GOOD SHEPHERD SERVICES LTD
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