MASONIC VILLAGE AT ELIZABETHTOWN
ELIZABETHTOWN, PA  17022

Medicare Provider Number: 395560
Cost report status: Settled Without Audit
[Record Code 1079954 - 2010]

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STATEMENT OF REVENUES AND EXPENSES Provider CCN: 395560
PERIOD:
FROM 01/01/2012
TO 12/31/2012
WORKSHEET G-3
1 Total patient revenues (from Wkst. G-2, Pt. I, col. 3, line 14) ### 1
2 Less: contractual allowances and discounts on patients accounts ### 2
3 Net patient revenues (line 1 minus line 2) ### 3
4 Less: total operating expenses (form Wkst. G-2, Pt. II, line 15) ### 4
5 Net income from service to patients (line 3 minus 4) ### 5
  Other income:    
6 Contributions, donations, bequests, etc. ### 6
7 Income from investments ### 7
8 Revenues from communications (telephone and internet service) ### 8
9 Revenue from television and radio service ### 9
10 Purchase discounts 10
11 Rebates and refunds of expenses 11
12 Parking lot receipts ### 12
13 Revenue from laundry and linen service ### 13
14 Revenue from meals sold to employees and guests ### 14
15 Revenue from rental of living quarters 15
16 Revenue from sale of medical and surgical supplies to other than patients 16
17 Revenue from sale of drugs to other than patients 17
18 Revenue from sale of medical records and abstracts 18
19 Tuition (fees, sale of textbooks, uniforms, etc.) 19
20 Revenue from gifts, flower, coffee shops, canteen ### 20
21 Rental of vending machines 21
22 Rental of skilled nursing space 22
23 Governmental appropriations 23
24 Other miscellaneous revenue (specify __REALIZED GAINS ON SALE OF INVESTMEN____) ### 24
24.01 TRANPORTATION ### 24.01
24.02 AMORT OF ENTRANCE FEES - OTHER REV ### 24.02
24.03 SALE OF FARM PRODUCTS ### 24.03
24.04 US DEPT OF AG GRANTS ### 24.04
24.05 RENTAL INCOME ### 24.05
24.06 PROFESSIONAL SERVICES ### 24.06
24.07 CLINICAL PROVIDER SUPPORT ### 24.07
24.08 CHILD CARE CENTER GRANTS ### 24.08
24.09 MISCELLANEOUS REVENUE ### 24.09
24.10 CHANGE IN FAIR VALUE OF SWAPS ### 24.10
24.11 ADJ OF ACTUARIAL LIAB - SPLI T INT ### 24.11
24.12 LOSS ON DISPOSAL OF EQUIPMENT ### 24.12
24.50 COVID-19 PHE Funding 24.50
25 Total other income (sum of lines 6 - 24) ### 25
26 Total (line 5 plus line 25) ### 26
27 Other expenses (specify _____) 27
28 28
29 29
30 Total other expenses (sum of lines 27 - 29) 30
31 Net income (or loss) for the period (line 26 minus line 30) ### 31
FORM CMS-2540-10 (06/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
06-21     Rev. 10