Worksheet G-3
- Return to Cost Report Summary
- Form G300
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
FORESTVIEW HEALTH CARE CENTER
ERIE, PA 16509
ERIE, PA 16509
Medicare Provider Number: 395907
Cost report status: Settled Without Audit
[Record Code 1063507 - 2010]
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| STATEMENT OF REVENUES AND EXPENSES | Provider CCN: 395907 | 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 __NUTRITIONAL SUPPLEMENTS____) | ### | 24 | |||
| 24.01 | HOME CARE | ### | 24.01 | |||
| 24.02 | HOUSEKEEPING CHARGE | ### | 24.02 | |||
| 24.03 | MAINTENANCE CHARGE | ### | 24.03 | |||
| 24.04 | BEAUTY SHOP CHARGE | ### | 24.04 | |||
| 24.05 | CATERING CHARGE | ### | 24.05 | |||
| 24.06 | COMMUNICATIONS SERVICES | ### | 24.06 | |||
| 24.07 | GUEST ROOM | ### | 24.07 | |||
| 24.08 | RENTAL CHARGE | ### | 24.08 | |||
| 24.09 | LAUNDRY CHARGE | ### | 24.09 | |||
| 24.10 | TRANSPORTATION CHARGE | ### | 24.10 | |||
| 24.11 | MEAL CHARGE/ADJ | ### | 24.11 | |||
| 24.12 | OTHER RESIDENT CHARGE | ### | 24.12 | |||
| 24.13 | CAFETERIA/GRILL INCOME | ### | 24.13 | |||
| 24.14 | LEASE SPACE INCOME | ### | 24.14 | |||
| 24.15 | BEAUTY SHOP FEE | ### | 24.15 | |||
| 24.16 | RENOVATION AND UPGRADE FEE | ### | 24.16 | |||
| 24.17 | BAD DEBT RECOVERY | ### | 24.17 | |||
| 24.18 | OTHER REVENUE | ### | 24.18 | |||
| 24.19 | ENTRANCE FEE AMORTIZATION | ### | 24.19 | |||
| 24.20 | TERMINAL INCOME | ### | 24.20 | |||
| 24.21 | INTEREST - BANK/PNOTES | ### | 24.21 | |||
| 24.22 | INVESTMENT INTEREST/DIVIDENDS | ### | 24.22 | |||
| 24.23 | BOND FUNDS INTEREST/DIVIDENDS | ### | 24.23 | |||
| 24.24 | INVESTMENT FEE: FIXED INCOME SECURIT | ### | 24.24 | |||
| 24.25 | INVESTMENT GAIN/LOSSES | ### | 24.25 | |||
| 24.26 | GAIN/LOSS ON DISPOSAL OF FIXED ASSET | ### | 24.26 | |||
| 24.27 | INVESTMENT FEE: EQUITY SECURITIES | ### | 24.27 | |||
| 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 | |||||