10-96 FORM CMS-2552-96 3690 (Cont.) 10-96 FORM CMS-2552-96 3690 (Cont.) 10-96 FORM CMS-2552-96 3690 (Cont.) ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," FROM _________ PART III FROM _________ PART III FROM _________ PART III _ TO ____________ _ TO ____________ _ TO ____________ DIRECTLY OLD CAPITAL NEW CAPITAL INTERN & ASSIGNED RELATED COSTS RELATED COSTS NON- INTERNS & INTERNS & RESIDENT NEW CAPITAL SUBTOTAL ADMINIS- MAIN- LAUNDRY MAIN- NURSING CENTRAL MEDICAL OTHER PHYSICIAN RESIDENTS RESIDENTS PARAMEDICAL COST & POST COST CENTER DESCRIPTIONS RELATED BLDGS. & MOVABLE BLDGS. & MOVABLE (sum of EMPLOYEE TRATIVE & TENANCE & OPERATION COST CENTER DESCRIPTIONS & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL COST CENTER DESCRIPTIONS GENERAL ANES- NURSING SALARY AND PROGRAM EDUCATION STEPDOWN COSTS FIXTURES EQUIPMENT FIXTURES EQUIPMENT (cols. 0-4) BENEFITS GENERAL REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (SPECIFY) SUBTOTAL ADJUSTMENTS TOTAL 0 1 2 3 4 4A 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 GENERAL SERVICE COST CENTERS GENERAL SERVICE COST CENTERS GENERAL SERVICE COST CENTERS 1 Old Capital Related Costs-Buildings and Fixtures 1 1 Old Capital Related Costs-Buildings and Fixtures 1 1 Old Capital Related Costs-Buildings and Fixtures 1 2 Old Capital Related Costs-Movable Equipment 2 2 Old Capital Related Costs-Movable Equipment 2 2 Old Capital Related Costs-Movable Equipment 2 3 New Capital Related Costs-Buildings and Fixtures 3 3 New Capital Related Costs-Buildings and Fixtures 3 3 New Capital Related Costs-Buildings and Fixtures 3 4 New Capital Related Costs-Movable Equipment 4 4 New Capital Related Costs-Movable Equipment 4 4 New Capital Related Costs-Movable Equipment 4 5 Employee Benefits X X X 5 5 Employee Benefits 5 5 Employee Benefits 5 6 Administrative and General X X X 6 6 Administrative and General 6 6 Administrative and General 6 7 Maintenance and Repairs X X X 7 7 Maintenance and Repairs 7 7 Maintenance and Repairs 7 8 Operation of Plant X X X 8 8 Operation of Plant 8 8 Operation of Plant 8 9 Laundry and Linen Service X X X 9 9 Laundry and Linen Service 9 9 Laundry and Linen Service 9 10 Housekeeping X X X 10 10 Housekeeping 10 10 Housekeeping 10 11 Dietary X X X 11 11 Dietary 11 11 Dietary 11 12 Cafeteria X X X 12 12 Cafeteria 12 12 Cafeteria 12 13 Maintenance of Personnel X X X 13 13 Maintenance of Personnel 13 13 Maintenance of Personnel 13 14 Nursing Administration X X X 14 14 Nursing Administration 14 14 Nursing Administration 14 15 Central Services and Supply X X X 15 15 Central Services and Supply 15 15 Central Services and Supply 15 16 Pharmacy X X X 16 16 Pharmacy 16 16 Pharmacy 16 17 Medical Records & Medical Records Library X X X 17 17 Medical Records & Medical Records Library 17 17 Medical Records & Medical Records Library 17 18 Social Service X X X 18 18 Social Service 18 18 Social Service 18 19 Other General Service (specify) X X X 19 19 Other General Service (specify) 19 19 Other General Service (specify) 19 20 Nonphysician Anesthetists X X X 20 20 Nonphysician Anesthetists 20 20 Nonphysician Anesthetists 20 21 Nursing School X X X 21 21 Nursing School 21 21 Nursing School 21 22 Intern & Res. Service-Salary & Fringes (Approved) X X X 22 22 Intern & Res. Service-Salary & Fringes (Approved) 22 22 Intern & Res. Service-Salary & Fringes (Approved) 22 23 Intern & Res. Other Program Costs (Approved) X X X 23 23 Intern & Res. Other Program Costs (Approved) 23 23 Intern & Res. Other Program Costs (Approved) 23 24 Paramedical Education Program (specify) X X X 24 24 Paramedical Education Program (specify) 24 24 Paramedical Education Program (specify) 24 INPATIENT ROUTINE SERVICE COST CENTERS INPATIENT ROUTINE SERVICE COST CENTERS INPATIENT ROUTINE SERVICE COST CENTERS 25 Adults and Pediatrics (General Routine Care) X X X 25 25 Adults and Pediatrics (General Routine Care) 25 25 Adults and Pediatrics (General Routine Care) X 25 26 Intensive Care Unit X X X 26 26 Intensive Care Unit 26 26 Intensive Care Unit X 26 27 Coronary Care Unit X X X 27 27 Coronary Care Unit 27 27 Coronary Care Unit X 27 28 Burn Intensive Care Unit X X X 28 28 Burn Intensive Care Unit 28 28 Burn Intensive Care Unit X 28 29 Surgical Intensive Care Unit X X X 29 29 Surgical Intensive Care Unit 29 29 Surgical Intensive Care Unit X 29 30 Other Special Care Unit (specify) X X X 30 30 Other Special Care Unit (specify) 30 30 Other Special Care Unit (specify) X 30 31 Subprovider (specify) X X X 31 31 Subprovider (specify) 31 31 Subprovider (specify) X 31 33 Nursery X X X 33 33 Nursery 33 33 Nursery X 33 34 Skilled Nursing Facility X X X X X X X X 34 34 Skilled Nursing Facility X X X X X X X X X X 34 34 Skilled Nursing Facility X X X 34 35 Nursing Facility X X X 35 35 Nursing Facility 35 35 Nursing Facility X 35 36 Other Long Term Care X X X 36 36 Other Long Term Care 36 36 Other Long Term Care X 36 "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" Rev. 1 36-542 Rev. 1 36-545 Rev. 1 36-548 10-96 FORM CMS-2552-96 3690 (Cont.) 10-96 FORM CMS-2552-96 3690 (Cont.) 10-96 FORM CMS-2552-96 3690 (Cont.) ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," FROM _________ PART III FROM _________ PART III FROM _________ PART III _ TO ____________ _ TO ____________ _ TO ____________ DIRECTLY OLD CAPITAL NEW CAPITAL INTERN & ASSIGNED RELATED COSTS RELATED COSTS NON- INTERNS & INTERNS & RESIDENT NEW CAPITAL SUBTOTAL ADMINIS- MAIN- LAUNDRY MAIN- NURSING CENTRAL MEDICAL OTHER PHYSICIAN RESIDENTS RESIDENTS PARAMEDICAL COST & POST COST CENTER DESCRIPTIONS RELATED BLDGS. & MOVABLE BLDGS. & MOVABLE (sum of EMPLOYEE TRATIVE & TENANCE & OPERATION COST CENTER DESCRIPTIONS & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL COST CENTER DESCRIPTIONS GENERAL ANES- NURSING SALARY AND PROGRAM EDUCATION STEPDOWN COSTS FIXTURES EQUIPMENT FIXTURES EQUIPMENT (cols. 0-4) BENEFITS GENERAL REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (SPECIFY) SUBTOTAL ADJUSTMENTS TOTAL 0 1 2 3 4 4A 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 ANCILLARY SERVICE COST CENTERS ANCILLARY SERVICE COST CENTERS ANCILLARY SERVICE COST CENTERS 37 Operating Room X X X 37 37 Operating Room 37 37 Operating Room X 37 38 Recovery Room X X X 38 38 Recovery Room 38 38 Recovery Room X 38 39 Delivery Room and Labor Room X X X 39 39 Delivery Room and Labor Room 39 39 Delivery Room and Labor Room X 39 40 Anesthesiology X X X 40 40 Anesthesiology 40 40 Anesthesiology X 40 41 Radiology-Diagnostic X X X 41 41 Radiology-Diagnostic 41 41 Radiology-Diagnostic X 41 42 Radiology-Therapeutic X X X 42 42 Radiology-Therapeutic 42 42 Radiology-Therapeutic X 42 43 Radioisotope X X X 43 43 Radioisotope 43 43 Radioisotope X 43 44 Laboratory X X X 44 44 Laboratory 44 44 Laboratory X 44 45 PBP Clinical Laboratory Services-Program Only 45 45 PBP Clinical Laboratory Services-Program Only 45 45 PBP Clinical Laboratory Services-Program Only 45 46 Whole Blood & Packed Red Blood Cells X X X 46 46 Whole Blood & Packed Red Blood Cells 46 46 Whole Blood & Packed Red Blood Cells X 46 47 "Blood Storing, Processing, & Trans." X X X 47 47 "Blood Storing, Processing, & Trans." 47 47 "Blood Storing, Processing, & Trans." X 47 48 Intravenous Therapy X X X 48 48 Intravenous Therapy 48 48 Intravenous Therapy X 48 49 Respiratory Therapy X X X 49 49 Respiratory Therapy 49 49 Respiratory Therapy X 49 50 Physical Therapy X X X 50 50 Physical Therapy 50 50 Physical Therapy X 50 51 Occupational Therapy X X X 51 51 Occupational Therapy 51 51 Occupational Therapy X 51 52 Speech Pathology X X X 52 52 Speech Pathology 52 52 Speech Pathology X 52 53 Electrocardiology X X X 53 53 Electrocardiology 53 53 Electrocardiology X 53 54 Electroencephalography X X X 54 54 Electroencephalography 54 54 Electroencephalography X 54 55 Medical Supplies Charged to Patients X X X 55 55 Medical Supplies Charged to Patients 55 55 Medical Supplies Charged to Patients X 55 56 Drugs Charged to Patients X X X 56 56 Drugs Charged to Patients 56 56 Drugs Charged to Patients X 56 57 Renal Dialysis X X X 57 57 Renal Dialysis 57 57 Renal Dialysis X 57 58 ASC (Non-Distinct Part) X X X 58 58 ASC (Non-Distinct Part) 58 58 ASC (Non-Distinct Part) X 58 59 Other Ancillary (specify) X X X 59 59 Other Ancillary (specify) 59 59 Other Ancillary (specify) X 59 OUTPATIENT SERVICE COST CENTERS OUTPATIENT SERVICE COST CENTERS OUTPATIENT SERVICE COST CENTERS 60 Clinic X X X 60 60 Clinic 60 60 Clinic X 60 61 Emergency X X X 61 61 Emergency 61 61 Emergency X 61 62 Observation Beds 62 62 Observation Beds 62 62 Observation Beds 62 63 Other Outpatient Service (specify) X X X 63 63 Other Outpatient Service (specify) 63 63 Other Outpatient Service (specify) X 63 OTHER REIMBURSABLE COST CENTERS OTHER REIMBURSABLE COST CENTERS OTHER REIMBURSABLE COST CENTERS 64 Home Program Dialysis X X X 64 64 Home Program Dialysis 64 64 Home Program Dialysis X 64 65 Ambulance Services X X X 65 65 Ambulance Services 65 65 Ambulance Services X 65 66 Durable Medical Equipment-Rented X X X 66 66 Durable Medical Equipment-Rented 66 66 Durable Medical Equipment-Rented X 66 67 Durable Medical Equipment-Sold X X X 67 67 Durable Medical Equipment-Sold 67 67 Durable Medical Equipment-Sold X 67 68 Other Reimbursable (specify) X X X 68 68 Other Reimbursable (specify) 68 68 Other Reimbursable (specify) X 68 69 Outpatient Rehabilitation Provider (specify) X X X 69 69 Outpatient Rehabilitation Provider (specify) 69 69 Outpatient Rehabilitation Provider (specify) X 69 70 Intern-Resident Service (not appvd. tchng. prgm.) X X X 70 70 Intern-Resident Service (not appvd. tchng. prgm.) 70 70 Intern-Resident Service (not appvd. tchng. prgm.) X 70 "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" Rev. 1 36-543 Rev. 1 36-546 Rev. 1 36-549 10-96 FORM CMS-2552-96 3690 (Cont.) 10-96 FORM CMS-2552-96 3690 (Cont.) 10-96 FORM CMS-2552-96 3690 (Cont.) ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," ALLOCATION OF NEW CAPITAL RELATED COSTS PROVIDER NO.: PERIOD: "WORKSHEET B," FROM _________ PART III FROM _________ PART III FROM _________ PART III _ TO ____________ _ TO ____________ _ TO ____________ DIRECTLY OLD CAPITAL NEW CAPITAL INTERN & ASSIGNED RELATED COSTS RELATED COSTS NON- INTERNS & INTERNS & RESIDENT NEW CAPITAL SUBTOTAL ADMINIS- MAIN- LAUNDRY MAIN- NURSING CENTRAL MEDICAL OTHER PHYSICIAN RESIDENTS RESIDENTS PARAMEDICAL COST & POST COST CENTER DESCRIPTIONS RELATED BLDGS. & MOVABLE BLDGS. & MOVABLE (sum of EMPLOYEE TRATIVE & TENANCE & OPERATION COST CENTER DESCRIPTIONS & LINEN HOUSE- TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL COST CENTER DESCRIPTIONS GENERAL ANES- NURSING SALARY AND PROGRAM EDUCATION STEPDOWN COSTS FIXTURES EQUIPMENT FIXTURES EQUIPMENT (cols. 0-4) BENEFITS GENERAL REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (SPECIFY) SUBTOTAL ADJUSTMENTS TOTAL 0 1 2 3 4 4A 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 71 Home Health Agency X X X 71 71 Home Health Agency 71 71 Home Health Agency X 71 SPECIAL PURPOSE COST CENTERS SPECIAL PURPOSE COST CENTERS SPECIAL PURPOSE COST CENTERS 82 Lung Acquisition X X X 82 82 Lung Acquisition 82 82 Lung Acquisition X 82 83 Kidney Acquisition X X X 83 83 Kidney Acquisition 83 83 Kidney Acquisition X 83 84 Liver Acquisition X X X 84 84 Liver Acquisition 84 84 Liver Acquisition X 84 85 Heart Acquisition X X X 85 85 Heart Acquisition 85 85 Heart Acquisition X 85 86 Other Organ Acquisition (specify) X X X 86 86 Other Organ Acquisition (specify) 86 86 Other Organ Acquisition (specify) X 86 92 Ambulatory Surgical Center (Distinct Part) X X X 92 92 Ambulatory Surgical Center (Distinct Part) 92 92 Ambulatory Surgical Center (Distinct Part) X 92 93 Hospice X X X 93 93 Hospice 93 93 Hospice X 93 94 Other Special Purpose (specify) X X X 94 94 Other Special Purpose (specify) 94 94 Other Special Purpose (specify) X 94 95 SUBTOTALS (sum of lines 1-94) X X X 95 95 SUBTOTALS (sum of lines 1-94) 95 95 SUBTOTALS (sum of lines 1-94) X 95 NONREIMBURSABLE COST CENTERS NONREIMBURSABLE COST CENTERS NONREIMBURSABLE COST CENTERS 96 "Gift, Flower, Coffee Shop, & Canteen" X X X 96 96 "Gift, Flower, Coffee Shop, & Canteen" 96 96 "Gift, Flower, Coffee Shop, & Canteen" X 96 97 Research X X X 97 97 Research 97 97 Research X 97 98 Physicians' Private Offices X X X 98 98 Physicians' Private Offices 98 98 Physicians' Private Offices X 98 99 Nonpaid Workers X X X 99 99 Nonpaid Workers 99 99 Nonpaid Workers X 99 100 Other Nonreimbursable (specify) X X X 100 100 Other Nonreimbursable (specify) 100 100 Other Nonreimbursable (specify) X 100 101 Cross Foot Adjustments 101 101 Cross Foot Adjustments 101 101 Cross Foot Adjustments X 101 102 Negative Cost Centers 102 102 Negative Cost Centers 102 102 Negative Cost Centers X 102 103 TOTAL (sum lines 95-102) X X X 103 103 TOTAL (sum lines 95-102) 103 103 TOTAL (sum lines 95-102) X 103 "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" "FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3618)" Rev. 1 36-544 Rev. 1 36-547 Rev. 1 36-550