Worksheet Formats

Worksheet formats are based on information supplied by the Centers for Medicare and Medicaid Studies (CMS).  Forms and instructions can be downloaded from the CMS website and are presented here as a convenient reference.

*Worksheets which are not yet available on SNFdata.com have been marked with an asterisk.

[+] 2010 Format

S001 Worksheet Worksheet S PARTS I, II & III *
Certification and Settlement Summary
form instructions
S201 Worksheet S-2 Part 1
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Idenfitication Data
form instructions
S202 Worksheet S-2 Part 2
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Reimbursement Questionnaire
form instructions
S301 Worksheet S-3, Part 1
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Statistical Data
form instructions
S302 Worksheet S-3, Parts II and III
SNF Wage Index Information
form instructions
S304 Worksheet S-3, Part IV
SNF Wage Related Costs
form instructions
S305 Worksheet S-3 Part V
SNF Reporting of Direct Care Expenditures
form instructions
S400 Worksheet S-4
SNF-Based Home Health Agency Statistical Data
form instructions
S500 Worksheet Worksheet S-5 *
SNF-based Rural Health Clinic Federally Qualified Health Center Statistical Data
form instructions
S600 Worksheet Worksheet S-6 *
SNF-based Community Mental Health Center and Other Outpatient Rehabilitation Provider Statistical Data
form instructions
S700 Worksheet S-7
Prospective Payment for SNF Statistical Data
form instructions
S800 Worksheet Worksheet S-8 *
Hospice Identification Data
form instructions
A000 Worksheet A
Reclassification and Adjustment of Trial Balance of Expenses
form instructions
A600 Worksheet A-6
Reclassifications
form instructions
A700 Worksheet A-7
Analysis of Changes During Cost Reporting Period in Capital Asset Balances
form instructions
A800 Worksheet A-8
Adjustments to Expenses
form instructions
A810 Worksheet A-8-1
Statement of Costs of Services From Related Organizations and Home Office Cost
form instructions
A820 Worksheet A-8-2
Provider-Based Physicians Adjustments
form instructions
B001 Worksheet B, Part I
Cost Allocation - General Service Costs
form instructions
B002 Worksheet Worksheet B PART II *
Allocation of Capital - Related Costs
form instructions
B100 Worksheet B-1
Cost Allocation - Statistical Basis
form instructions
B200 Worksheet B-2
Post Step Down Adjustments
form instructions
C000 Worksheet C
Ratio of Cost to Charges for Ancillary and Outpatient Cost Centers
form instructions
D001 Worksheet D, Part I
Apportionment of Ancillary and Outpatient Cost
form instructions
D002 Worksheet D, Part II
Apportionment of Ancillary and Outpatient Cost
form instructions
D101 Worksheet Worksheet D-1 PART I & II *
Computation of Inpatient Routine Costs
form instructions
E001 Worksheet E, Part 1
Calculation of Reimbursement Settlement Title XVIII
form instructions
E002 Worksheet Worksheet E PART II *
Calculation of Reimbursement Settlement for Title V and Title XIX Only
form instructions
E100 Worksheet Worksheet E-1 *
Analysis of Payments to Providers for Services Rendered
form instructions
G000 Worksheet G
Balance Sheet
form instructions
G100 Worksheet Worksheet G-1 *
Statement of Changes in Fund Balances
form instructions
G200 Worksheet G-2
Statement of Patient Revenues and Operating Expenses
form instructions
G300 Worksheet G-3
Statement of Revenues and Expenses
form instructions
H000 Worksheet Worksheet H *
Analysis of Provider-based Home Health Agency Costs
form instructions
H101 Worksheet Worksheet H-1 PART I *
Cost Allocation - HHA General Service Cost
form instructions
H102 Worksheet Worksheet H-1 PART II *
Cost Allocation - HHA Statistical Basis
form instructions
H201 Worksheet Worksheet H-2 PART I *
Allocation of General Service Costs to HHA Cost Centers
form instructions
H202 Worksheet Worksheet H-2 PART II *
Allocation of General Service Costs to HHA Cost Centers Statistical Basis
form instructions
H300 Worksheet Worksheet H-3 Parts I & II *
Apportionment of Patient Service Costs
form instructions
H400 Worksheet Worksheet H-4 Parts I & II  *
Calculation of HHA Reimbursement Settlement
form instructions
H500 Worksheet Worksheet H-5 *
Analysis of Payments to Provider-based HHAs for Services Rendered to Program Beneficiaries
form instructions
I100 Worksheet Worksheet I-1 *
Analysis of SNF-based Rural Health Clinic / Federally Qualified Health Center Costs
form instructions
I200 Worksheet Worksheet I-2 *
Allocation of Overhead to RHC / FQHC Services
form instructions
I300 Worksheet Worksheet I-3 *
Calculation of Reimbursement Settlement for RHC / FQHC Services
form instructions
I400 Worksheet Worksheet I-4 *
Computation of Pneumococcal and Influenza Vaccine Cost
form instructions
I500 Worksheet Worksheet I-5 *
Analysis of Payments to SNF-based Rural Health Clinic and Federally Qualified Health Centers
form instructions
J101 Worksheet Worksheet J-1 Part I *
Allocation of General Service Costs to Cost Centers for CMHC
form instructions
J102 Worksheet Worksheet J-1 Part II *
Allocation of General Service Costs to Cost Centers for CMHC
form instructions
J201 Worksheet Worksheet J-2 Part I *
Computation of CMHC Rehabilitation Costs
form instructions
J202 Worksheet Worksheet J-2 Part II *
Apportionment of Cost of CMHC Services Furnished by Shared Departments
form instructions
J300 Worksheet Worksheet J-3 *
Calculation of Reimbursement Settlement of Community Mental Health Center Provider Services
form instructions
J400 Worksheet Worksheet J-4 *
Analysis of Payments to Provider-based CMHC for Services Rendered to Program Beneficiaries
form instructions
K000 Worksheet Worksheet K *
Analysis of Provider-based Hospice Costs
form instructions
K100 Worksheet Worksheet K-1 *
Hospice Compensation Analysis Salaries and Wages
form instructions
K200 Worksheet Worksheet K-2 *
Hospice Compensation Analysis Employee Benefits (Payroll Related)
form instructions
K300 Worksheet Worksheet K-3 *
Hospice Compensation Analysis Contracted Services / Purchased Services
form instructions
K401 Worksheet Worksheet K-4 Part I *
Cost Allocation - Hospice General Service Cost
form instructions
K402 Worksheet Worksheet K-4 Part II *
Cost Allocation - Hospice Statistical Basis
form instructions
K501 Worksheet Worksheet K-5 Part I *
Allocation of General Service Costs to Hospice Cost Centers
form instructions
K502 Worksheet Worksheet K-5 Part II *
Allocation of General Service Costs to Hospice Cost Centers - Statistical Basis
form instructions
K503 Worksheet Worksheet K-5 Part III *
Apportionment of Hospice Shared Services
form instructions
K600 Worksheet Worksheet K-6 *
Calculation of Per Diem Cost
form instructions
O000 Worksheet Worksheet O *
ANALYSIS OF SNF-BASED HOSPICE COSTS
form instructions
O100 Worksheet Worksheet O-1 *
ANALYSIS OF SNF-BASED HOSPICE COSTS HOSPICE CONTINUOUS HOME CARE
form instructions
O200 Worksheet Worksheet O-2 *
ANALYSIS OF SNF-BASED HOSPICE COSTS HOSPICE ROUTINE HOME CARE
form instructions
O300 Worksheet Worksheet O-3 *
ANALYSIS OF SNF-BASED HOSPICE COSTS HOSPICE INPATIENT RESPITE CARE
form instructions
O400 Worksheet Worksheet O-4 *
ANALYSIS OF SNF-BASED HOSPICE COSTS HOSPICE GENERAL INPATIENT CARE
form instructions
O500 Worksheet Worksheet O-5 *
COST ALLOCATION - DETERMINATION OF SNF-BASED HOSPICE NET EXPENSES FOR ALLOCATION
form instructions
O601 Worksheet Worksheet O-6 Part I *
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COSTS
form instructions
O602 Worksheet Worksheet O-6 Part II *
COST ALLOCATION - SNF-BASED HOSPICE GENERAL SERVICE COST STATISTICAL BASIS
form instructions
O700 Worksheet Worksheet O-7 *
APPORTIONMENT OF SNF-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE
form instructions
O800 Worksheet Worksheet O-8 *
CALCULATION OF SNF-BASED HOSPICE PER DIEM COST
form instructions

[+] 1996 Format

S200 Worksheet S-2
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Identification Data
form instructions
S301 Worksheet S-3, Part I
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Statistical Data
form instructions
S302 Worksheet S-3, Parts II and III
SNF Wage Index Information
form instructions
S701 Worksheet S-7, Part I
NHCMQ Demonstration Statistical Data
form instructions
S702 Worksheet S-7, Part II
PPS Statistical Data
form instructions
S703 Worksheet S-7, Part III
PPS Statistical Data
form instructions
S704 Worksheet S-7, Part IV
Prospective Payment for SNF Statistical Data
form instructions
A000 Worksheet A
Reclassification and Adjustment of Trial Balance of Expenses
form instructions
A700 Worksheet A-7
Analysis of Changes During Cost Reporting Period in Capital Asset Balances
form instructions
A800 Worksheet A-8
Adjustments to Expenses
form instructions
B001 Worksheet B, Part I
Cost Allocation - General Service Costs
form instructions
B002 Worksheet B, Part II
Allocation of Capital - Related Costs
form instructions
B100 Worksheet B-1
Cost Allocation - General Service Costs
form instructions
C000 Worksheet C
Ratio of Cost to Charges for Ancillary Outpatient Cost Centers
form instructions
D001 Worksheet D, Part I
Apportionment of Ancillary and Outpatient Cost and Reduction of Therapy Cost
form instructions
D002 Worksheet D, Part II
Apportionment of Vaccine Cost and Costs for Interns and Residents
form instructions
E003 Worksheet E, Part III
Calculation of Reimbursement Settlement - SNF Reimbursement Under PPS
form instructions
G000 Worksheet G
Balance Sheet
form instructions
G201 Worksheet G-2, Part I
Statement of Patient Revenues and Operating Expenses
form instructions
G300 Worksheet G-3
Statement of Revenues and Expenses
form instructions