11-05 Form CMS-216-94 3390(Cont.) This report is required by law (42 USC 1395g) and 42CFR 413.20 and 413.24. FORM APPROVED OMB NO. 0938-0102 Failure to report can result in all payments made during the reporting period being deemed overpayments (42 USC 1395g). ORGAN PROCUREMENT ORGANIZATION PROVIDER NO. HISTOCOMPATIBILITY LABORATORY GENERAL PERIOD: WORKSHEET FROM:_______ _______________ DATA AND CERTIFICATION STATEMENT S TO:__________ Intermediary Use Only: [ ] Audited Date Received ________________ [ ] Initial [ ] Desk Reviewed Intermediary No. ______________ [ ] Final [ ] Re-opened PART I - GENERAL Check [ ] Electronic filed cost report Date: applicable box [ ] Manually submitted cost report Time: 1 Name: Medicare Number: 1.01 Street: 1 P.O. Box: Zip Code: 2.01 Zip Code: State: 2 Name: 1.02 P.O. Box: 1.02 City: 1.01 2.02 Medicare Number: 2.01 Street: 2.02 City: State: 3 Reporting Period: From 2 To 3 Type of Control 1 Type of Provider (see instructions) (see instructions) Participation Date 3 4 2 4 4 PART II-CERTIFICATION BY OFFICER OR ADMINISTRATOR OF FACILITY 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. FUTHERMORE, IF SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLYOF A KICKBACK OR WERE OTHERWIS ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATION ACTION, FINES AND/OR IMPRISONMENT MAY RESULT CERTIFICATION BY OFFICER, ADMINISTRATOR OR DIRECTOR OF ORGANIZATION/LABORATORY I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Statement of Reimbursable Cost and the Balance Sheet and Statement of Revenue and Expenses prepared by _____________________________________________ _________________________________________________________________________________________ (name(s) and number(s) for the cost reporting period beginning _____________________ and ending_________________________, and that to the best of my knowledge and belief, it is a true, correct and complete ststement prepared from the books and records of the Organization/Laboratory 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 regulations. (Signed) ______________________________________________ Officer, Administrator or Director ______________________________________________ Title ______________________________________________ Date PART III - SETTLEMENT SUMMARY TITLE XVIII Organ Acquisition Tissue Typing 1 2 1 OPO/Lab 1 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 0938-0102. The time required to complete this information collection is estimated to average 45 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 comments concerning the accuracy of the time estimate(s) or suggestions for improving this form please write to: Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimor, Maryland 21244-1850. FORM CMS-216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3302,3302.1 and 3302.2) Rev. 4 33-303 American LegalNet, Inc. www.USCourtForms.com 3390 (Cont.) ORGAN PROCUREMENT ORGANIZATION/ HISTOCOMPATIBILITY LABORATORY IDENTIFICATION DATA PART I-OPO STATISTICS Form CMS 216-94 MEDICARE PERIOD: NUMBER FROM_______________ ___________________ TO________________ 1 Local 1 2 3 Total number of kidneys sent to military or DVA hospitals that were included in line 3,column 3. Amount received for kidneys listed in line 5. 2 Imported 3 Total (Columns 1 & 2) Total number of kidneys included in line 3, column 3 that were exported out of local retrieval areas 5 WORKSHEET S Total number of kidneys retrieved (viable and non-viable) Total number of kidneys included in line 1 that were non-viable. Net number of kidneys for which payment should have been received (line 1 minus line 2). 4 11-05 1 2 3 USA VA Total 5 Number Amount Received 6 Number of Kidneys 7 Total 4 Military 6 Foreign Country Amount Received Was payment received for kidneys furnished to foreign countries and included on line 4,column 2. Enter "Y" for yes or "N" for no. If yes, enter the total number of kidneys and amount received in columns 2 and 3, respectively. 7 Total number of organs/tissue other than kidneys retrieved and administratively processed. In the amount received column enter the total amount of payment received for each type of organ. Organ Total Nonviable Amount Received 8 Cornea 8.01 Liver 8.02 Pancreas 8.03 Pancreas Islet 8.04 Heart 8.05 Heart Valves 8.06 Heart/Lung 8.07 Bone 8.08 Skin 8.09 Lung 8.10 Other 8.20 Total PART II-LAB STATISTICS 1 Total number of tests performed- all laboratory. 2 Total number of tests performed-tissue typing laboratory. 3 Total number of pre-transplant tests performed for kidney transplantation that are included in line 2. Tissue typing pre-transplant tests performed for kidney transplant: Test Name Number of Tests 4 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.20 Total Tests PART III-FTEs Number of full-time equivalent employees Administrative OPO Histo-Lab 1 2 3 4 5 6 1 Medical Director Medical Director Lab Director 1.01 Exec. Director Procurement Coordinator Technicians 1.02 Clerical Preservation Technicians Tissue Typing Tech. 1.03 Other Other Other 2 Total FTEs 8 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.20 1 2 3 4 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.20 1 1.01 1.02 1.03 2 FORM CMS 216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II SECTIONS 3303, 3303.1, 3303.2 and 3303.3) 33-304 Rev. 4 American LegalNet, Inc. www.USCourtForms.com S-1 American LegalNet, Inc. www.USCourtForms.com 11-05 RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES Form CMS-216-94 MEDICARE NUMBER _________________ 3390 (Cont.) REPORTING PERIOD FROM:_______________________ TO:____________________ WORKSHEET A RECLASS. COST CENTERS (OMIT CENTS) RECLASSIFIED ADJUSTMENTS NET COST TO EXPENSES TRIAL BALANCE TO COST FOR COST 0100 0200 0300 0400 0500 0600 0700 0800 9 10 11 12 0900 1000 1100 1200 (FROM (COL.3 (FROM ALLOCATION OTHER (Cols. 1 & 2) WKST.A-4) +/- COL.4) (WKST. A-5) (COL.5+/-COL.6) 1 1 2 3 4 5 6 7 8 TOTAL SALARIES 2 3 4 5 6 7 GENERAL SERVICE COST CENTERS Capital Costs--Buildings and Fixtures Capital Costs--Movable Equipment Employee Benefits Administrative and General-Cols. 1-3-From W/S-A-1 Operation and Maintenance of Plant Housekeeping Medical Supplies Other Overhead (Specify) ORGAN ACQUISITION OVERHEAD Procurement Coordinators Professional Education Public Education Other Acquisition (Specify) REIMBURSABLE COST CENTERS Kidney Acquisition(From W/S A-2 Cols. 1-3,line 23) 13 1300 14 1400 Tissue Typing Laboratory (Cols. 1-3,From W/S-A-3, Line 11) NON-REIMBURSABLE COST CENTERS 15 1500 Liver Acquisitions (W/S-A-2, Col. 1-3, Line 23) 16 1600 Heart Acquisitions (W/S-A-2, Col.1-3, Line 23) 17 1700 Pancreas Acquisitions (W/S-A-2, Col.1-3, Line 23) 18 1800 Lung Acquisitions (W/S-A-2, Col. 1-3, line 23) 19 1900 Other Acquisitions (W/S-A-2, Col. 1-3, line 23) 20 2000 Other Acquisitions (W/S-A-2, Col. 1-3) 21 2100 Research 22 2200 Blood Bank 23 2300 Laboratory-Non-Tissue Typing 24 2400 Dialysis Units 25 2500 Other Non-Reimbursable (Specify) 26 Total Expenses (Sum of lines 1-25), Transfer Column 7 to W/S-B 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 line 1, or W/S-C, as per instructions FORM CMS-216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3304) Rev. 4 33-305 American LegalNet, Inc. www.USCourtForms.com 3390 (Cont.) Form CMS-216-94 ADMINISTRATIVE AND GENERAL EXPENSES MEDICARE NUMBER 11-05 REPORTING WORKSHEET A-1 PERIOD: FROM___________ TO______________ COST CENTER SALARIES OTHER TOTAL 1 2 3 1 Medical Director 1 2 Executive Director 2 3 Home Office/Central Administration 3 4 Data Processing 4 5 Accounting-Legal-Audit 5 6 Rent and Lease Expense 6 7 Office Supplies 7 8 Telephone 8 9 Travel-Meetings and Seminars 9 10 Insurance 10 11 Employee Professional Education 11 12 Public Relations 12 13 Interest Expense 13 14 Taxes 14 15 Office Salaries 15 16 Other Administrative and General: 16 17 17 18 18 19 19 20 Total Administrative and General 20 Sum of Lines 1-19 Transfer Line 20 columns 1-3 to Worksheet A, Line 4, columns 1-3 FORM CMS 216-94 (3/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3305) 33-306 Rev. 4 American LegalNet, Inc. www.USCourtForms.com 06-02 ORGAN ACQUISITION COST Form CMS-216-94 MEDICARE NUMBER REPORTING PERIOD: FROM___________ 3390 (Cont.) WORKSHEET A-2 TO______________ Check One: [ ] Kidney [ ] Liver [ ] Heart [ ] Pancreas COST CENTER [ ] Lung [ ] Other ___________ SALARIES 1 OTHER 2 TOTAL 3 Organ Acquisition Costs Amounts Paid To Excision Hospitals 1 Operating Room 1 2 Anesthesiology 2 3 Respiratory Therapy 3 4 Intensive Care Unit 4 5 Medical Supplies 5 6 Pharmacy 6 7 Electroencephalography 7 8 Hospital Laboratory 8 9 Other Excision Hospital Cost 9 10 Subtotal-Excision Hospital Cost (Sum of Lines 1-9) 10 Other Acquisitions Costs 11 Computer Registry 11 12 Donor Evaluation 12 13 Surgeon Fee 13 14 Organ Preservation 14 15 Donor Tissue Typing 15 16 Recipient Crossmatch 16 17 Imported Organ Cost 17 18 Transportation of Organs 18 19 Tissue Typing Lab-Under Agreement 19 20 Anesthesiologist Professional Fees 20 21 Other Acquisition Costs 21 22 Subtotal-Other Acquisition Cost (Sum of Lines 11-21) 22 23 Total-Organ Acquisition Cost 23 (Sum of Lines 10 and 22) Transfer Line 23 columns 1-3 to W/S A Lines 13, 15-20, Cols 1-3 as Appropriate FORM CMS 216-94 (3/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3306) Rev. 3 33-307 American LegalNet, Inc. www.USCourtForms.com 3390 (Cont.) TISSUE TYPING LABORATORY COSTS Form CMS-216-94 MEDICARE NUMBER 06-02 REPORTING WORKSHEET A-3 PERIOD: FROM___________ TO______________ COST CENTER SALARIES OTHER TOTAL 1 2 3 1 Laboratory Director 1 2 Tissue Typing Technologist 2 3 Sera Procurement 3 4 Equipment Maintenance 4 5 Other Tissue Typing Cost (Specify) 5 6 6 7 7 8 8 9 9 10 10 11 Total -Tissue Typing Cost 11 (Sum of Lines 1-10) Transfer Line 11 columns 1-3 to Worksheet A, Line 14, columns 1-3 FORM CMS 216-94 (3/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3307) 33-308 Rev. 3 American LegalNet, Inc. www.USCourtForms.com 06-02 RECLASSIFICATIONS Form CMS-216-94 MEDICARE NUMBER REPORTING PERIOD: FROM:___________________ _______________________ TO:____________________ CODE INCREASE COST LINE COST AMOUNT (2) CENTER EXPLANATION OF RECLASSIFICATION ENTRY (1) CENTER NO. 1 2 3 4 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 TOTAL RECLASSIFICATIONS (Sum of Column 4 must equal sum of Column 7) (1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry. (2) Transfer to Worksheet A, Column 4, line as appropriate. FORM CMS-216-94 (3/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3308) Rev. 3 3390 (Cont.) WORKSHEET A-4 DECREASE LINE NO. AMOUNT (2) 6 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 33-309 American LegalNet, Inc. www.USCourtForms.com 3390 (Cont.) ADJUSTMENTS TO EXPENSES Form CMS-216-94 MEDICARE NUMBER ___________________ Description (1) Basis for Adjustment (2) 1 Amount 2 06-02 REPORTING PERIOD: WORKSHEET A-5 FROM:_____________ TO:____________ Expense Classification on Worksheet A from which amount is to be deducted or to which the amount is to be added Ln No. Cost Center 3 4 1 Purchase Discounts (Chapter 8) 1 2 Rebates and Refunds (Chapter 8) 2 3 Home Office Costs (Chapter 21) 3 4 Adjustments resulting from transactions with related organizations (Chapter 10) 4 From Supp. W/S A-5-1 5 Income received from the procurement 5 of organs other than kidneys. (3) 6 Vending Machines 6 7 Rental or Lease Income 7 8 Organs Sold for Research 8 9 Public Relations-Not related to 9 Organ Procurement 10 Income received from Professional 10 Education 11 Sale of Supplies 11 12 Interest Income applied to interest exp. 12 13 Capital Costs -Buildings & Fixtures 13 14 Capital Costs -Movable Equipment 14 15 15 16 16 17 Total -Transfer to W/S. A, Column 6, 17 Line as Appropriate (1) Description-all line references in this column pertain to CMS Pub. 15-I (2) Basis for adjustment (SEE INSTRUCTIONS) A. Costs-if cost, including applicable overhead, can be determined B. Amount Received-if cost cannot be determined (3) Only the income from organs such as Cornea, Skin, Heart Valves, Bone, and Pancreas Islet may be offset. All internal organs such as Kidneys, Hearts, Livers, Lung, and Pancreas must go through cost finding on W/S B FORM CMS-216-94 (3/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3309) 33-310 Rev. 3 American LegalNet, Inc. www.USCourtForms.com 11-05 Form CMS-216-94 3390 (Cont.) CAPITAL EXPENDITURES AND MEDICARE NUMBER REPORTING PERIOD WORKSHEET A-6 DEPRECIATION RECONCILIATION FROM:__________________ TO:_____________________ Acquisitions Part I - Analysis of Changes in Beginning Ending Capital Asset Balances During Cost Balance Purchase Donations Total Disposals Balance Reporting Period 1 2 3 4 5 6 1 Land 1 2 Land Improvements 2 3 Building and Fixtures 3 4 Fixed Equipment 4 5 Movable Equipment 5 6 Auto,Truck, Van 6 7 Other (Specify) 7 8 Total 8 Part II - Analysis of Changes In Accumulated Depreciation Description 1 Land 2 Land Improvements 3 Buildings and Fixtures 4 Building Improvements 5 Fixed Equipment 6 Movable Equipment 7 Auto,Truck, Van 8 Other (Specify) 9 Total Beginning Balance 1 Additions 2 Deletions 3 Ending Balance 4 1 2 3 4 5 6 7 8 9 Part III - Depreciation Reported In Cost Statement 1 Straight Line 2 Declining Balance 3 Sum of Years Digits 4 Depreciation reported on W/S -A column 7. (Total- Sum of 1, 2 and 3) 1 2 3 4 1 5 6 2 Is depreciation funded? Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the balance in fund at the end of the period. Was there a gain or loss on the sale of assets during the cost reporting period? (See CMS Pub-15-1, Section 132) 5 6 FORM CMS-216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II SECTION 3310) Rev. 4 33-311 American LegalNet, Inc. www.USCourtForms.com Form CMS-216-94 3390 (Cont.) COST ALLOCATION-GENERAL SERVICE COSTS 1 COSTS TO BE ALLOCATED 2 CAPITALBUILDING, OPERATION OF PLANT AND HOUSE KEEPING 1 COST CENTER NET COST FOR ALLOCATION (FROM WKST. A, COL.7) 2 ( 11-05 MEDICARE NUMBER REPORTING PERIOD FROM____________________ TO_______________________ WORKSHEET B EMPLOYEE BENEFITS MEDICAL SUPPLIES OTHER OTHER ORGAN ACQUISITION COSTS SUBTOTAL (COLS.1-8) ADMIN. & GENERAL TOTAL EXPENSES 3 ) CAPITAL COSTS MOVABLE EQUIPMENT 4 5 6 7 8 9 10 11 ( ) ( ) ( ) ( ) ( ) Organ Acquisitions ( ( ) ) -0- 1 2 REIMBURSABLE COST CENTERS 3 4 Kidney Acquisitions (1) 3 Tissue Typing Laboratory(2) 4 NONREIMBURSABLE COST CENTERS 5 Liver Acquisitions 5 6 Heart Acquisitions 6 7 Pancreas Acquisitions 7 8 Lung Acquisitions 8 9 Other Acquisitions 9 10 Research 10 11 Blood Bank 11 12 Laboratory-Non-Tissue Typing 12 13 Dialysis Units 13 14 14 15 15 16 Totals Expenses -0- -0- -0- -0- -0- -0- -0- -0- 16 (1) Transfer amount on line 3, column 11 to Worksheet C, line 4, Part I (2) Transfer amount on line 4, column 11 to Worksheet C, line 4, Part II FORM CMS-216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3311) 33-312 Rev. 4 American LegalNet, Inc. www.USCourtForms.com 11-05 3390 (Cont.) Form CMS-216-94 COST ALLOCATION-STATISTICAL BASIS MEDICARE NUMBER REPORTING PERIOD: FROM________________ WORKSHEET B-1 TO_______________ ___________________ CAPITAL BUILDING COST CENTERS OPERATION CAPITAL OF PLANT COSTS EMPLOYEE AND MOVABLE BENEFITS MEDICAL SUPPLIES HOUSEKEEPING (SQ. FEET) EQUIPMENT (DOLLAR VALUE) (ADJUSTED SALARIES) (COSTED REQUISITIONS) 2 3 4 5 OTHER OTHER 6 7 ORGAN ACQUISITION COSTS (NUMBER OF ORGANS) 8 ADMINISTRATION & GENERAL (ACCUMULATED COSTS) 9 10 1 COSTS TO BE ALLOCATED 1 2 Organ Acquisition Costs 2 REIMBURSABLE COST CENTERS 3 Kidney Acquisitions 3 4 Tissue Typing Laboratory 4 NONREIMBURSABLE COST CENTERS 5 Liver Acquisitions 5 6 Heart Acquisitions 6 7 Pancreas Acquisitions 7 8 Lung Acquisitions 8 9 Other Organ Acquisitions 9 10 Research 10 11 Blood Bank 11 12 Laboratory-Non-Tissue Typing 12 13 Dialysis Units 13 14 14 15 15 16 Total (Lines 2-15) 16 17 COSTS TO BE ALLOCATED PER W/S B 17 UNIT COST MULTIPLIER (17/16) 18 18 FORM CMS-216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3311) Rev. 4 33-313 American LegalNet, Inc. www.USCourtForms.com 11-05 Form CMS-216-94 COMPUTATION OF MEDICARE COST MEDICARE NUMBER 3390 (Cont.) REPORTING PERIOD WORKSHEET C FROM_____________ TO________________ Part I - KIDNEY ACQUISITION 1 Total Number of Viable Kidneys Procured (W/S S-1,Part 1, Line 3, Column 3) 1 2 Total Number of Medicare Kidneys (See Instructions) 2 3 Ratio of Medicare Kidneys to Total Kidneys (Line 2/line 1) 3 4 Total Cost Applicable to Kidney Acquisition from W/S B, Col. 11, Line 3 or W/S A, 4 Col. 7, Line 26 5 Total Medicare Kidney Acquisition Costs (Line 3 x Line 4) (1) 5 (1) Transfer amount on line 5 to Worksheet D, Column 1, Line 1 Part II - TISSUE TYPING LABORATORY 1 Gross Revenues-Tissue Typing Laboratory-All Tests 1 2 Gross Revenues-Tissue Typing Laboratory-Kidney Transplant Related Tests Only (2) 2 3 Ration of Kidney Transplant to Total (Line 2/Line 1) 3 4 Total Cost Applicable to Tissue Typing Lab. From W/S-B, Col. 11, Line 4 or W/S-A, 4 Col.7, Line 26 5 Reimbursable Kidney Transplant Related Costs (Line 3 x Line 4) (3) 5 (2) If the cost report is a partial year under the program, show only the kidney related revenue earned since the participation date (3) Transfer Line 5 to Worksheet D, Column 2, Line 1. Form CMS-216-94 (11-2005) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 3312) 33-314 Rev. 4 American LegalNet, Inc. www.USCourtForms.com 06-02 3390 (Cont.) Form CMS-216-94 CALCULATION OF REIMBURSEMENT MEDICARE REPORTING PERIOD SETTLEMENT NUMBER WORKSHEET D FROM_____________ TO________________ 1 Kidney Acquisition 1 2 Tissue Typing Lab Medicare Reimbursable Cost-Kidney Acquisition- 1 Worksheet-C,Column 1,line 5 Tissue Typing-Laboratory W/S-C, Column 2, Line 5 2 Total Revenue Received for Lab Services Furnished to 2 Foreign Countries, Military and DVA Hospitals 3 Total Cost Reimbursable to OPO/LAB (Line 1-Line 2) 3 4 Total Payments Received and Receivable from OPOs 4 and Transplant Hospitals for Kidneys Furnished or Laboratory Services Provided for Kidney Transplantation (From Your Records) 5 Subtotal (Line 3-Line 4) 5 6 Sequestration Adjustment (See Instructions) 6 7 Interim Payments 7 8 Net Balance Due OPO/LAB (Medicare Program) 8 (Line 5 - (Line 6 + Line 7) Form CMS-216-94 (3/95) (INSTRUCTION FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 3313) Rev. 3 33-315 American LegalNet, Inc. www.USCourtForms.com 3390 (Cont.) BALANCE SHEET Form CMS 216-94 MEDICARE PERIOD: NUMBER FROM _____________________ TO ________________________ Assets (Omit cents) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 CURRENT ASSETS Cash on hand and in banks Temporary investments Notes receivable Accounts receivable Other receivables Less: allowances for uncollectible notes and accounts receivable Inventory Prepaid expenses Other current assets Due from other funds TOTAL CURRENT ASSETS (Sum of lines 1 - 10) FIXED ASSETS Land Land improvements Less: Accumulated depreciation Buildings Less: Accumulated depreciation Leasehold improvements Less: Accumulated depreciation Fixed equipment Less: Accumulated depreciation Automobiles and trucks Less: Accumulated depreciation Major movable equipment Less: Accumulated depreciation Minor equipment nondepreciable Other fixed assets TOTAL FIXED ASSETS (Sum of lines 12 - 26) OTHER ASSETS Investments Deposits on leases Due from owners/officers Liabilities and Fund Balance (Omit Cents) General Fund 1 ( ) 34 35 36 37 38 39 40 41 42 06-02 WORKSHEET E General Fund 1 CURRENT LIABILITIES Accounts payable Salaries, wages & fees payable Payroll taxes payable Notes & loans payable (Short term) Advanced blood deposits Due to other funds TOTAL CURRENT LIABILITIES (Sum of lines 34 - 41) LONG TERM LIABILITIES 43 Mortgage payable 44 Notes payable 45 Unsecured loans 46 ( ) ( ) ( ) ( ) ( ) ( ) 47 48 49 TOTAL LONG TERM LIABILITIES (Sum of lines 43 - 48) 50 TOTAL LIABILITIES (Sum of lines 42 and 49) CAPITAL ACCOUNTS 51 General fund balance 52 Specific purpose fund balance 53 Donor created - endowment fund balance - restricted 54 Donor created - endowment fund balance - unrestricted 55 Governing board created - endowment fund balance 56 Plant fund balance - invested in plant 57 Plant fund balance - reserve for plant improvement, replacement and expansion 58 TOTAL FUND BALANCE (Sum of lines 51 thru 57) 59 TOTAL LIABILITIES AND FUND BALANCE (Sum of lines 50 and 58) 28 29 30 31 32 TOTAL OTHER ASSETS (Sum of lines 28 - 31) 33 TOTAL ASSETS (Sum of lines 11, 27 and 32) ( ) = contra amount FORM CMS -216-94 ( 03/95 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3314 ) 33-316 Rev. 3 American LegalNet, Inc. www.USCourtForms.com 06-02 Form CMS-216-94 STATEMENT OF OPERATING EXPENSES MEDICARE NUMBER AND REVENUES 3390 (Cont.) REPORTING PERIOD WORKSHEET E-1 FROM_____________ TO________________ PART I OPO BLOOD BANK/LAB TOTAL REVENUES 1 Whole Blood and Components 1 2 Processing Fees 2 3 Other Blood Products and Services 3 4 Tissue Typing Services 4 5 Other Laboratory Services 5 6 Other Patient Service Fees: 6 7 7 8 8 9 9 10 Kidney Procurement Revenue 10 11 Other Organ Procurement Revenue 11 12 Total Revenue for Services Provided 12 PART II EXPENSES 1 Operating Expenses (Per W/S-A, Column 3, Line 26) 1 2 Add (Specify) 2 3 3 4 4 5 5 6 Total Additions 6 7 Deduct (Specify) 7 8 ( ) 8 9 ( ) 9 10 ( ) 10 11 Total Deductions ( 12 Total Operating Expenses (Sum of Lines 1 and 6 minus 11) ) 11 12 Transfer to Worksheet E-2 Line 4 Form CMS 216-94 (3/95) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II Section 3315) Rev. 3 33-317 American LegalNet, Inc. www.USCourtForms.com 3390 (Cont.) Form CMS-216-94 STATEMENT OF REVENUES MEDICARE NUMBER AND EXPENSES 06-02 REPORTING PERIOD WORKSHEET E-2 FROM_____________ TO________________ 1 Total Revenues for Services Provided (From W/S E-1, Part I, Line 12) 2 Less: Allowances for Discounts on Services 3 Net Revenue for Services Provided 4 Less: Total Operating Expenses (From W/S E-1, Part II Line 12) 5 Net Income From Services 5 6 Other Income: 6 7 Contributions 7 8 Income From Investments 8 9 Purchase Discounts 9 1 ( ) 2 3 ( ) 4 10 Rebates and Refunds of Expenses 10 11 Parking Lot Receipts 11 12 Vending Machine Receipts 12 13 Rental or Lease Income 13 14 Income From Sales of Supplies 14 15 Federal Research Grants (Specify) 15 16 Federal Research Grants (Specify) 16 17 Federal Research Grants (Specify) 17 18 Other Research Grants (Specify) 18 19 Other Research Grants (Specify) 19 20 Other (Specify) 20 21 Other (Specify) 21 22 Other (Specify) 22 23 Other (Specify) 23 24 Total Other Income (Sum of Lines 6-23) 24 25 Total (Line 5 plus line 24) 25 26 Other Expenses(Specify) 26 27 Other Expenses(Specify) 27 28 Total Other Expenses (Sum of lines 26 & 27) ( 29 Net Income (or Loss) for the Period (Line 25 minus Line 28) ) 28 29 Form CMS 216-94 (3/95) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II Section 3316) 33-318 Rev. 3 American LegalNet, Inc. www.USCourtForms.com Form CMS-216-94 3390 (Cont.) MEDICARE NUMBER REPORTING PERIOD: SUPPLEMENTAL FROM__________________ WORKSHEET ____________________ TO_________________ A-5-1 A. Are there any costs included on Worksheet A which resulted from transactions with related organizations as defined in the Provider Reimbursement Manual, Part I, Chapter 10? [ ] Yes [ ] No (If "Yes", complete Parts II and III ) B. Costs incurred and adjustments required as result of transactions with related organizations: AMOUNT NET LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COLUMN 6 ALLOWABLE ADJUSTMENT IN COST (COL.4 MINUS LINE NO. COST CENTER EXPENSES ITEMS AMOUNT COL. 5) 1 2 3 4 5 6 06-02 STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS 1 1 2 2 3 3 4 5 4 5 TOTALS (sum of lines 1-4) Transfer col.6, line 1-4 to Wkst. A,col.6 as appropriate) (Transfer col.6, line 5 to Wkst. A-5, col.2, line 4, Adjustment to Expenses) Interrelationship of facility to related organization (s): C. The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the provider to furnish the information requested on Part C of this worksheet. This information will be used by the Centers for Medicare and Medicaid Services and its intermediaries in determining that the costs applicable to services, facilities, and supplies furnished by organizations related to the facility by common ownership or control, represent reasonable costs as determined under section 1861(v) (1) (a) of the Social Security Act. If the provider does not provide all or any part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII. SYMBOL (1) 1 Name 2 Percentage of Ownership 3 Name 4 RELATED ORGANIZATION (S) Percentage of Ownership 5 Type of Business 6 1 1 2 2 3 3 4 4 (1) Use the following symbols to indicate interrelationship to related organizations: A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in the facility; B. Corporation, partnership, or other organization has financial interest in the facility; C. Facility has financial interest in corporation, partnership, or other organization(s); D. Director, officer, administrator, or key person of the facility or relative of such person has financial interest in related organization; E. Individual is director, officer, administrator, or key person of the facility and related organization; F. Director, officer, administrator, or key person of related organization or relative of such person has financial interest in the facility; G. Other (financial or non-financial) specify _____________________________ FORM CMS-216-94(3/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,Section 3317) 33-319 Rev. 3 American LegalNet, Inc. www.USCourtForms.com