03-05,,,,Form CMS-265-94,,,,,,,3490 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE ,,,,FACILITY NO.:,,REPORTING PERIOD,,,WORKSHEET A,,
OF EXPENSES,,,,,,FROM:_______________________,,,,,
,,,,_________________,,TO:____________________,,,,,
,,,,,,,RECLASS.,RECLASSIFIED,ADJUSTMENTS,NET EXPENSES,
,,,SALARIES,,,,TO EXPENSES,TRIAL BALANCE,TO EXPENSES,FOR COST,
,,FACILITY HEALTH CARE COSTS,PHYSICIAN,              ,,TOTAL,(FROM ,(COL.4,(FROM,ALLOCATION,
,,,COMPENSATION,OTHER,OTHER,(COL.1-COL.3),WKST.A-1),+/- COL.5),(WKST. A-2),(COL.6+/-COL.7) ,
,,,1,2,3,4,5,6,7,8,
 ,,COST CENTERS,,,,,,,,,
1,0100,Capital-Related--Buildings and Fixtures ,,,,,,,,,1
2,0200,Capital-Related--Moveable Equipment,,,,,,,,,2
3,0300,Operation and Maintenance of Plant,,,,,,,,,3
4,0400,Housekeeping,,,,,,,,,4
5*,,Subtotal (sum of lines 1-4),,,,,,,,,5*
6*,0600,Machine Capital-Related or Rental and Maintenance,,,,,,,,,6*
7*,0700,Salaries for Direct Patient Care,,,,,,,,,7*
8*,0800,Emp. Health & Welfare Benefits for Direct Patient Care,,,,,,,,,8*
9*,0900,Drugs,,,,,,,,,9*
10*,1000,Supplies,,,,,,,,,10*
11*,1100,Laboratory,,,,,,,,,11*
12,1200,Administrative and General,,,,,,,,,12
13,1300,Interest Expense,,,,,,,,-0-,13
14,1400,Laundry and Linen,,,,,,,,,14
15,1500,Medical Records,,,,,,,,,15
16,1600,Physicians' Routine Professional Services-Initial Method,,,,,,,,,16
17,1700,Other (Specify),,,,,,,,,17
18*,,Subtotal(sum of lines 12-17),,,,,,,,,18*
19,1900,Physicians' Routine Professional Services-MCP Method,,,,,,,(             ),-0-,19
20*,2000,Whole Blood and Packed Red Blood Cells,,,,,,,,,20*
21*,2100,Hepatitis B Vaccine,,,,,,,,,21*
,,NONREIMBURSABLE COSTS CENTERS,,,,,,,,,
22*,2200,Physicians' Private Offices,,,,,,,,,22*
23,2300,Epoetin,,,,,,,,-0-,23
24*,2400,Method II Patients (Direct Dealing),,,,,,,,,24*
25*,2500,Other Nonreimbursable (Specify),,,,,,,,,25*
26*,2600,Other Nonreimbursable (Specify),,,,,,,,,26*
27,,Total,,,,,-0-,,,,27
,,,,,,,,,,,
"* Transfer the amounts in column 8 to Worksheet B and B-1, as appropriate.",,,,,,,,,,,
,,,,,,,,,,,
"FORM CMS-265-94 (3-2005)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3406)",,,,,,,,,,,
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Rev. 7,,,,,,,,,,,34-305