12-05,,,,,Form CMS-265-94,,,,,,,,3490 (Cont.)
COST ALLOCATION-STATISTICAL BASIS,,,,,FACILITY NO.:,,,REPORTING PERIOD:,,,WORKSHEET B-1,,
,,,,,,,,FROM________________,,,,,
,,,,,___________________,,,TO_______________,,,,,
,,,CAP. RELATED,,,EMPLOYEE,,,,,,,
,,,OPERATION,,SALARIES ,HEALTH &,,,,,,,
,COST CENTERS,,AND MAINT.,MACHINE,FOR,WELFARE,,,,,UNIT,,
,,,OF PLANT,CAP. RELATED,DIRECT ,BENEFITS ,DRUGS,SUPPLIES,LABORATORY,,COST,,
,,,AND ,OR RENTAL,PATIENT ,FOR DIRECT,,,,,MULTIPLIER,,
,,,HOUSE,AND MAINT.,CARE,PATIENT,,,,,COMPUTATION,,
,,,KEEPING,(%0F,(HRS. OF,CARE,,,,,,9 & 10),
,,,,(% OF,(HRS. OF,(GROSS,,,,,,,
,,,(SQ. FEET),TIME SPENT),SERVICE),SALARIES),(CHARGES),(CHARGES),(CHARGES),,,,
,,1,2,3,4,5,6,7,8,9,10,11,
1,COSTS TO BE ALLOCATED,,,,,,,,,,,,1
2 ,Separately Billable Drugs,,,,,,,,,,,,2 
3,Separately Billable Supplies,,,,,,,,,,,,3 
4,Separately Billable,,,,,,,,,,,,4 
,Laboratory Services,,,,,,,,,,,,
5,Whole Blood and Packed ,,,,,,,,,,,,5 
,Red Blood Cells,,,,,,,,,,,,
6,Hepatitis B Vaccine,,,,,,,,,,,,6 
,REIMBURSABLE ,,,,,,,,,,,,
,COST CENTERS,,,,,,,,,,,,
7,Maintenance-Hemodialysis,,,,,,,,,,,,7 
8,Maintenance,,,,,,,,,,,,8 
,Peritoneal Dialysis,,,,,,,,,,,,
9,Training-Hemodialysis,,,,,,,,,,,,9 
10,Training-Peritoneal Dialysis,,,,,,,,,,,,10 
11,Training-CAPD,,,,,,,,,,,,11 
12,Training-CCPD,,,,,,,,,,,,12 
13,Home Program-Hemodialysis,,,,,,,,,,,,13 
14,Home Program-,,,,,,,,,,,,14 
,Peritoneal Dialysis,,,,,,,,,,,,
15,Home Program-CAPD,,,,,,,,,,,,15 
16,Home Program-CCPD,,,,,,,,,,,,16 
,NONREIMBURSABLE ,,,,,,,,,,,,
,COST CENTERS,,,,,,,,,,,,
17,Physicians' Private Offices,,,,,,,,,,,,17 
18,Method II Patients,,,,,,,,,,,,18 
19,,,,,,,,,,,,,19 
20,,,,,,,,,,,,,20 
21,Total (SEE INSTRUCTIONS),,,,,,,,,,,,21 
22,Total Costs to be Allocated,,,,,,,,,,,,22 
23,Unit Cost Multiplier (22/21),,,,,,,,,,,,23
,,,,,,,,,,,,,
"FORM CMS-265-94 (2/95)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3411)",,,,,,,,,,,,,
,,,,,,,,,,,,,
Rev. 9,,,,,,,,,,,,,34-311