Medicare Provider Number: -E
[Record Code 1322370 - 2010]

You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').

If you would like to become a subscriber, please look at our subscription details.

If you are already a subscriber, please login.

STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES Provider CCN:
PERIOD:
FROM 12/31/1969
TO 12/31/1969
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) 13
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 )   2
3   3
4   4
5   5
6   6
7   7
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