Worksheet G-2
- Return to Cost Report Summary
- Form G200
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
GOOD SHEPHERD SERVICES LTD
SEYMOUR, WI 54165
SEYMOUR, WI 54165
Medicare Provider Number: 525509
Cost report status: Settled Without Audit
[Record Code 1242529 - 2010]
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STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES | Provider CCN: 525509 | PERIOD: FROM 01/01/2018 TO 12/31/2018 |
WORKSHEET G - 2 PARTS I & II | ||
PART I - PATIENT REVENUES | |||||
Revenue Center | INPATIENT | OUTPATIENT | TOTAL | ||
1 | 2 | 3 | |||
General Inpatient Routine Care Services | |||||
1 | Skilled nursing facility | ### | ### | 1 | |
2 | Nursing facility | 2 | |||
3 | ICF/IID | 3 | |||
4 | Other long term care | 4 | |||
5 | Total general inpatient care services | ### | ### | 5 | |
(sum of lines 1 - 4) | |||||
All Other Care Service | |||||
6 | Ancillary services | ### | ### | 6 | |
7 | Clinic | 7 | |||
8 | Home health agency | 8 | |||
9 | Ambulance | 9 | |||
10 | RHC/FQHC | 10 | |||
11 | CMHC | 11 | |||
12 | Hospice | 12 | |||
13 | Other (specify) BIRCH WAY | ### | ### | 13 | |
13.01 | OUTPATIENT REHAB PROVIDER | ### | ### | 13.01 | |
13.02 | CHILD CARE | ### | ### | 13.02 | |
13.03 | OTHER OPERATING REVENUE | ### | ### | 13.03 | |
13.05 | MEADOW WOOD APARTMENTS | ### | ### | 13.05 | |
13.06 | SHEPHERDS INN | ### | ### | 13.06 | |
13.07 | FOREST GLEN | ### | ### | 13.07 | |
14 | Total patient revenues (sum of lines 5 - 13) (transfer to Wkst. G-3, col. 3, line 1 ) | ### | ### | ### | 14 |
PART II - OPERATING EXPENSES | |||||
1 | Operating Expenses (per Wkst. A, col. 3, line 100) | ### | 1 | ||
2 | Add ( Specify ) SHEPHERDS INN | ### | 2 | ||
3 | REHAB EXPENSES | ### | 3 | ||
4 | CHILD CARE EXPENSES | ### | 4 | ||
5 | 5 | ||||
6 | MEADOW WOOD EXPENSES | ### | 6 | ||
7 | BIRCH WAY | ### | 7 | ||
7.01 | FOREST GLEN | ### | 7.01 | ||
8 | Total Additions (sum of lines 2 - 7) | ### | 8 | ||
9 | Deduct (Specify) | 9 | |||
10 | 10 | ||||
11 | 11 | ||||
12 | 12 | ||||
13 | 13 | ||||
14 | Total Deductions (sum of lines 9 - 13) | 14 | |||
15 | Total Operating Expenses (sum of lines 1 and 8, minus line 14) | ### | 15 | ||
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140) | |||||
08-16 | Rev. 7 |