OELWEIN HEALTHCARE
OELWEIN, IA  50662

Medicare Provider Number: 165341
Cost report status: Settled Without Audit
[Record Code 1249308 - 2010]

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RECLASSIFICATIONS Provider CCN: 165341
PERIOD:
FROM 07/01/2018
TO 06/30/2019
WORKSHEET A-6
- Select other programs and provider types available
EXPLANATION OF RECLASSIFICATION(S)
CODE
(1)
INCREASE DECREASE
COST CENTER LN NO. SALARY NON SALARY COST CENTER LN NO. SALARY NON SALARY  
1 2 3 4 5 6 7 8 9
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34 34
35 35
100 TOTAL RECLASSIFICATIONS (Sum of columns 4 and 5 must equal sum of columns 8 and 9 (2) ###     ### 100
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer the amounts in columns 4, 5, 8 and 9 to Worksheet A, column 4, lines as appropriate.
FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4114)
41-318   Rev. 2