HOLLENBECK PALMS
LOS ANGELES, CA  90033

Medicare Provider Number: 055115
Cost report status: Settled Without Audit
[Record Code 1151373 - 2010]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST Provider CCN: 055115
PERIOD:
FROM 07/01/2015
TO 06/30/2016
WORKSHEET D PART I
SNF - SNF Medicare - Title XVIII
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST
Cost Center Description Ratio of Cost to Charges (from Wkst. C, col. 3) Health Care Program Charges Healthcare Program Cost  
Part A Part B Part A ( col. 1 x col. 2 ) Part B ( col. 1 x col. 3 )
1 2 3 4 5
ANCILLARY SERVICE COST CENTERS
40 Radiology ### ### ### 40
41 Laboratory ### ### ### 41
42 Intravenous Therapy ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy ### ### ### 44
45 Occupational Therapy ### ### ### 45
46 Speech Pathology ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients ### ### ### 48
49 Drugs Charged to Patients ### ### ### 49
50 Dental Care - Title XIX only     50
51 Support Surfaces 51
52 Other Ancillary Service Cost ### 52
OUTPATIENT COST CENTERS            
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
71 Ambulance (2) 71
100 Total (sum of lines 40 - 71)   ### ### 100
(1) For titles V and XIX use columns 1, 2 and 4 only.
(2) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124)
08-16   Rev. 7