03-05,,,Form CMS 265-94,,,,3490 (Cont.)
This report is required by law (42 USC. 1395g: CFR 413.20(b)).  Failure to report can result,,,,,,FORM APPROVED,
in all payments made during the reporting period being deemed overpayments (42 USC 1395g).,,,,,,OMB NO: 0938-0236,
INDEPENDENT RENAL DIALYSIS FACILITY,,,,PROVIDER NO:,PERIOD:,WORKSHEET,
COST REPORT CERTIFICATION,,,,,From:_________,S,
,,,,_______________,To: ____________,,
Intermediary Use Only:,,,,,,,
,,[      ]  Audited    ,Date Received ________________,,[      ]  Initial,[     ]  Re-opened,
,,[      ]  Desk Reviewed,Intermediary No.  ______________,,[      ]  Final,,
PART I - GENERAL,,,,,,,
Check,,,[     ] Electronic filed cost report,,Date:,,
applicable box,,,[     ] Manually submitted cost report,,Time:,,
1,Name:,,,,,,1
1.01,Street:,,,,P.O. Box:,,1.01
1.02,City:,,State:,,Zip Code:,,1.02
1.03,County:,,,,,,1.03
2,Provider Number:,,,,,,2
3,Date Certified:,,,,,,3
4,Name :,,,Phone Number:,,,4
5,Cost reporting period (mm/dd/yyyy),,,From:_________,To: ____________,,5
,,,,,1,2,
6,Type of control (see instructions),,,,,,6
,,,,,1,2,
7,Type  of  Physicians' Reimbursement (see instructions),,,,,,7
8,Was this facility previously certified as a hospital-based unit?,,,,,,8
,"Enter ""Y"" for yes or ""N"" for no.",,,,,,
9,"If you are part of a chain organization enter ""y"" for yes and enter the name and address of the home office, ",,,,,,9
,"if not, enter ""N"" for no.",,,,,,
9.01,Name:,,,,,,9.01
9.02,Street:,,,,P.O. Box:,,9.02
9.03,City:,,State:,,Zip Code:,,9.03
PART II - 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 OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL,",,,,,,,
"CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.",,,,,,,
,,,,,,,
I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report prepared by ________________________                                                           ,,,,,,,
______________________(Provider Name and Number) for the cost report period beginning ________________ and ending__________________and that,,,,,,,
"to the best of my knowledge and belief, it is  a true, correct and complete statement 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 regulation.,,,,,,,
,,,,,,,
(Signed),,,,,,,
Officer or Administrator of Facility,,,,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 to average 50 hours per response, including the time to review instructions, search existing data",,,,,,,
"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: Centers for Medicare & Medicaid Services, 7500",,,,,,,
"Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.",,,,,,,
"FORM CMS-265-94 (3-2005) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, ",,,,,,,
"SECTIONS 3404, 3404.1 AND 3404.2)",,,,,,,
,,,,,,,
Rev. 7,,,,,,,34-303