04-02,,,,Form CMS-265-94,,,,,3490 (Cont.)
ADJUSTMENTS TO EXPENSES,,FACILITY NO.:,,,REPORTING PERIOD:,,WORKSHEET A-2,,
,,,,,FROM:_____________,,,,
,,___________________,,,TO:____________,,,,
,,Basis for,,,Expense Classification on Worksheet A,,,,
,, Adjust-,,,from which amount is to be deducted,,,,
,Description (1),  ment,,,or to which the amount is to be added,,,,
,,    (2),,Amount,                 Cost Center,,,Line No.,
,,     1,,2,                          3,,,4,
1, Investment Income on Commingled,,,,,,,,1
, Restricted and Unrestricted Funds,,,,,,,,
, (chapter 2),,,,,,,,
2,"Trade, Quantity and Time Discounts",,,,,,,,2
, on Purchases (chapter 8),,B,,,Administrative & General,,12,
3, Rebates and Refunds of,,,,,,,,3
, Expenses (chapter 8),,,,,,,,
4, Rental of Building or Office,,,,,,,,4
, Space to Others,,,,,,,,
5, Physician Non Routine Professional,,,,,,,,5
, Patient Care Services,,,,,,,,
6, Home Office Costs,,,,,,,,6
, (chapter 21),,,,,,,,
7, Adjustment Resulting From Transactions,  From,,,,,,,7
, With Related Organizations,  Wkst.,,,,,,,
, (chapter 10),    A-3,,,,,,,
8, Vending Machines,,,,,,,,8
9, Meals Served to Patients,,,,,,,,9
10, Physicians' Professional    ,,,,,,,,10
, Services--MCP Method,,,,,,,19,
11, Services Under Arrangement,,,,,,,,11
12, Provision for Doubtful Accounts,,,,,,,,12
13, Capital Related -Buildings & Fixtures,,,,,Capital-Related,,1,13
14, Capital Related -Moveable Equipment,,,,,Capital-Related,,2,14
15, Rebates on Epoetin,,,,,Epoetin,,23,15
16, Epoetin,,,,,Epoetin,,23,16
17, Other (Specify),,,,,,,,17
18, Other (Specify),,,,,,,,18
19, Other (Specify),,,,,,,,19
20, Other (Specify),,,,,,,,20
21,Total Transfer to Wkst. A,,,,,,,,21
,"col.7, line 27",,,,,,,,
,,,,,,,,,
,(1) Description-all chapter references in this column pertain to CMS Pub. 15-II,,,,,,,,
,(2) Basis for adjustment (SEE INSTRUCTIONS),,,,,,,,
,"       A. Costs-if cost, including applicable overhead, can be determined",,,,,,,,
,       B. Amount Received-if cost cannot be determined,,,,,,,,
,,,,,,,,,
,FORM CMS-265-94 (8/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS,,,,,,,,
,"PUB 15-II, SECTION 3408)",,,,,,,,
Rev. 6,,,,,,,,,34-307