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

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FROM 12/31/1969
TO 12/31/1969
Skilled Nursing Facility and Skilled Nursing Facility Complex Address:
1 Street: P.O. Box:             1
2 City: State: ZIP Code:         2
3 County: CBSA Code: Urban / Rural:         3
SNF and SNF - Based Component Identification:
  Component Component Name Provider CCN Date Certified Payment System (P, O or N)  
0 1 2 3 4 5 6
4 SNF 4
5 Nursing Facility   5
6 ICF/IID     6
7 SNF-Based HHA 7
8 SNF-Based RHC 8
9 SNF-Based FQHC 9
10 SNF-Based CMHC 10
11 SNF-Based OLTC           11
12 SNF-Based HOSPICE       12
13 OTHER (specify)       13
14 Cost Reporting Period (mm/dd/yyyy) From: To:           14
15 Type of Control (see instructions) 15
Type of Freestanding Skilled Nursing Facility Y / N          
16 Is this a distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?         16
17 Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?         17
18 Are there any costs included in Worksheet A that resulted from transactions with related organizations as defined in CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1.         18
Miscellaneous Cost Reporting Information
19 Is this a low Medicare utilization cost report, enter "Y" for yes or "N" for no.         19
19.01 If the response to line 19 is "Y", does this cost report meet your contractor's criteria for filing a low utilization cost report? (Y/N)         19.01
Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on lines 20 - 22.
20 Straight Line         20
21 Declining Balance         21
22 Sum of the Year's Digits         22
23 Sum of line 20 through 22         23
24 If depreciation is funded, enter the balance as of the end of the period.         24
25 Were there any disposal of capital assets during the cost reporting period? (Y/N)         25
26 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)         26
27 Did you cease to participate in the Medicare program at end of the period to which this cost report applies? (Y?N)         27
28 Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports? (Y/N)         28
If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of costs or charges, enter "Y" for each component and type of service that qualifies for the exemption. Part A Part B Other
29 Skilled Nursing Facility   29
30 Nursing Facility     30
31 ICF/MR     31
32 SNF-Based HHA   32
33 SNF-Based RHC     33
34 SNF-Based FQHC     34
35 SNF-Based CMHC     35
36 SNF-Based OLTC       36
  Y / N      
37 Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for Titles V & XIX patients. (Y/N)     37
38 Are you legally required to carry malpractice insurance? (Y/N)     38
39 Is the malpractice a "claims-made" or "occurrence" policy? If the policy is "claims-made," enter 1. If the policy is "occurrence", enter 2.     39
  Premiums Paid Losses Self insurance    
41 List malpractice premiums and paid losses:   41
  Y / N          
42 Are malpractice premiums and paid losses reported in other than the Administrative and General cost center? Enter Y or N. If "Y", check box, and submit supporting schedule listing cost centers and amounts.         42
43 Are there any home office costs as defined in CMS Pub. 15-1, chapter 10?         43
44 If line 43 = "Y", and there are costs for the home office, enter the applicable home office chain number in column 1.         44
If this facility is part of a chain organization, enter the name and address of the home office on the lines below.
45 Name: Contractor Name: Contractor Number: 45
46 Street: P.O. Box: 46
47 City: State: ZIP Code: 47
Rev. 10         06-21