SNFData - 395423 - 06/1996 - Worksheet D, Part I

FORBES NURSING CENTER
PITTSBURGH, PA 15206

Medicare Provider Number: 395423

Cost report status: Reopened

[Record Code 54646 - 1996]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST COSTS							PROVIDER NO: 395423	PERIOD: FROM 07/01/1995 TO 06/30/1996		WORKSHEET D Part I
SNF - SNF Medicare - Title XVIII
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST
Cost Center		RATIO OF COST TO CHARGES (Fr. Wkst. C Column 3)	HEALTH CARE PROGRAM CHARGES		HEALTH CARE PROGRAM COST		TITLE XVIII CHARGES ON AND AFTER 1/1/1998	PART B THERAPY COSTS ON AND AFTER 1/1/1998 Col. 1 X 6)	10% REDUCTION OF THERAPY (Col. 7 X 10%)	NET ALLOWABLE PART B COSTS Col. 5 less Col. 8)
		RATIO OF COST TO CHARGES (Fr. Wkst. C Column 3)	Part A	Part B	Part A (Col. 1 X Col. 2)	Part B (Col. 1 X Col. 3)	TITLE XVIII CHARGES ON AND AFTER 1/1/1998	PART B THERAPY COSTS ON AND AFTER 1/1/1998 Col. 1 X 6)	10% REDUCTION OF THERAPY (Col. 7 X 10%)	NET ALLOWABLE PART B COSTS Col. 5 less Col. 8)
		1	2	3	4	5	6	7	8	9
ANCILLARY SERVICE COST CENTERS
21	Radiology		###	###							21
22	Laboratory		###								22
23	Intravenous Therapy										23
24	Oxygen (Inhalation) Therapy		###								24
25	Physical Therapy		###	###							25
26	Occupational Therapy		###	###							26
27	Speech Pathology										27
28	Electrocardiology		###	###							28
29	Medical Supplies Charged To Patients		###	###							29
30	Drugs Charged to Patients		###								30
31	Dental Care - Title XIX										31
32	Support Surfaces										32
33	Other Ancillary Services										33
OUTPATIENT COST CENTERS
34	Clinic										34
35	R H C										35
36	Other Outpatient Services										36
48	Ambulance (2)										48
75	Total (Sum of lines 21 - 48)		###	###	###	###					75
(1) For titles V and XIX use columns 1, 2 and 4 only.
(2) Line 48 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.