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

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FROM 12/31/1969
TO 12/31/1969
General Instruction:
For all column 1 responses, enter in column 1, "Y" for Yes or "N" for No
For all dates responses, use the format mm/dd/yyyy.
Completed by All Skilled Nursing Facilities
  Y/N Date  
Provider Organization and Operation 1 2
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period? If column 1 is "Y", enter the date of the change in column 2. (see instructions) 1
  Y/N Date V/I  
1 2 3
2 Has the provider terminated participation in the Medicare Program? If column 1 is "Y", enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary. 2
3 Is the provider involved in business transactions, including management contracts, with individuals or entities (e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, medical staff, management personnel, or members of the board of directors through ownership, control, or family and other similar relationships? (see instructions)     3
Financial Data and Reports Y/N Type Date  
1 2 3
4 Column 1: Were the financial statements prepared by a Certified Public Accountant? (Y/N) Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter date available in column 3. (see instructions) If no, see instructions. 4
5 Are the cost report total expenses and total revenues different from those on the filed financial statements? If column 1 is "Y", submit reconciliation.     5
  Y/N Y/N  
Approved Educational Activities 1 2
6 Column 1: Were costs claimed for nursing school? (Y/N) Column 2: Is the provider the legal operator of the program? (Y/N) 6
7 Were costs claimed for allied health programs? (Y/N) (see instructions)   7
8 Were approvals and/or renewals obtained during the cost reporting period for nursing school and/or allied health program? (Y/N) (see instructions)   8
Bad Debts 1
9 Is the provider seeking reimbursement for bad debts? (Y/N) (see instructions) 9
10 If line 9 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy. 10
11 If line 9 is "Y", are patient deductibles and/or coinsurance waived? If "Y", see instructions. 11
Bed Complement
12 Have total beds available changed from prior cost reporting period? If "Y", see instructions. 12
PS&R Report Data Y/N Date Y/N Date  
Part A Part A Part B Part B
1 2 3 4
13 Was the cost report prepared using the PS&R only? If either col. 1 or 3 is "Y", enter the paid-through date of the PS&R used to prepare this cost report in cols. 2 and 4 . (see Instructions) 13
14 Was the cost report prepared using the PS&R for total and the provider's records for allocation? If either col. 1 or 3 is "Y", enter the paid-through date of the PS&R used to prepare this cost report in columns 2 and 4. 14
15 If line 13 or 14 is "Y", were adjustments made to PS&R data for additional claims that have been billed but are not included on the PS&R used to file this cost report? If "Y", see instructions.     15
16 If line 13 or 14 is "Y", were adjustments made to PS&R data for corrections of other PS&R Report information? If yes, see instructions.     16
17 If line 13 or 14 is "Y", were adjustments made to PS&R data for Other? Describe the other adjustments:__     17
18 Was the cost report prepared only using the provider's records? If "Y", see instructions.     18
Cost Report Preparer Contact Information
19 First Name: * Last Name: * Title: * 19
20 Employer: * 20
21 Phone Number: * Email Address: * 21
* Lines 19 -21 Redacted by CMS
06-21                 Rev. 10