,,2 ,,,,,3 ,,, 4 ," Column 1: Were the financial statements prepared by a Certified Public Accountant? Enter ""Y"" for yes or ""N"" for no.",,,,,,,,,,,,,,,,,,,,,4 ," Column 2: If yes, enter in column 2: ""A"" for Audited, ""C"" for Compiled, or ""R"" for Reviewed. Submit complete copy",,,,,,,,,,,,,,,,,,,,, ," of financial statements or enter date available (mm/dd/yyyy) in column 3. (see instructions) If no, see instructions.",,,,,,,,,,,,,,,,,,,,, 5 ," Are the cost report total expenses and total revenues different from those on the filed financial statements? Enter ""Y""",,,,,,,,,,,,,,,,,,,,,5 ," for yes or ""N"" for no in column 1. If yes, submit reconciliation.",,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, BAD DEBTS,,,,,,,,,,,,,,,,,Y/N,,,,, 6 ," Is the provider seeking reimbursement for bad debts? Enter ""Y"" for yes or ""N"" for no. If yes, see instructions.",,,,,,,,,,,,,,,,,,,,,6 7 ," If line 6 is yes, did the provider's bad debt collection policy change during the cost reporting period? ""Y"" for yes or ""N"" for no. If yes, submit copy.",,,,,,,,,,,,,,,,,,,,,7 8 ," If line 6 is yes, were patient deductibles and/or co-payments waived? Enter ""Y"" for yes or ""N"" for no. If yes, see instructions.",,,,,,,,,,,,,,,,,,,,,8 ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,Y/N,,,,,DATE,,,,, PS&R REPORT DATA,,,,,,,,,,,,,,1 ,,,,,2 ,,, 9 ," Was the cost report prepared using the PS&R report only? Enter ""Y"" for yes or ""N"" for no in column 1. If yes, enter in column 2 the",,,,,,,,,,,,,,,,,,,,,9 , paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions.),,,,,,,,,,,,,,,,,,,,, 10 ," Was the cost report prepared using the PS&R report for totals and the provider's records for allocation? Enter ""Y"" for yes or ""N"" for no",,,,,,,,,,,,,,,,,,,,,10 ," in col.1. If yes, enter in col. 2 the paid-through date (mm/dd/yyyy) of the PS&R report used to prepare the cost report. (see instructions)",,,,,,,,,,,,,,,,,,,,, 11 ," If line 9 or 10 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included on the",,,,,,,,,,,,,,,,,,,,,11 ," PS&R report used to file the cost report? Enter ""Y"" for yes or ""N"" for no. If yes, see instructions.",,,,,,,,,,,,,,,,,,,,, 12 ," If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter ""Y"" for yes",,,,,,,,,,,,,,,,,,,,,12 ," or ""N"" for no. If yes, see instructions.",,,,,,,,,,,,,,,,,,,,, 13 ," If line 9 or 10 is yes, were adjustments made to PS&R report data for Other? Enter ""Y"" for yes or ""N"" for no.",,,,,,,,,,,,,,,,,,,,,13 ," If yes, describe the other adjustments: ",,__________________________________________________________________________,,,,,,,,,,,,,,,,,,, 14 ," Was the cost report prepared only using the provider's records? Enter ""Y"" for yes or ""N"" for no. ",,,,,,,,,,,,,,,,,,,,,14 ," If yes, see instructions.",,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, "FORM CMS-265-11 (12/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4205.1)",,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,, Rev. 1,,,,,,,,,,,,,,,,,,,,,,42-305