3490 (Cont.),,,Form CMS-265-94 ,,,,03-05
,,INDEPENDENT,PROVIDER NO.:,PERIOD:,,,
,,RENAL DIALYSIS FACILITY,,FROM_______________,,WORKSHEET S-1,
,,STATISTICAL DATA,___________________,TO________________,,,
,,,,,,,
,,RENAL DIALYSIS STATISTICS,,,,,
,,,                         OUTPATIENT,,                            TRAINING,,
,,,,PERITONEAL,,PERITONEAL,
,,,HEMODIALYSIS,DIALYSIS,HEMODIALYSIS,DIALYSIS,
,,,1,2,3,4,
1,Number of treatments not billed to Medicare and ,,,,,,1
,furnished directly,,,,,,
2,Number of treatments not billed to Medicare and,,,,,,2
,furnished under arrangements,,,,,,
3,Number of patients currently in dialysis program,,,,,,3
4,Average times per week patient receives dialysis,,,,,,4
5,Number of days in an average week for patient,,,,,,5
,dialysis treatments,,,,,,
6,Average time of patient dialysis treatment,,,,,,6
,including set up time,,,,,,
7,Number of machines regularly available for use,,,,,,7
8,Number of standby machines,,,,,,8
9,Number of shifts in typical week during regular,,,,,,9
,reporting period,,,,,,
10,Hours per shift in typical week during regular,,,,,,10
,reporting period,,,,,,
,.01,First shift,,,,,.01
,.02,Second Shift,,,,,.02
,.03,Third shift,,,,,.03
11,Number of treatments provided,,,,,,11
,.01,One (1) time per week,,,,,.01
,.02,Two (2) times per week,,,,,.02
,.03,Three (3) times per week,,,,,.03
,.04,More than three  (3) times per week,,,,,.04
,.05,Total,,,,,.05
,,,,Type of Dialyzers,Dialyzer Reuse Count,Other Dialyzers,
,,,,1,2,3,
12,"Type of dialyzers used. If dialyzers are reused, indicate the number of times (see instruction)",,,,,,12
13,Number of back-up sessions furnished to home patients (see instructions) ,,,,,,13
,,,,,,,
14,Number of units of epoetin furnished during cost reporting period,,,,,,14
,,,                TRANSPLANT STATISTICS,,,,
15,Number of patients who are awaiting transplants,,,,,,15
16,Number of patients who received transplants during this period,,,,,,16
,,,                      HOME PROGRAM,,,,
17,Number of patients commencing home dialysis training during this period,,,,,,17
18,Number of patients currently in home program,,,,,,18
,,,,1,2,3,
19,"Type of dialyzers used. If dialyzers are reused, indicate number of times (see instructions)",,,,,,19
,,,,,,,
,RENAL DIALYSIS FACILITY--NUMBER OF EMPLOYEES,,,,,,
,,(FULL TIME EQUIVALENTS),,,,,
Enter the number of hours in your normal work week  ,,,,Staff,Contract,Total,
,,,,1,2,3,
20,Physicians,,,,,,20
21,Registered Nurses,,,,,,21
22,Licensed Practical Nurses,,,,,,22
23,Nurses Aides,,,,,,23
24,Technicians,,,,,,24
25,Social Workers,,,,,,25
26,Dieticians,,,,,,26
27,Administrative,,,,,,27
28,Management,,,,,,28
29,Other (Specify),,,,,,29
,,,,,,,
,,,,,,,
FORM CMS 265-94 (3-2005)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II SECTION 3405,,,,,,,
,,,,,,,
34-304,,,,,,,Rev. 7