06-13,,, FORM CMS-265-11,,,,,,,,4290 (Cont.) This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim,,,,,,,,,FORM APPROVED,, payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).,,,,,,,,,OMB NO: 0938-0236,, INDEPENDENT RENAL DIALYSIS FACILITY,,,,, PROVIDER CCN:,, PERIOD:,, WORKSHEET S,, COST REPORT CERTIFICATION,,,,,,, From: ,,,, ,,,,,,, To: ,,,, PART I - COST REPORT STATUS,,,,,,,,,,, Provider use only,, 1. [ ] Electronically filed cost report,,Date (mm/dd/yyyy): ____________________,,,Time: ____________________,,,, ,, 2. [ ] Manually submitted cost report,,,,,,,,, ,, 3. If this is an amended report enter the number of times the provider resubmitted this cost report. ______,,,,,,,,, Contractor ,, 4. [ ] Cost Report Status,,,5. Date Received: _________,,,,,, use only,, (1) As Submitted,,,6. Contractor No._________,,,,,, ,, (2) Settled without Audit,,,7. [ ] First Cost Report for this Provider CCN,,,,,, ,, (3) Settled with Audit,,,8. [ ] Last Cost Report for this Provider CCN,,,,,, ,, (4) Reopened,,,9. NPR Date: __________,,,,,, ,, (5) Amended ,,,"10. If line 4, column 1 is ""4"", enter number of times reopened _______",,,,,, ,,,,,11. Contractor Vendor Code ________,,,,,, ,,,,,,,,,,, PART II - GENERAL,,,,,,,,,,, 1 , Name: ,,,,,,,,,,1 2 , Street: ,,,,,, P.O. Box:,,,,2 3 , City: ,,, State: ,,, ZIP Code: ,,,,3 4 , County: ,,, CBSA: ,,,,,,,4 5 , Provider CCN: ,,,,,,,,,,5 6 , Date Certified: ,,,,,,,,,,6 7 , Contact Person Name : ,,,,,, Phone Number: ,,,,7 8 , Cost reporting period (mm/dd/yyyy),, From: ,,To: ,,,,,,8 ,,,,,,,1,,2,, 9 , Type of control (see instructions),,,,,,,,,,9 10 ," Is this facility approved as a low-volume facility for this cost reporting period? Enter ""Y"" for yes or ""N"" for no.",,,,,,,,,,10 ,,,,,,,1,,2,, 11 , Type of physicians' reimbursement (see instructions),,,,,,,,,,11 12 ," Was this facility previously certified as a hospital-based unit? Enter ""Y"" for yes or ""N"" for no.",,,,,,,,,,12 13 ," Did your facility elect 100% PPS effective January 1, 2011? Enter ""Y"" for yes or ""N"" for no. (If certified on/after 1/1/2011, see instructions.)",,,,,,,,,,13 ,,,,,,,1,,2,, 14 ," If you responded ""N"" to line 13, enter in column 1 the year of transition for periods prior to January 1 and",,,,,,,,,,14 , enter in column 2 the year of transition for periods after December 31. (see instructions),,,,,,,,,, 15 , Malpractice premiums,,,,,,,,,,15 16 , Malpractice paid losses,,,,,,,,,,16 17 , Malpractice self insurance,,,,,,,,,,17 18 ," Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center? Enter ""Y"" for yes or ""N"" for no.",,,,,,,,,,18 ," If yes, submit a supporting schedule listing cost centers and amounts contained therein.",,,,,,,,,, 19 ," Are you part of a chain organization? Enter ""Y"" for yes or ""N"" for no. If yes, complete lines 20 through 22.",,,,,,,,,,19 20 , Name:,,,,,,,,,,20 21 , Street:,,,,,, P.O. Box:,,,,21 22 , City:,,, State:,,, ZIP Code: ,,,,22 ,,,,,,,,,,, PART III - CERTIFICATION BY OFFICER OR ADMINISTRATOR,,,,,,,,,,, " MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL, AND ",,,,,,,,,,, " ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED ",,,,,,,,,,, " THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION, FINES ",,,,,,,,,,, AND/OR IMPRISONMENT MAY RESULT.,,,,,,,,,,, ,,,,,,,,,,, ,CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER,,,,,,,,,, ,,,,,,,,,,, ,I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted cost report,,,,,,,,,, ,and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Provider CCN(s)} for the cost reporting,,,,,,,,,, ,"period beginning _______________ and ending _______________ and that to the best of my knowledge and belief, this report and statement are true, correct, complete and",,,,,,,,,, ,"prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations ",,,,,,,,,, ,"regarding the provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and regulations.",,,,,,,,,, ,,,,,,,,,,, ,OFFICER OR ADMINISTRATOR OF PROVIDER,,,,,,,,,, ,,,,,,,,,,, , Printed Name___________________________________________,,,Signed________________________________________________,,,,,,, ,,,,,,,,,,, , Title__________________________________________________,,,Date__________________________________________________,,,,,,, ,,,,,,,,,,, " According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information",,,,,,,,,,, " collection is 0938-0236. The time required to complete this information collection is estimated 65 hours per response, including the time to review instructions, search existing resources, gather the data needed, and",,,,,,,,,,, " complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,",,,,,,,,,,, " Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.",,,,,,,,,,, ,,,,,,,,,,, "FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4204, 4204.1 AND 4204.2)",,,,,,,,,,, ,,,,,,,,,,, Rev. 2,,,,,,,,,,,42-303