3490 (Cont.),,,,,Form CMS-265-94,,,,,,,,12-05
COST ALLOCATION-GENERAL SERVICE COSTS,,,,,FACILITY NO.:,,,REPORTING PERIOD,,,WORKSHEET B,,
,,,,,,,,FROM,,,,,
,,,,,,,,TO,,,,,
,,NET,CAP. RELATED,,,EMPLOYEE,,,,,,TOTAL,
,,EXPENSES,OPERATION,,SALARIES ,HEALTH &,,,,,,EXPENSES,
,,FOR COST,AND MAINT.,MACHINE,FOR,WELFARE,,,,SUBTOTAL,A & G,ALL,
,,ALLOCATION,OF PLANT,CAP. RELATED,DIRECT ,BENEFITS ,DRUGS,SUPPLIES,LABORATORY,(COLS.1-8),& OTHER,PATIENT,
,,(FROM,AND ,OR RENTAL,PATIENT ,FOR DIRECT,,,,,COST,SERVICES,
,,"WKST. A, ",HOUSE,AND MAINT.,CARE,PATIENT,,,,,CENTERS,(COLS.,
,,COL.8),KEEPING,,,CARE,,,,,,9 & 10),
,,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*
16.01,Subtotal (sum oflines 1-16),,,,,,,,,,,,16.01
,NONREIMBURSABLE ,,,,,,,,,,,,
,COST CENTERS,,,,,,,,,,,,
17,Physicians' Private Offices,,,,,,,,,,,,17 
18,Method II Patients,,,,,,,,,,,,18 
19,,,,,,,,,,,,,19 
20,,,,,,,,,,,,,20 
21,Totals (see instructions) ,,,,,,,,,,,,21 
"*Transfer the amounts to Worksheet C, column 2, as appropriate",,,,,,,,,,,,,
"The total of column 1, line 21 must equal the amount on Worksheet A, column 8, line 27.",,,,,,,,,,,,,
"FORM CMS-265-94 (12-2005)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3411)",,,,,,,,,,,,,
,,,,,,,,,,,,,
34-310,,,,,,,,,,,,,Rev. 9