Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(04/2005) PREPARED 6/ 4/2010 16:10 THIS REPORT IS REQUIRED BY LAW (42 USC 1395g; 42 CFR 413.20(b)). FORM APPROVED FAILURE TO REPORT CAN RESULT IN ALL INTERIM PAYMENTS MADE SINCE OMB NO. 0938-0050 THE BEGINNING OF THE COST REPORT PERIOD BEING DEEMED OVERPAYMENTS (42 USC 1395g). WORKSHEET S PARTS I & II HOSPITAL AND HOSPITAL HEALTH I PROVIDER NO: I PERIOD I INTERMEDIARY USE ONLY I DATE RECEIVED: CARE COMPLEX I 15-0172 I FROM 1/ 1/2009 I --AUDITED --DESK REVIEW I / / COST REPORT CERTIFICATION I I TO 12/31/2009 I --INITIAL --REOPENED I INTERMEDIARY NO: AND SETTLEMENT SUMMARY I I I --FINAL 1-MCR CODE I I 00 - # OF REOPENINGS I ELECTRONICALLY FILED COST REPORT DATE: 6/ 4/2010 TIME 16:10 PART I - CERTIFICATION MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED BY THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISIONMENT MAY RESULT. CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S) I HEREBY CERTIFY THAT I HAVE READ THE ABOVE STATEMENT AND THAT I HAVE EXAMINED THE ACCOMPANYING ELECTRONICALLY FILED OR MANUALLY SUBMITTED COST REPORT AND THE BALANCE SHEET AND STATEMENT OF REVENUE AND EXPENSES PREPARED BY: PHYSICIANS MEDICAL CENTER 15-0172 FOR THE COST REPORTING PERIOD BEGINNING 1/ 1/2009 AND ENDING 12/31/2009 AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE, CORRECT, AND COMPLETE STATEMENT PREPARED FROM THE BOOKS AND RECORDS OF THE PROVIDER IN ACCORDANCE WITH APPLICABLE INSTRUCTIONS, EXCEPT AS NOTED. I FURTHER CERTIFY THAT I AM FAMILIAR WITH THE LAWS AND REGULATIONS REGARDING THE PROVISION OF HEALTH CARE SERVICES, AND THAT THE SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED IN COMPLIANCE WITH SUCH LAWS AND REGULATIONS. ____________________________________________________________ OFFICER OR ADMINISTRATOR OF PROVIDER(S) ____________________________________________________________ TITLE ____________________________________________________________ DATE PART II - SETTLEMENT SUMMARY TITLE TITLE TITLE V XVIII XIX A B 1 2 3 4 1 HOSPITAL 0 90,128 0 0 100 TOTAL 0 90,128 0 0 __________________________________________________________________________________________________________________________________ THE ABOVE AMOUNTS REPRESENT "DUE TO" OR "DUE FROM" THE APPLICABLE PROGRAM FOR THE ELEMENT OF THE ABOVE COMPLEX INDICATED __________________________________________________________________________________________________________________________________ According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0050. The time required to complete this information collection is estimated 662 hours per response, including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, N2-14-26, Baltimore, MD 21244-1850, and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503. __________________________________________________________________________________________________________________________________ MCRIF32 1.19.0.3 ~ 2552-96 21.0.119.3 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (01/2010) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL & HOSPITAL HEALTH CARE COMPLEX I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-2 IDENTIFICATION DATA I I TO 12/31/2009 I HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX ADDRESS 1 STREET: 4023 REAS LANE P.O. BOX: 1.01 CITY: NEW ALBANY STATE: IN ZIP CODE: 47150- COUNTY: FLOYD HOSPITAL AND HOSPITAL-BASED COMPONENT IDENTIFICATION; PAYMENT SYSTEM DATE (P,T,O OR N) COMPONENT COMPONENT NAME PROVIDER NO. NPI NUMBER CERTIFIED V XVIII XIX 0 1 2 2.01 3 4 5 6 02.00 HOSPITAL PHYSICIANS MEDICAL CENTER 15-0172 10/30/2008 N P N 17 COST REPORTING PERIOD (MM/DD/YYYY) FROM: 1/ 1/2009 TO: 12/31/2009 1 2 18 TYPE OF CONTROL 4 TYPE OF HOSPITAL/SUBPROVIDER 19 HOSPITAL 1 20 SUBPROVIDER OTHER INFORMATION 21 INDICATE IF YOUR HOSPITAL IS EITHER (1)URBAN OR (2)RURAL AT THE END OF THE COST REPORT PERIOD IN COLUMN 1. IF YOUR HOSPITAL IS GEOGRAPHICALLY CLASSIFIED OR LOCATED IN A RURAL AREA, IS YOUR BED SIZE IN ACCORDANCE WITH CFR 42 412.105 LESS THAN OR EQUAL TO 100 BEDS, ENTER IN COLUMN 2 "Y" FOR YES OR "N" FOR NO. 21.01 DOES YOUR FACILITY QUALIFY AND IS CURRENTLY RECEIVING PAYMENT FOR DISPROPORTIONATE SHARE HOSPITAL ADJUSTMENT IN ACCORDANCE WITH 42 CFR 412.106? ENTER IN COLUMN 1 "Y" FOR YES OR "N" FOR NO. IS THIS FACILITY SUBJECT TO THE PROVISIONS OF 42 CFR 412.106(c)(2) (PICKLE AMENDENT HOSPITALS)? ENTER IN COLUMN 2 "Y" FOR YES OR "N" FOR NO. N 21.02 HAS YOUR FACILITY RECEIVED A NEW GEOGRAPHIC RECLASSICATION STATUS CHANGE AFTER THE FIRST DAY OF THE COST REPORTING PERIOD FROM RURAL TO URBAN AND VICE VERSA? ENTER "Y" FOR YES AND "N" FOR NO. IF YES, ENTER IN COLUMN 2 THE EFFECTIVE DATE (MM/DD/YYYY) (SEE INSTRUCTIONS). 21.03 ENTER IN COLUMN 1 YOUR GEOGRAPHIC LOCATION EITHER (1)URBAN OR (2)RURAL. IF YOU ANSWERED URBAN IN COLUMN 1 INDICATE IF YOU RECEIVED EITHER A WAGE OR STANDARD GEOGRAPHICAL RECLASSIFICATION TO A RURAL LOCATION, ENTER IN COLUMN 2 "Y" FOR YES AND "N" FOR NO. IF COLUMN 2 IS YES, ENTER IN COLUMN 3 THE EFFECTIVE DATE (MM/DD/YYYY)(SEE INSTRUCTIONS) DOES YOUR FACILITY CONTAIN 100 OR FEWER BEDS IN ACCORDANCE WITH 42 CFR 412.105? ENTER IN COLUMN 4 "Y" OR "N". ENTER IN COLUMN 5 THE PROVIDERS ACTUAL MSA OR CBSA. 2 N Y 31140 21.04 FOR STANDARD GEOGRAPHIC CLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE BEGINNING OF THE COST REPORTING PERIOD. ENTER (1)URBAN OR (2)RURAL 1 21.05 FOR STANDARD GEOGRAPHIC CLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE END OF THE COST REPORTING PERIOD. ENTER (1)URBAN OR (2)RURAL 1 21.06 DOES THIS HOSPITAL QUALIFY FOR THE 3-YEAR TRANSITION OF HOLD HARMLESS PAYMENTS FOR SMALL RURAL HOSPITAL; UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT SERVICES UNDER DRA §5105 OR MIPPA §147? (SEE INSTRUC) ENTER "Y" FOR YES, AND "N" FOR NO. N 21.07 DOES THIS HOSPITAL QUALIFY AS A SCH WITH 100 OR FEWER BEDS UNDER MIPPA §147? ENTER "Y" FOR YES AND "N" FOR NO. (SEE INSTRUCTIONS) N 21.08 WHICH METHOD IS USED TO DETERMINE MEDICAID DAYS ON S-3, PART I, COL. 5 ENTER IN COLUMN 1, "1" IF IT IS BASED ON DATE OF ADMISSION, "2" IF IT IS BASED ON CENSUS DAYS, OR "3" IF IT IS BASED ON DATE OF DISCHARGE. IS THIS METHOD DIFFERENT THAN THE METHOD USED IN THE PRECEEDING COST REPORTING PERIOD? ENTER IN COLUMN 2, "Y" FOR YES OR "N" FOR NO. 22 ARE YOU CLASSIFIED AS A REFERRAL CENTER? N 23 DOES THIS FACILITY OPERATE A TRANSPLANT CENTER? IF YES, ENTER CERTIFICATION DATE(S) BELOW. N 23.01 IF THIS IS A MEDICARE CERTIFIED KIDNEY TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / / COL. 2 AND TERMINATION DATE IN COL. 3. 23.02 IF THIS IS A MEDICARE CERTIFIED HEART TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / / COL. 2 AND TERMINATION DATE IN COL. 3. 23.03 IF THIS IS A MEDICARE CERTIFIED LIVER TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / / COL. 2 AND TERMINATION DATE IN COL. 3. 23.04 IF THIS IS A MEDICARE CERTIFIED LUNG TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / / COL. 2 AND TERMINATION DATE IN COL. 3. 23.05 IF MEDICARE PANCREAS TRANSPLANTS ARE PERFORMED SEE INSTRUCTIONS FOR ENTERING CERTIFICATION / / / / AND TERMINATION DATE. 23.06 IF THIS IS A MEDICARE CERTIFIED INTESTINAL TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / / COL. 2 AND TERMINATION DATE IN COL. 3. 23.07 IF THIS IS A MEDICARE CERTIFIED ISLET TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / / COL. 2 AND TERMINATION DATE IN COL. 3. 24 IF THIS IS AN ORGAN PROCUREMENT ORGANIZATION (OPO), ENTER THE OPO NUMBER IN COLUMN 2 AND / / TERMINATION DATE IN COLUMN 3 (MM/DD/YYYY) 24.01 IF THIS IS A MEDICARE TRANSPLANT CENTER; ENTER THE CCN (PROVIDER NUMBER) IN COLUMN 2, THE / / CERTIFICATION DATE OR RECERTIFICATION DATE (AFTER 12/26/2007) IN COLUMN 3 (mm/dd/yyyy). Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (01/2010) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL & HOSPITAL HEALTH CARE COMPLEX I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-2 IDENTIFICATION DATA I I TO 12/31/2009 I 25 IS THIS A TEACHING HOSPITAL OR AFFILIATED WITH A TEACHING HOSPITAL AND YOU ARE RECEIVING PAYMENTS FOR I&R? N 25.01 IS THIS TEACHING PROGRAM APPROVED IN ACCORDANCE WITH CMS PUB. 15-I, CHAPTER 4? 25.02 IF LINE 25.01 IS YES, WAS MEDICARE PARTICIPATION AND APPROVED TEACHING PROGRAM STATUS IN EFFECT DURING THE FIRST MONTH OF THE COST REPORTING PERIOD? IF YES, COMPLETE WORKSHEET E-3, PART IV. IF NO, COMPLETE WORKSHEET D-2, PART II. 25.03 AS A TEACHING HOSPITAL, DID YOU ELECT COST REIMBURSEMENT FOR PHYSICIANS' SERVICES AS DEFINED IN CMS PUB. 15-I, SECTION 2148? IF YES, COMPLETE WORKSHEET D-9. 25.04 ARE YOU CLAIMING COSTS ON LINE 70 OF WORKSHEET A? IF YES, COMPLETE WORKSHEET D-2, PART I. N 25.05 HAS YOUR FACILITY DIRECT GME FTE CAP (COLUMN 1) OR IME FTE CAP (COLUMN 2) BEEN REDUCED UNDER 42 CFR 413.79(c)(3) OR 42 CFR 412.105(f)(1)(iv)(B)? ENTER "Y" FOR YES AND "N" FOR NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS) 25.06 HAS YOUR FACILITY RECEIVED ADDITIONAL DIRECT GME FTE RESIDENT CAP SLOTS OR IME FTE RESIDENTS CAP SLOTS UNDER 42 CFR 413.79(c)(4) OR 42 CFR 412.105(f)(1)(iv)(C)? ENTER "Y" FOR YES AND "N" FOR NO IN THE APPLICABLE COLUMNS (SEE INSTRUCTIONS) 26 IF THIS IS A SOLE COMMUNITY HOSPITAL (SCH),ENTER THE NUMBER OF PERIODS SCH STATUS IN EFFECT IN THE C/R PERIOD. ENTER BEGINNING AND ENDING DATES OF SCH STATUS ON LINE 26.01. SUBSCRIPT LINE 26.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 0 26.01 ENTER THE APPLICABLE SCH DATES: BEGINNING: / / ENDING: / / 26.02 ENTER THE APPLICABLE SCH DATES: BEGINNING: / / ENDING: / / 27 DOES THIS HOSPITAL HAVE AN AGREEMENT UNDER EITHER SECTION 1883 OR SECTION 1913 N / / FOR SWING BEDS. IF YES, ENTER THE AGREEMENT DATE (MM/DD/YYYY) IN COLUMN 2. 28 IF THIS FACILITY CONTAINS A HOSPITAL-BASED SNF, ARE ALL PATIENTS UNDER MANAGED CARE OR THERE WERE NO MEDICARE UTILIZATION ENTER "Y", IF "N" COMPLETE LINES 28.01 AND 28.02 28.01 IF HOSPITAL BASED SNF, ENTER APPROPRIATE TRANSITION PERIOD 1, 2, 3, OR 100 IN COLUMN 1. 1 2 3 4 ENTER IN COLUMNS 2 AND 3 THE WAGE INDEX ADJUSTMENT FACTOR BEFORE AND ON OR AFTER THE ------- ------- ------- ------ OCTOBER 1ST (SEE INSTRUCTIONS) 0 0.0000 0.0000 28.02 ENTER IN COLUMN 1 THE HOSPITAL BASED SNF FACILITY SPECIFIC RATE(FROM YOUR FISCAL INTERMEDIARY) IF YOU HAVE NOT TRANSITIONED TO 100% PPS SNF PPS PAYMENT. IN COLUMN 2 ENTER 0.00 0 THE FACILITY CLASSIFICATION URBAN(1) OR RURAL (2). IN COLUMN 3 ENTER THE SNF MSA CODE OR TWO CHARACTER STATE CODE IF A RURAL BASED FACILITY. IN COLUMN 4, ENTER THE SNF CBSA CODE OR TWO CHARACTER CODE IF RURAL BASED FACILITY A NOTICE PUBLISHED IN THE "FEDERAL REGISTER" VOL. 68, NO. 149 AUGUST 4, 2003 PROVIDED FOR AN INCREASE IN THE RUG PAYMENTS BEGINNING 10/01/2003. CONGRESS EXPECTED THIS INCREASE TO BE USED FOR DIRECT PATIENT CARE AND RELATED EXPENSES. ENTER IN COLUMN 1 THE PERCENTAGE OF TOTAL EXPENSES FOR EACH CATEGORY TO TOTAL SNF REVENUE FROM WORKSHEET G-2, PART I, LINE 6, COLUMN 3. INDICATE IN COLUMN 2 "Y" FOR YES OR "N" FOR NO IF THE SPENDING REFLECTS INCREASES ASSOCIATED WITH DIRECT PATIENT CARE AND RELATED EXPENSES FOR EACH CATEGORY. (SEE INSTR) % Y/N 28.03 STAFFING 0.00% 28.04 RECRUITMENT 0.00% 28.05 RETENTION 0.00% 28.06 TRAINING 0.00% 29 IS THIS A RURAL HOSPITAL WITH A CERTIFIED SNF WHICH HAS FEWER THAN 50 BEDS IN THE N AGGREGATE FOR BOTH COMPONENTS, USING THE SWING BED OPTIONAL METHOD OF REIMBURSEMENT? 30 DOES THIS HOSPITAL QUALIFY AS A RURAL PRIMARY CARE HOSPITAL (RPCH)/CRITICAL ACCESS N HOSPITAL(CAH)? (SEE 42 CFR 485.606ff) 30.01 IF SO, IS THIS THE INITIAL 12 MONTH PERIOD FOR THE FACILITY OPERATED AS AN RPCH/CAH? SEE 42 CFR 413.70 30.02 IF THIS FACILITY QUALIFIES AS AN RPCH/CAH, HAS IT ELECTED THE ALL-INCLUSIVE METHOD OF PAYMENT FOR OUTPATIENT SERVICES? (SEE INSTRUCTIONS) N 30.03 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIBIBLE FOR COST REIMBURSEMENT FOR AMBULANCE SERVICES? IF YES, ENTER IN COLUMN 2 THE DATE OF ELIGIBILITY DETERMINATION (DATE MUST BE ON OR AFTER 12/21/2000). N 30.04 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIBIBLE FOR COST REIMBURSEMENT FOR I&R TRAINING PROGRAMS? ENTER "Y" FOR YES AND "N" FOR NO. IF YES, THE GME ELIMINATION WOULD NOT BE ON WORKSHEET B, PART I, COLUMN 26 AND THE PROGRAM WOULD BE COST REIMBURSED. IF YES COMPLETE WORKSHEET D-2, PART II N 31 IS THIS A RURAL HOSPITAL QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42 CFR 412.113(c). N 31.01 IS THIS A RURAL SUBPROVIDER 1 QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42 CFR 412.113(c). N 31.02 IS THIS A RURAL SUBPROVIDER 2 QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42 CFR 412.113(c). N 31.03 IS THIS A RURAL SUBPROVIDER 3 QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42 CFR 412.113(c). N 31.04 IS THIS A RURAL SUBPROVIDER 4 QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42 CFR 412.113(c). N 31.05 IS THIS A RURAL SUBPROVIDER 5 QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42 CFR 412.113(c). N MISCELLANEOUS COST REPORT INFORMATION 32 IS THIS AN ALL-INCLUSIVE PROVIDER? IF YES, ENTER THE METHOD USED (A, B, OR E ONLY) COL 2. N 33 IS THIS A NEW HOSPITAL UNDER 42 CFR 412.300 PPS CAPITAL? ENTER "Y" FOR YES AND "N" FOR NO IN COLUMN 1. IF YES, FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2002, DO YOU ELECT TO BE REIMBURSED AT 100% FEDERAL CAPITAL PAYMENT? ENTER "Y" FOR YES AND "N" FOR NO IN COLUMN 2 Y N 34 IS THIS A NEW HOSPITAL UNDER 42 CFR 413.40 (f)(1)(i) TEFRA? N 35 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? N 35.01 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? N 35.02 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? N 35.03 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? N 35.04 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? N Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (01/2010) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL & HOSPITAL HEALTH CARE COMPLEX I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-2 IDENTIFICATION DATA I I TO 12/31/2009 I V XVIII XIX PROSPECTIVE PAYMENT SYSTEM (PPS)-CAPITAL 1 2 3 36 DO YOU ELECT FULLY PROSPECTIVE PAYMENT METHODOLOGY FOR CAPITAL COSTS? (SEE INSTRUCTIONS) N N N 36.01 DOES YOUR FACILITY QUALIFY AND RECEIVE PAYMENT FOR DISPROPORTIONATE SHARE IN ACCORDANCE WITH 42 CFR 412.320? (SEE INSTRUCTIONS) N N N 37 DO YOU ELECT HOLD HARMLESS PAYMENT METHODOLOGY FOR CAPITAL COSTS? (SEE INSTRUCTIONS) N N N 37.01 IF YOU ARE A HOLD HARMLESS PROVIDER, ARE YOU FILING ON THE BASIS OF 100% OF THE FED RATE? N N N TITLE XIX INPATIENT SERVICES 38 DO YOU HAVE TITLE XIX INPATIENT HOSPITAL SERVICES? N 38.01 IS THIS HOSPITAL REIMBURSED FOR TITLE XIX THROUGH THE COST REPORT EITHER IN FULL OR IN PART? N 38.02 DOES THE TITLE XIX PROGRAM REDUCE CAPITAL FOLLOWING THE MEDICARE METHODOLOGY? N 38.03 ARE TITLE XIX NF PATIENTS OCCUPYING TITLE XVIII SNF BEDS (DUAL CERTIFICATION)? N 38.04 DO YOU OPERATE AN ICF/MR FACILITY FOR PURPOSES OF TITLE XIX? N 40 ARE THERE ANY RELATED ORGANIZATION OR HOME OFFICE COSTS AS DEFINED IN CMS PUB 15-I, CHAP 10? IF YES, AND THIS FACILITY IS PART OF A CHAIN ORGANIZATION, ENTER IN COLUMN 2 THE CHAIN HOME OFFICE CHAIN NUMBER. (SEE INSTRUCTIONS). Y 40.01 NAME: FI/CONTRACTOR NAME FI/CONTRACTOR # 40.02 STREET: P.O. BOX: 40.03 CITY: STATE: ZIP CODE: - 41 ARE PROVIDER BASED PHYSICIANS' COSTS INCLUDED IN WORKSHEET A? N 42 ARE PHYSICAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N 42.01 ARE OCCUPATIONAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N 42.02 ARE SPEECH PATHOLOGY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N 43 ARE RESPIRATORY THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N 44 IF YOU ARE CLAIMING COST FOR RENAL SERVICES ON WORKSHEET A, ARE THEY INPATIENT SERVICES ONLY? N 45 HAVE YOU CHANGED YOUR COST ALLOCATION METHODOLOGY FROM THE PREVIOUSLY FILED COST REPORT? N 00/00/0000 SEE CMS PUB. 15-II, SECTION 3617. IF YES, ENTER THE APPROVAL DATE IN COLUMN 2. 45.01 WAS THERE A CHANGE IN THE STATISTICAL BASIS? 45.02 WAS THERE A CHANGE IN THE ORDER OF ALLOCATION? 45.03 WAS THE CHANGE TO THE SIMPLIFIED COST FINDING METHOD? 46 IF YOU ARE PARTICIPATING IN THE NHCMQ DEMONSTRATION PROJECT (MUST HAVE A HOSPITAL-BASED SNF) DURING THIS COST REPORTING PERIOD, ENTER THE PHASE (SEE INSTRUCTIONS). IF THIS FACILITY CONTAINS A 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. ENTER "N" IF NOT EXEMPT. (SEE 42 CFR 413.13.) OUTPATIENT OUTPATIENT OUTPATIENT PART A PART B ASC RADIOLOGY DIAGNOSTIC 1 2 3 4 5 47.00 HOSPITAL N N N N N 52 DOES THIS HOSPITAL CLAIM EXPENDITURES FOR EXTRAORDINARY CIRCUMSTANCES IN ACCORDANCE WITH 42 CFR 412.348(e)? (SEE INSTRUCTIONS) N 52.01 IF YOU ARE A FULLY PROSPECTIVE OR HOLD HARMLESS PROVIDER ARE YOU ELIGIBLE FOR THE SPECIAL EXCEPTIONS PAYMENT PURSUANT TO 42 CFR 412.348(g)? IF YES, COMPLETE WORKSHEET L, PART IV N 53 IF YOU ARE A MEDICARE DEPENDENT HOSPITAL (MDH), ENTER THE NUMBER OF PERIODS MDH STATUS IN EFFECT. ENTER BEGINNING AND ENDING DATES OF MDH STATUS ON LINE 53.01. SUBSCRIPT LINE 53.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 0 53.01 MDH PERIOD: BEGINNING: / / ENDING: / / 54 LIST AMOUNTS OF MALPRACTICE PREMIUMS AND PAID LOSSES: PREMIUMS: 37,843 PAID LOSSES: 0 AND/OR SELF INSURANCE: 0 54.01 ARE MALPRACTICE PREMIUMS AND PAID LOSSES REPORTED IN OTHER THAN THE ADMINISTRATIVE AND GENERAL COST CENTER? IF YES, SUBMIT SUPPORTING SCHEDULE LISTING COST CENTERS AND AMOUNTS CONTAINED THEREIN. N 55 DOES YOUR FACILITY QUALIFY FOR ADDITIONAL PROSPECTIVE PAYMENT IN ACCORDANCE WITH 42 CFR 412.107. ENTER "Y" FOR YES AND "N" FOR NO. N 56 ARE YOU CLAIMING AMBULANCE COSTS? IF YES, ENTER IN COLUMN 2 THE PAYMENT LIMIT PROVIDED FROM YOUR FISCAL INTERMEDIARY AND THE APPLICABLE DATES FOR THOSE LIMITS DATE Y OR N LIMIT Y OR N FEES IN COLUMN 0. IF THIS IS THE FIRST YEAR OF OPERATION NO ENTRY IS REQUIRED IN COLUMN 0 1 2 3 4 2. IF COLUMN 1 IS Y, ENTER Y OR N IN COLUMN 3 WHETHER THIS IS YOUR FIRST YEAR OF ------------------------------------------- OPERATIONS FOR RENDERING AMBULANCE SERVICES. ENTER IN COLUMN 4, IF APPLICABLE, N 0.00 0 THE FEE SCHEDULES AMOUNTS FOR THE PERIOD BEGINNING ON OR AFTER 4/1/2002. 56.01 ENTER SUBSEQUENT AMBULANCE PAYMENT LIMIT AS REQUIRED. SUBSCRIPT IF MORE THAN 2 0.00 0 LIMITS APPLY. ENTER IN COLUMN 4 THE FEE SCHEDULES AMOUNTS FOR INITIAL OR SUBSEQUENT PERIOD AS APPLICABLE. 56.02 THIRD AMBULANCE LIMIT AND FEE SCHEDULE IF NECESSARY. 0.00 0 56.03 FOURTH AMBULANCE LIMIT AND FEE SCHEDULE IF NECESSARY. 0.00 0 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (01/2010) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL & HOSPITAL HEALTH CARE COMPLEX I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-2 IDENTIFICATION DATA I I TO 12/31/2009 I 57 ARE YOU CLAIMING NURSING AND ALLIED HEALTH COSTS? N 58 ARE YOU AN INPATIENT REHABILITATION FACILITY(IRF), OR DO YOU CONTAIN AN IRF SUBPROVIDER? ENTER IN COLUMN 1 "Y" FOR YES AND "N" FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100% FEDERAL PPS REIMBURSEMENT? ENTER IN COLUMN 2 "Y" FOR YES AND "N" FOR NO. THIS OPTION IS N ONLY AVAILABLE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 1/1/2002 AND BEFORE 10/1/2002. 58.01 IF LINE 58 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT COST 0 REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER "Y" FOR YES OR "N" FOR NO. IS THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH 42 CFR SEC. 412.424(d)(1)(iii)(2)? ENTER IN COLUMN 2 "Y"FOR YES OR "N" FOR NO. IF COLUMN 2 IS Y, ENTER 1, 2 OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS). IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5. (SEE INSTR). 59 ARE YOU A LONG TERM CARE HOSPITAL (LTCH)? ENTER IN COLUMN 1 "Y" FOR YES AND "N" FOR NO. IF YES, HAVE YOU MADE THE ELECTION FOR 100% FEDERAL PPS REIMBURSEMENT? ENTER IN COLUMN 2 "Y" FOR YES AND "N" FOR NO. (SEE INSTRUCTIONS) N 60 ARE YOU AN INPATIENT PSYCHIATRIC FACILITY (IPF), OR DO YOU CONTAIN AN IPF SUBPROVIDER? ENTER IN COLUMN 1 "Y" FOR YES AND "N" FOR NO. IF YES, IS THE IPF OR IPF SUBPROVIDER A NEW FACILITY? ENTER IN COLUMN 2 "Y" FOR YES AND "N" FOR NO. (SEE INSTRUCTIONS) N 60.01 IF LINE 60 COLUMN 1 IS Y, AND THE FACILITY IS AN IPF SUBPROVIDER, WERE RESIDENTS TRAINING IN 0 THIS FACILITY IN ITS MOST RECENT COST REPORTING PERIOD FILED BEFORE NOV. 15, 2004? ENTER "Y" FOR YES AND "N" FOR NO. IS THIS FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH 42 CFR §412.424(d)(1)(iii)(C)? ENTER IN COL. 2 "Y" FOR YES OR "N" FOR NO. IF COL. 2 IS Y, ENTER 1, 2 OR 3 RESPECTIVELY IN COL. 3, (SEE INSTRUC). IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COL. 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5. (SEE INSTRUC). MULTICAMPUS 61.00 IS THIS FACILITY PART OF A MULTICAMPUS HOSPITAL THAT HAS ONE OR MORE CAMPUSES IN DIFFERENT CBSA? ENTER "Y" FOR YES AND "N" FOR NO. IF LINE 61 IS YES, ENTER THE NAME IN COL. 0, COUNTY IN COL. 1, STATE IN COL.2, ZIP IN COL 3, CBSA IN COL. 4 AND FTE/CAMPUS IN COL. 5. NAME COUNTY STATE ZIP CODE CBSA FTE/CAMPUS ------------------------------------ ------------------------------------ ----- ---------- ----- ---------- 62.00 0.00 SETTLEMENT DATA 63.00 WAS THE COST REPORT FILED USING THE PS&R (EITHER IN ITS ENTIRETY OR FOR TOTAL CHARGES AND DAYS Y 5/27/2010 ONLY)? ENTER "Y" FOR YES AND "N" FOR NO IN COL. 1. IF COL. 1 IS "Y", ENTER THE "PAID THROUGH" DATE OF THE PS&R IN COL. 2 (MM/DD/YYYY). Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (01/2010) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL AND HOSPITAL HEALTH CARE I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-3 COMPLEX STATISTICAL DATA I I TO 12/31/2009 I PART I -------- I/P DAYS / O/P VISITS / TRIPS -------- NO. OF BED DAYS CAH TITLE TITLE NOT LTCH TOTAL COMPONENT BEDS AVAILABLE N/A V XVIII N/A TITLE XIX 1 2 2.01 3 4 4.01 5 1 ADULTS & PEDIATRICS 12 4,380 188 7 2 HMO 2 01 HMO - (IRF PPS SUBPROVIDER) 3 ADULTS & PED-SB SNF 4 ADULTS & PED-SB NF 5 TOTAL ADULTS AND PEDS 12 4,380 188 7 6 INTENSIVE CARE UNIT 12 TOTAL 12 4,380 188 7 13 RPCH VISITS 25 TOTAL 12 26 OBSERVATION BED DAYS 27 AMBULANCE TRIPS 28 EMPLOYEE DISCOUNT DAYS 28 01 EMP DISCOUNT DAYS -IRF 29 LABOR & DELIVERY DAYS ---------- I/P DAYS / O/P VISITS / TRIPS ------------ -- INTERNS & RES. FTES -- TITLE XIX OBSERVATION BEDS TOTAL TOTAL OBSERVATION BEDS LESS I&R REPL COMPONENT ADMITTED NOT ADMITTED ALL PATS ADMITTED NOT ADMITTED TOTAL NON-PHYS ANES 5.01 5.02 6 6.01 6.02 7 8 1 ADULTS & PEDIATRICS 521 2 HMO 2 01 HMO - (IRF PPS SUBPROVIDER) 3 ADULTS & PED-SB SNF 4 ADULTS & PED-SB NF 5 TOTAL ADULTS AND PEDS 521 6 INTENSIVE CARE UNIT 12 TOTAL 521 13 RPCH VISITS 25 TOTAL 26 OBSERVATION BED DAYS 309 12 297 27 AMBULANCE TRIPS 28 EMPLOYEE DISCOUNT DAYS 28 01 EMP DISCOUNT DAYS -IRF 29 LABOR & DELIVERY DAYS I & R FTES --- FULL TIME EQUIV --- --------------- DISCHARGES ------------------ EMPLOYEES NONPAID TITLE TITLE TITLE TOTAL ALL COMPONENT NET ON PAYROLL WORKERS V XVIII XIX PATIENTS 9 10 11 12 13 14 15 1 ADULTS & PEDIATRICS 79 3 219 2 HMO 2 01 HMO - (IRF PPS SUBPROVIDER) 3 ADULTS & PED-SB SNF 4 ADULTS & PED-SB NF 5 TOTAL ADULTS AND PEDS 6 INTENSIVE CARE UNIT 12 TOTAL 51.00 79 3 219 13 RPCH VISITS 25 TOTAL 51.00 26 OBSERVATION BED DAYS 27 AMBULANCE TRIPS 28 EMPLOYEE DISCOUNT DAYS 28 01 EMP DISCOUNT DAYS -IRF 29 LABOR & DELIVERY DAYS Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (05/2004) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL WAGE INDEX INFORMATION I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-3 I I TO 12/31/2009 I PARTS II & III PAID HOURS AVERAGE AMOUNT RECLASS OF ADJUSTED RELATED TO HOURLY PART II - WAGE DATA REPORTED SALARIES SALARIES SALARY WAGE DATA SOURCE 1 2 3 4 5 6 SALARIES 1 TOTAL SALARY 2,624,309 2,624,309 106,054.00 24.75 2 NON-PHYSICIAN ANESTHETIST PART A 3 NON-PHYSICIAN ANESTHETIST PART B 4 PHYSICIAN - PART A 4.01 TEACHING PHYSICIAN SALARIES (SEE INSTRUCTIONS) 5 PHYSICIAN - PART B 5.01 NON-PHYSICIAN - PART B 6 INTERNS & RESIDENTS (APPRVD) 6.01 CONTRACT SERVICES, I&R 7 HOME OFFICE PERSONNEL 8 SNF 8.01 EXCLUDED AREA SALARIES OTHER WAGES & RELATED COSTS 9 CONTRACT LABOR: 9.01 PHARMACY SERVICES UNDER CONTRACT 9.02 LABORATORY SERVICES UNDER CONTRACT 9.03 MANAGEMENT & ADMINISTRATIVE UNDER CONRACT 10 CONTRACT LABOR: PHYS PART A 10.01 TEACHING PHYSICIAN UNDER CONTRACT (SEE INSTRUCTIONS) 11 HOME OFFICE SALARIES & WAGE RELATED COSTS 12 HOME OFFICE: PHYS PART A 12.01 TEACHING PHYSICIAN SALARIES (SEE INSTRUCTIONS) WAGE RELATED COSTS 13 WAGE-RELATED COSTS (CORE) 224,694 224,694 CMS 339 14 WAGE-RELATED COSTS (OTHER) 355,394 355,394 CMS 339 15 EXCLUDED AREAS CMS 339 16 NON-PHYS ANESTHETIST PART A CMS 339 17 NON-PHYS ANESTHETIST PART B CMS 339 18 PHYSICIAN PART A CMS 339 18.01 PART A TEACHING PHYSICIANS CMS 339 19 PHYSICIAN PART B CMS 339 19.01 WAGE-RELATD COSTS (RHC/FQHC) CMS 339 20 INTERNS & RESIDENTS (APPRVD) CMS 339 OVERHEAD COSTS - DIRECT SALARIES 21 EMPLOYEE BENEFITS 22 ADMINISTRATIVE & GENERAL 476,457 -32,667 443,790 20,488.00 21.66 22.01 A & G UNDER CONTRACT 23 MAINTENANCE & REPAIRS 24 OPERATION OF PLANT 41,837 41,837 2,080.00 20.11 25 LAUNDRY & LINEN SERVICE 26 HOUSEKEEPING 22,835 22,835 1,712.00 13.34 26.01 HOUSEKEEPING UNDER CONTRACT 27 DIETARY 27.01 DIETARY UNDER CONTRACT 28 CAFETERIA 29 MAINTENANCE OF PERSONNEL 30 NURSING ADMINISTRATION 32,667 32,667 880.00 37.12 31 CENTRAL SERVICE AND SUPPLY 69,093 69,093 4,446.00 15.54 32 PHARMACY 33 MEDICAL RECORDS & MEDICAL RECORDS LIBRARY 34 SOCIAL SERVICE 35 OTHER GENERAL SERVICE PART III - HOSPITAL WAGE INDEX SUMMARY 1 NET SALARIES 2,624,309 2,624,309 106,054.00 24.75 2 EXCLUDED AREA SALARIES 3 SUBTOTAL SALARIES 2,624,309 2,624,309 106,054.00 24.75 4 SUBTOTAL OTHER WAGES & RELATED COSTS 5 SUBTOTAL WAGE-RELATED COSTS 580,088 580,088 22.10 6 TOTAL 3,204,397 3,204,397 106,054.00 30.21 7 NET SALARIES 8 EXCLUDED AREA SALARIES 9 SUBTOTAL SALARIES 10 SUBTOTAL OTHER WAGES & RELATED COSTS 11 SUBTOTAL WAGE-RELATED COSTS 12 TOTAL 13 TOTAL OVERHEAD COSTS 610,222 610,222 29,606.00 20.61 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 S-10 (05/2004) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL UNCOMPENSATED CARE DATA I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-10 I I TO 12/31/2009 I I I I DESCRIPTION UNCOMPENSATED CARE INFORMATION 1 DO YOU HAVE A WRITTEN CHARITY CARE POLICY? 2 ARE PATIENTS WRITE-OFFS IDENTIFIED AS CHARITY? IF YES ANSWER LINES 2.01 THRU 2.04 2.01 IS IT AT THE TIME OF ADMISSION? 2.02 IS IT AT THE TIME OF FIRST BILLING? 2.03 IS IT AFTER SOME COLLECTION EFFORT HAS BEEN MADE? 2.04 3 ARE CHARITY WRITE-OFFS MADE FOR PARTIAL BILLS? 4 ARE CHARITY DETERMINATIONS BASED UPON ADMINISTRATIVE JUDGMENT WITHOUT FINANCIAL DATA? 5 ARE CHARITY DETERMINATIONS BASED UPON INCOME DATA ONLY? 6 ARE CHARITY DETERMINATIONS BASED UPON NET WORTH (ASSETS) DATA? 7 ARE CHARITY DETERMINATIONS BASED UPON INCOME AND NET WORTH DATA? 8 DOES YOUR ACCOUNTING SYSTEM SEPARATELY IDENTIFY BAD DEBT AND CHARITY CARE? IF YES ANSWER 8.01 8.01 DO YOU SEPARATELY ACCOUNT FOR INPATIENT AND OUTPATIENT SERVICES? 9 IS DISCERNING CHARITY FROM BAD DEBT A HIGH PRIORITY IN YOUR INSTITUTION? IF NO ANSWER 9.01 THRU 9.04 9.01 IS IT BECAUSE THERE IS NOT ENOUGH STAFF TO DETERMINE ELIGIBILITY? 9.02 IS IT BECAUSE THERE IS NO FINANCIAL INCENTIVE TO SEPARATE CHARITY FROM BAD DEBT? 9.03 IS IT BECAUSE THERE IS NO CLEAR DIRECTIVE POLICY ON CHARITY DETERMINATION? 9.04 IS IT BECAUSE YOUR INSTITUTION DOES NOT DEEM THE DISTINCTION IMPORTANT? 10 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, WHAT IS THE MAXIMUM INCOME THAT CAN BE EARNED BY PATIENTS (SINGLE WITHOUT DEPENDENT) AND STILL DETERMINED TO BE A CHARITY WRITE OFF? 11 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, IS THE INCOME DIRECTLY TIED TO FEDERAL POVERTY LEVEL? IF YES ANSWER 11.01 THRU 11.04 11.01 IS THE PERCENTAGE LEVEL USED LESS THAN 100% OF THE FEDERAL POVERTY LEVEL? 11.02 IS THE PERCENTAGE LEVEL USED BETWEEN 100% AND 150% OF THE FEDERAL POVERTY LEVEL? 11.03 IS THE PERCENTAGE LEVEL USED BETWEEN 150% AND 200% OF THE FEDERAL POVERTY LEVEL? 11.04 IS THE PERCENTAGE LEVEL USED GREATER THAN 200% OF THE FEDERAL POVERTY LEVEL? 12 ARE PARTIAL WRITE-OFFS GIVEN TO HIGHER INCOME PATIENTS ON A GRADUAL SCALE? 13 IS THERE CHARITY CONSIDERATION GIVEN TO HIGH NET WORTH PATIENTS WHO HAVE CATASTROPHIC OR OTHER EXTRAORDINARY MEDICAL EXPENSES? 14 IS YOUR HOSPITAL STATE OR LOCAL GOVERNMENT OWNED? IF YES ANSWER LINES 14.01 AND 14.02 14.01 DO YOU RECEIVE DIRECT FINANCIAL SUPPORT FROM THAT GOVERNMENT ENTITY FOR THE PURPOSE OF PROVIDING COMPENSATED CARE? 14.02 WHAT PERCENTAGE OF THE AMOUNT ON LINE 14.01 IS FROM GOVERNMENT FUNDING? 15 DO YOU RECEIVE RESTRICTED GRANTS FOR RENDERING CARE TO CHARITY PATIENTS? 16 ARE OTHER NON-RESTRICTED GRANTS USED TO SUBSIDIZE CHARITY CARE? UNCOMPENSATED CARE REVENUES 17 REVENUE FROM UNCOMPENSATED CARE 17.01 GROSS MEDICAID REVENUES 18 REVENUES FROM STATE AND LOCAL INDIGENT CARE PROGRAMS 19 REVENUE RELATED TO SCHIP (SEE INSTRUCTIONS) 20 RESTRICTED GRANTS 21 NON-RESTRICTED GRANTS 22 TOTAL GROSS UNCOMPENSATED CARE REVENUES UNCOMPENSATED CARE COST 23 TOTAL CHARGES FOR PATIENTS COVERED BY STATE AND LOCAL INDIGENT CARE PROGRAMS 24 COST TO CHARGE RATIO (WKST C, PART I, COLUMN 3, LINE 103, .208987 DIVIDED BY COLUMN 8, LINE 103) 25 TOTAL STATE AND LOCAL INDIGENT CARE PROGRAM COST (LINE 23 * LINE 24) 26 TOTAL SCHIP CHARGES FROM YOUR RECORDS 27 TOTAL SCHIP COST, (LINE 24 * LINE 26) 28 TOTAL GROSS MEDICAID CHARGES FROM YOUR RECORDS Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 S-10 (05/2004) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 HOSPITAL UNCOMPENSATED CARE DATA I 15-0172 I FROM 1/ 1/2009 I WORKSHEET S-10 I I TO 12/31/2009 I I I I DESCRIPTION 29 TOTAL GROSS MEDICAID COST (LINE 24 * LINE 28) 30 OTHER UNCOMPENSATED CARE CHARGES FROM YOUR RECORDS 31 UNCOMPENSATED CARE COST (LINE 24 * LINE 30) 32 TOTAL UNCOMPENSATED CARE COST TO THE HOSPITAL (SUM OF LINES 25, 27, AND 29) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(9/1996) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 RECLASSIFICATION AND ADJUSTMENT OF I 15-0172 I FROM 1/ 1/2009 I WORKSHEET A TRIAL BALANCE OF EXPENSES I I TO 12/31/2009 I COST COST CENTER DESCRIPTION SALARIES OTHER TOTAL RECLASS- RECLASSIFIED CENTER IFICATIONS TRIAL BALANCE 1 2 3 4 5 GENERAL SERVICE COST CNTR 3 0300 NEW CAP REL COSTS-BLDG & FIXT 875,502 875,502 582,095 1,457,597 4 0400 NEW CAP REL COSTS-MVBLE EQUIP 55,560 55,560 55,560 5 0500 EMPLOYEE BENEFITS 580,088 580,088 580,088 6 0600 ADMINISTRATIVE & GENERAL 476,457 2,003,126 2,479,583 -32,667 2,446,916 8 0800 OPERATION OF PLANT 41,837 451,697 493,534 493,534 9 0900 LAUNDRY & LINEN SERVICE 42,719 42,719 42,719 10 1000 HOUSEKEEPING 22,835 81,564 104,399 104,399 11 1100 DIETARY 18,432 18,432 18,432 14 1400 NURSING ADMINISTRATION 32,667 32,667 15 1500 CENTRAL SERVICES & SUPPLY 69,093 108,123 177,216 177,216 16 1600 PHARMACY 17 1700 MEDICAL RECORDS & LIBRARY 66,140 66,140 66,140 INPAT ROUTINE SRVC CNTRS 25 2500 ADULTS & PEDIATRICS 566,108 78,567 644,675 644,675 26 2600 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 37 3700 OPERATING ROOM 1,385,915 1,385,915 1,385,915 38 3800 RECOVERY ROOM 40 4000 ANESTHESIOLOGY 41 4100 RADIOLOGY-DIAGNOSTIC 62,064 62,064 62,064 44 4400 LABORATORY 45 4500 PBP CLINICAL LAB SERVICES-PRGM ONLY 49 4900 RESPIRATORY THERAPY 50 5000 PHYSICAL THERAPY 55 5500 MEDICAL SUPPLIES CHARGED TO PATIENTS 2,052,050 2,052,050 2,052,050 56 5600 DRUGS CHARGED TO PATIENTS 307,719 307,719 307,719 OUTPAT SERVICE COST CNTRS 61 6100 EMERGENCY 62 6200 OBSERVATION BEDS (NON-DISTINCT PART) SPEC PURPOSE COST CENTERS 88 8800 INTEREST EXPENSE 582,095 582,095 -582,095 90 9000 OTHER CAPITAL RELATED COSTS 95 SUBTOTALS 2,624,309 7,303,382 9,927,691 -0- 9,927,691 NONREIMBURS COST CENTERS 96 9600 GIFT, FLOWER, COFFEE SHOP & CANTEEN 96.01 9601 SHELLED SPACE 97 9700 RESEARCH 98 9800 PHYSICIANS' PRIVATE OFFICES 99 9900 NONPAID WORKERS 101 TOTAL 2,624,309 7,303,382 9,927,691 -0- 9,927,691 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(9/1996) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 RECLASSIFICATION AND ADJUSTMENT OF I 15-0172 I FROM 1/ 1/2009 I WORKSHEET A TRIAL BALANCE OF EXPENSES I I TO 12/31/2009 I COST COST CENTER DESCRIPTION ADJUSTMENTS NET EXPENSES CENTER FOR ALLOC 6 7 GENERAL SERVICE COST CNTR 3 0300 NEW CAP REL COSTS-BLDG & FIXT -119,147 1,338,450 4 0400 NEW CAP REL COSTS-MVBLE EQUIP 55,560 5 0500 EMPLOYEE BENEFITS 580,088 6 0600 ADMINISTRATIVE & GENERAL -885,901 1,561,015 8 0800 OPERATION OF PLANT 493,534 9 0900 LAUNDRY & LINEN SERVICE 42,719 10 1000 HOUSEKEEPING 104,399 11 1100 DIETARY 18,432 14 1400 NURSING ADMINISTRATION 32,667 15 1500 CENTRAL SERVICES & SUPPLY 177,216 16 1600 PHARMACY 17 1700 MEDICAL RECORDS & LIBRARY 66,140 INPAT ROUTINE SRVC CNTRS 25 2500 ADULTS & PEDIATRICS 644,675 26 2600 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 37 3700 OPERATING ROOM 1,385,915 38 3800 RECOVERY ROOM 40 4000 ANESTHESIOLOGY 41 4100 RADIOLOGY-DIAGNOSTIC 62,064 44 4400 LABORATORY 45 4500 PBP CLINICAL LAB SERVICES-PRGM ONLY 49 4900 RESPIRATORY THERAPY 50 5000 PHYSICAL THERAPY 55 5500 MEDICAL SUPPLIES CHARGED TO PATIENTS 2,052,050 56 5600 DRUGS CHARGED TO PATIENTS 307,719 OUTPAT SERVICE COST CNTRS 61 6100 EMERGENCY 62 6200 OBSERVATION BEDS (NON-DISTINCT PART) SPEC PURPOSE COST CENTERS 88 8800 INTEREST EXPENSE -0- 90 9000 OTHER CAPITAL RELATED COSTS -0- 95 SUBTOTALS -1,005,048 8,922,643 NONREIMBURS COST CENTERS 96 9600 GIFT, FLOWER, COFFEE SHOP & CANTEEN 96.01 9601 SHELLED SPACE 97 9700 RESEARCH 98 9800 PHYSICIANS' PRIVATE OFFICES 99 9900 NONPAID WORKERS 101 TOTAL -1,005,048 8,922,643 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COST CENTERS USED IN COST REPORT I 15-0172 I FROM 1/ 1/2009 I NOT A CMS WORKSHEET I I TO 12/31/2009 I LINE NO. COST CENTER DESCRIPTION CMS CODE STANDARD LABEL FOR NON-STANDARD CODES GENERAL SERVICE COST 3 NEW CAP REL COSTS-BLDG & FIXT 0300 4 NEW CAP REL COSTS-MVBLE EQUIP 0400 5 EMPLOYEE BENEFITS 0500 6 ADMINISTRATIVE & GENERAL 0600 8 OPERATION OF PLANT 0800 9 LAUNDRY & LINEN SERVICE 0900 10 HOUSEKEEPING 1000 11 DIETARY 1100 14 NURSING ADMINISTRATION 1400 15 CENTRAL SERVICES & SUPPLY 1500 16 PHARMACY 1600 17 MEDICAL RECORDS & LIBRARY 1700 INPAT ROUTINE SRVC C 25 ADULTS & PEDIATRICS 2500 26 INTENSIVE CARE UNIT 2600 ANCILLARY SRVC COST 37 OPERATING ROOM 3700 38 RECOVERY ROOM 3800 40 ANESTHESIOLOGY 4000 41 RADIOLOGY-DIAGNOSTIC 4100 44 LABORATORY 4400 45 PBP CLINICAL LAB SERVICES-PRGM ONLY 4500 49 RESPIRATORY THERAPY 4900 50 PHYSICAL THERAPY 5000 55 MEDICAL SUPPLIES CHARGED TO PATIENTS 5500 56 DRUGS CHARGED TO PATIENTS 5600 OUTPAT SERVICE COST 61 EMERGENCY 6100 62 OBSERVATION BEDS (NON-DISTINCT PART) 6200 SPEC PURPOSE COST CE 88 INTEREST EXPENSE 8800 90 OTHER CAPITAL RELATED COSTS 9000 95 SUBTOTALS OLD CAP REL COSTS-BLDG & FIXT NONREIMBURS COST CEN 96 GIFT, FLOWER, COFFEE SHOP & CANTEEN 9600 96.01 SHELLED SPACE 9601 GIFT, FLOWER, COFFEE SHOP & CANTEEN 97 RESEARCH 9700 98 PHYSICIANS' PRIVATE OFFICES 9800 99 NONPAID WORKERS 9900 101 TOTAL OLD CAP REL COSTS-BLDG & FIXT Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (09/1996) | PROVIDER NO: | PERIOD: | PREPARED 6/ 4/2010 RECLASSIFICATIONS | 150172 | FROM 1/ 1/2009 | WORKSHEET A-6 | | TO 12/31/2009 | ----------------------------------- INCREASE ----------------------------------- CODE LINE EXPLANATION OF RECLASSIFICATION (1) COST CENTER NO SALARY OTHER 1 2 3 4 5 1 INTEREST EXPENSE A NEW CAP REL COSTS-BLDG & FIXT 3 582,095 2 NURSING ADM RECLASS C NURSING ADMINISTRATION 14 32,667 36 TOTAL RECLASSIFICATIONS 32,667 582,095 ________________________________________________________________________________________________________________________________ (1) A letter (A, B, etc) must be entered on each line to identify each reclassification entry. Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate. See instructions for column 10 referencing to Worksheet A-7, Part III, columns 9 through 14. Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (09/1996) | PROVIDER NO: | PERIOD: | PREPARED 6/ 4/2010 RECLASSIFICATIONS | 150172 | FROM 1/ 1/2009 | WORKSHEET A-6 | | TO 12/31/2009 | ----------------------------------- DECREASE ----------------------------------- CODE LINE A-7 EXPLANATION OF RECLASSIFICATION (1) COST CENTER NO SALARY OTHER REF 1 6 7 8 9 10 1 INTEREST EXPENSE A INTEREST EXPENSE 88 582,095 11 2 NURSING ADM RECLASS C ADMINISTRATIVE & GENERAL 6 32,667 36 TOTAL RECLASSIFICATIONS 32,667 582,095 ________________________________________________________________________________________________________________________________ (1) A letter (A, B, etc) must be entered on each line to identify each reclassification entry. Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate. See instructions for column 10 referencing to Worksheet A-7, Part III, columns 9 through 14. Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(09/1996) ANALYSIS OF CHANGES DURING COST REPORTING PERIOD IN CAPITAL I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 ASSET BALANCES OF HOSPITAL AND HOSPITAL HEALTH CARE I 15-0172 I FROM 1/ 1/2009 I WORKSHEET A-7 COMPLEX CERTIFIED TO PARTICIPATE IN HEALTH CARE PROGRAMS I I TO 12/31/2009 I PARTS I & II PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES DESCRIPTION ACQUISITIONS DISPOSALS FULLY BEGINNING AND ENDING DEPRECIATED BALANCES PURCHASES DONATION TOTAL RETIREMENTS BALANCE ASSETS 1 2 3 4 5 6 7 1 LAND 2 LAND IMPROVEMENTS 3 BUILDINGS & FIXTURE 4 BUILDING IMPROVEMEN 5 FIXED EQUIPMENT 6 MOVABLE EQUIPMENT 7 SUBTOTAL 8 RECONCILING ITEMS 9 TOTAL PART II - ANALYSIS OF CHANGES IN NEW CAPITAL ASSET BALANCES DESCRIPTION ACQUISITIONS DISPOSALS FULLY BEGINNING AND ENDING DEPRECIATED BALANCES PURCHASES DONATION TOTAL RETIREMENTS BALANCE ASSETS 1 2 3 4 5 6 7 1 LAND 850,190 850,190 2 LAND IMPROVEMENTS 768,718 768,718 3 BUILDINGS & FIXTURE 4 BUILDING IMPROVEMEN 7,340,255 56,005 56,005 7,396,260 5 FIXED EQUIPMENT 6 MOVABLE EQUIPMENT 3,450,378 315,575 315,575 19,233 3,746,720 7 SUBTOTAL 12,409,541 371,580 371,580 19,233 12,761,888 8 RECONCILING ITEMS 9 TOTAL 12,409,541 371,580 371,580 19,233 12,761,888 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(12/1999) RECONCILIATION OF CAPITAL COSTS CENTERS I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 I 15-0172 I FROM 1/ 1/2009 I WORKSHEET A-7 I I TO 12/31/2009 I PARTS III & IV PART III - RECONCILIATION OF CAPITAL COST CENTERS DESCRIPTION COMPUTATION OF RATIOS ALLOCATION OF OTHER CAPITAL GROSS CAPITLIZED GROSS ASSETS OTHER CAPITAL ASSETS LEASES FOR RATIO RATIO INSURANCE TAXES RELATED COSTS TOTAL * 1 2 3 4 5 6 7 8 3 NEW CAP REL COSTS-BL 9,015,168 9,015,168 .714435 4 NEW CAP REL COSTS-MV 3,603,431 3,603,431 .285565 5 TOTAL 12,618,599 12,618,599 1.000000 DESCRIPTION SUMMARY OF OLD AND NEW CAPITAL OTHER CAPITAL DEPRECIATION LEASE INTEREST INSURANCE TAXES RELATED COST TOTAL (1) * 9 10 11 12 13 14 15 3 NEW CAP REL COSTS-BL 863,817 462,948 11,685 1,338,450 4 NEW CAP REL COSTS-MV 19,025 9,877 26,658 55,560 5 TOTAL 882,842 9,877 462,948 38,343 1,394,010 PART IV - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 THRU 4 DESCRIPTION SUMMARY OF OLD AND NEW CAPITAL OTHER CAPITAL DEPRECIATION LEASE INTEREST INSURANCE TAXES RELATED COST TOTAL (1) * 9 10 11 12 13 14 15 3 NEW CAP REL COSTS-BL 863,817 11,685 875,502 4 NEW CAP REL COSTS-MV 19,025 9,877 26,658 55,560 5 TOTAL 882,842 9,877 38,343 931,062 ____________________________________________________________________________________________________________________________________ * All lines numbers except line 5 are to be consistent with Workhseet A line numbers for capital cost centers. (1) The amounts on lines 1 thru 4 must equal the corresponding amounts on Worksheet A, column 7, lines 1 thru 4. Columns 9 through 14 should include related Worksheet A-6 reclassifications and Worksheet A-8 adjustments. (See instructions). Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/1999) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 ADJUSTMENTS TO EXPENSES I 15-0172 I FROM 1/ 1/2009 I WORKSHEET A-8 I I TO 12/31/2009 I EXPENSE CLASSIFICATION ON DESCRIPTION (1) WORKSHEET A TO/FROM WHICH THE WKST. (2) AMOUNT IS TO BE ADJUSTED A-7 BASIS/CODE AMOUNT COST CENTER LINE NO REF. 1 2 3 4 5 1 INVST INCOME-OLD BLDGS AND FIXTURES **COST CENTER DELETED** 1 2 INVESTMENT INCOME-OLD MOVABLE EQUIP **COST CENTER DELETED** 2 3 INVST INCOME-NEW BLDGS AND FIXTURES B -119,147 NEW CAP REL COSTS-BLDG & 3 11 4 INVESTMENT INCOME-NEW MOVABLE EQUIP NEW CAP REL COSTS-MVBLE E 4 5 INVESTMENT INCOME-OTHER 6 TRADE, QUANTITY AND TIME DISCOUNTS 7 REFUNDS AND REBATES OF EXPENSES B -514 ADMINISTRATIVE & GENERAL 6 8 RENTAL OF PRVIDER SPACE BY SUPPLIERS 9 TELEPHONE SERVICES 10 TELEVISION AND RADIO SERVICE 11 PARKING LOT 12 PROVIDER BASED PHYSICIAN ADJUSTMENT A-8-2 13 SALE OF SCRAP, WASTE, ETC. 14 RELATED ORGANIZATION TRANSACTIONS A-8-1 15 LAUNDRY AND LINEN SERVICE 16 CAFETERIA--EMPLOYEES AND GUESTS 17 RENTAL OF QTRS TO EMPLYEE AND OTHRS 18 SALE OF MED AND SURG SUPPLIES 19 SALE OF DRUGS TO OTHER THAN PATIENTS 20 SALE OF MEDICAL RECORDS & ABSTRACTS 21 NURSG SCHOOL(TUITN,FEES,BOOKS, ETC.) 22 VENDING MACHINES 23 INCOME FROM IMPOSITION OF INTEREST 24 INTRST EXP ON MEDICARE OVERPAYMENTS 25 ADJUSTMENT FOR RESPIRATORY THERAPY A-8-3/A-8-4 RESPIRATORY THERAPY 49 26 ADJUSTMENT FOR PHYSICAL THERAPY A-8-3/A-8-4 PHYSICAL THERAPY 50 27 ADJUSTMENT FOR HHA PHYSICAL THERAPY A-8-3 28 UTILIZATION REVIEW-PHYSIAN COMP **COST CENTER DELETED** 89 29 DEPRECIATION-OLD BLDGS AND FIXTURES **COST CENTER DELETED** 1 30 DEPRECIATION-OLD MOVABLE EQUIP **COST CENTER DELETED** 2 31 DEPRECIATION-NEW BLDGS AND FIXTURES NEW CAP REL COSTS-BLDG & 3 32 DEPRECIATION-NEW MOVABLE EQUIP NEW CAP REL COSTS-MVBLE E 4 33 NON-PHYSICIAN ANESTHETIST **COST CENTER DELETED** 20 34 PHYSICIANS' ASSISTANT 35 ADJUSTMENT FOR OCCUPATIONAL THERAPY A-8-4 **COST CENTER DELETED** 51 36 ADJUSTMENT FOR SPEECH PATHOLOGY A-8-4 **COST CENTER DELETED** 52 37 REMOVAL OF SUITE LEASE A -859,512 ADMINISTRATIVE & GENERAL 6 38 MARKETING COSTS A -25,283 ADMINISTRATIVE & GENERAL 6 39 DONATIONS A -592 ADMINISTRATIVE & GENERAL 6 40 41 42 OTHER ADJUSTMENTS (SPECIFY) 43 OTHER ADJUSTMENTS (SPECIFY) 44 OTHER ADJUSTMENTS (SPECIFY) 45 OTHER ADJUSTMENTS (SPECIFY) 46 OTHER ADJUSTMENTS (SPECIFY) 47 OTHER ADJUSTMENTS (SPECIFY) 48 OTHER ADJUSTMENTS (SPECIFY) 49 OTHER ADJUSTMENTS (SPECIFY) 50 TOTAL (SUM OF LINES 1 THRU 49) -1,005,048 ____________________________________________________________________________________________________________________________________ (1) Description - all chapter references in this columnpertain to CMS Pub. 15-I. (2) Basis for adjustment (see instructions). A. Costs - if cost, including applicable overhead, can be determined. B. Amount Received - if cost cannot be determined. (3) Additional adjustments may be made on lines 37 thru 49 and subscripts thereof. Note: See instructions for column 5 referencing to Worksheet A-7 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(09/2000) STATEMENT OF COSTS OF SERVICES I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 FROM RELATED ORGANIZATIONS AND I 15-0172 I FROM 1/ 1/2009 I HOME OFFICE COSTS I I TO 12/31/2009 I WORKSHEET A-8-1 A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR THE CLAIMING OF HOME OFFICE COSTS: AMOUNT OF NET* WKSHT A-7 ALLOWABLE ADJUST- COL. REF. LINE NO. COST CENTER EXPENSE ITEMS COST AMOUNT MENTS 1 2 3 4 5 6 1 6 ADMINISTRATIVE & GENERAL 1 1 2 3 4 5 TOTALS 1 1 * THE AMOUNTS ON LINES 1-4 AND SUBSCRIPTS AS APPROPRIATE ARE TRANSFERRED IN DETAIL TO WORKSHEET A, COLUMN 6, LINES AS APPROPRIATE. POSITIVE AMOUNTS INCREASE COST AND NEGATIVE AMOUNTS DECREASE COST. FOR RELATED ORGANIZATIONAL OR HOME OFFICE COST WHICH HAS NOT BEEN POSTED TO WORKSHEET A, COLUMNS 1 AND/OR 2, THE AMOUNT ALLOWABLE SHOULD BE IN COLUMN 4 OF THIS PART. B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE: THE SECRETARY, BY VIRTUE OF AUTHORITY GRANTED UNDER SECTION 1814(B)(1) OF THE SOCIAL SECURITY ACT, REQUIRES THAT YOU FURNISH THE INFORMATION REQUESTED UNDER PART B OF THIS WORKSHEET. THIS INFORMATION IS USED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES AND ITS INTERMEDIARIES IN DETERMINING THAT THE COSTS APPLICABLE TO SERVICES, FACILITIES, AND SUPPLIES FURNISHED BY ORGANIZATIONS RELATED TO YOU BY COMMON OWNERSHIP OR CONTROL REPRESENT REASONABLE COSTS AS DETERMINED UNDER SECTION 1861 OF THE SOCIAL SECURITY ACT. IF YOU DO NOT PROVIDE ALL OR ANY PART OF THE REQUESTED INFORMATION, THE COST REPORT IS CONSIDERED INCOMPLETE AND NOT ACCEPTABLE FOR PURPOSES OF CLAIMING REIMBURSEMENT UNDER TITLE XVIII. SYMBOL NAME PERCENTAGE RELATED ORGANIZATION(S) AND/OR HOME OFFICE (1) OF NAME PERCENTAGE OF TYPE OF OWNERSHIP OWNERSHIP BUSINESS 1 2 3 4 5 6 1 C VARIOUS PHSICIANS 100.00 PHYSICIANS MEDICAL CENTER 0.00 HOSPITAL 2 A VARIOUS PHYSICIANS 100.00 PHYSICIANS SURG PROP, LLC 0.00 PROPERTY COMPANY 3 0.00 0.00 4 0.00 0.00 5 0.00 0.00 (1) USE THE FOLLOWING SYMBOLS TO INDICATE INTERELATIONSHIP TO RELATED ORGANIZATIONS: A. INDIVIDUAL HAS FINANCIAL INTEREST (STOCKHOLDER, PARTNER, ETC.) IN BOTH RELATED ORGANIZATION AND IN PROVIDER. B. CORPORATION, PARTNERSHIP OR OTHER ORGANIZATION HAS FINANCIAL INTEREST IN PROVIDER. C. PROVIDER HAS FINANCIAL INTEREST IN CORPORATION, PARTNERSHIP OR OTHER ORGANIZATION. D. DIRECTOR, OFFICER, ADMINISTRATOR OR KEY PERSON OF PROVIDER OR RELATIVE OF SUCH PERSON HAS A FINANCIAL INTEREST IN RELATED ORGANIZATION. E. INDIVIDUAL IS DIRECTOR, OFFICER, ADMINISTRATOR OR KEY PERSON OF PROVIDER AND RELATED ORGANIZATION. F. DIRECTOR, OFFICER, ADMINISTRATOR OR KEY PERSON OF RELATED ORGANIZATION OR RELATIVE OF SUCH PERSON HAS FINANCIAL INTEREST IN PROVIDER. G. OTHER (FINANCIAL OR NON-FINANCIAL) SPECIFY. COMMON OWNERSHIP IN HOSP AND ENTITY Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COST ALLOCATION STATISTICS I 15-0172 I FROM 1/ 1/2009 I NOT A CMS WORKSHEET I I TO 12/31/2009 I LINE NO. COST CENTER DESCRIPTION STATISTICS CODE STATISTICS DESCRIPTION GENERAL SERVICE COST 3 NEW CAP REL COSTS-BLDG & FIXT 3 SQUARE FEET ENTERED 4 NEW CAP REL COSTS-MVBLE EQUIP 3 SQUARE FEET ENTERED 5 EMPLOYEE BENEFITS 5 GROSS SALARIES ENTERED 6 ADMINISTRATIVE & GENERAL # ACCUM. COST NOT ENTERED 8 OPERATION OF PLANT 3 SQUARE FEET ENTERED 9 LAUNDRY & LINEN SERVICE 8 PATIENT DAYS ENTERED 10 HOUSEKEEPING 3 SQUARE FEET ENTERED 11 DIETARY 10 PATIENT DAYS ENTERED 14 NURSING ADMINISTRATION 14 NURSING HOURS ENTERED 15 CENTRAL SERVICES & SUPPLY 15 COSTED REQUIS. ENTERED 16 PHARMACY 16 COSTED REQUISITION ENTERED 17 MEDICAL RECORDS & LIBRARY 17 PATIENT REVENUE ENTERED Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COST ALLOCATION - GENERAL SERVICE COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B I I TO 12/31/2009 I PART I NET EXPENSES NEW CAP REL C NEW CAP REL C EMPLOYEE BENE SUBTOTAL ADMINISTRATIV OPERATION OF COST CENTER FOR COST OSTS-BLDG & OSTS-MVBLE E FITS E & GENERAL PLANT DESCRIPTION ALLOCATION 0 3 4 5 5a.00 6 8 GENERAL SERVICE COST CNTR 003 NEW CAP REL COSTS-BLDG & 1,338,450 1,338,450 004 NEW CAP REL COSTS-MVBLE E 55,560 55,560 005 EMPLOYEE BENEFITS 580,088 580,088 006 ADMINISTRATIVE & GENERAL 1,561,015 229,421 9,523 98,097 1,898,056 1,898,056 008 OPERATION OF PLANT 493,534 85,178 3,536 9,248 591,496 159,823 751,319 009 LAUNDRY & LINEN SERVICE 42,719 42,719 11,543 010 HOUSEKEEPING 104,399 18,929 786 5,048 129,162 34,900 13,890 011 DIETARY 18,432 20,594 855 39,881 10,776 15,112 014 NURSING ADMINISTRATION 32,667 7,221 39,888 10,778 015 CENTRAL SERVICES & SUPPLY 177,216 213,209 8,850 15,273 414,548 112,012 156,456 016 PHARMACY 5,214 216 5,430 1,467 3,826 017 MEDICAL RECORDS & LIBRARY 66,140 20,944 869 87,953 23,765 15,369 INPAT ROUTINE SRVC CNTRS 025 ADULTS & PEDIATRICS 644,675 346,235 14,372 125,135 1,130,417 305,441 254,073 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 037 OPERATING ROOM 1,385,915 392,504 16,295 306,347 2,101,061 567,709 288,027 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 62,064 6,222 258 13,719 82,263 22,228 4,566 044 LABORATORY 045 PBP CLINICAL LAB SERVICES 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHARGED 2,052,050 2,052,050 554,468 056 DRUGS CHARGED TO PATIENTS 307,719 307,719 83,146 OUTPAT SERVICE COST CNTRS 061 EMERGENCY 062 OBSERVATION BEDS (NON-DIS SPEC PURPOSE COST CENTERS 095 SUBTOTALS 8,922,643 1,338,450 55,560 580,088 8,922,643 1,898,056 751,319 NONREIMBURS COST CENTERS 096 GIFT, FLOWER, COFFEE SHOP 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE OFFIC 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENT 102 NEGATIVE COST CENTER 103 TOTAL 8,922,643 1,338,450 55,560 580,088 8,922,643 1,898,056 751,319 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009)CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COST ALLOCATION - GENERAL SERVICE COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B I I TO 12/31/2009 I PART I LAUNDRY & LIN HOUSEKEEPING DIETARY NURSING ADMIN CENTRAL SERVI PHARMACY MEDICAL RECOR COST CENTER EN SERVICE ISTRATION CES & SUPPLY DS & LIBRARY DESCRIPTION 9 10 11 14 15 16 17 GENERAL SERVICE COST CNTR 003 NEW CAP REL COSTS-BLDG & 004 NEW CAP REL COSTS-MVBLE E 005 EMPLOYEE BENEFITS 006 ADMINISTRATIVE & GENERAL 008 OPERATION OF PLANT 009 LAUNDRY & LINEN SERVICE 54,262 010 HOUSEKEEPING 177,952 011 DIETARY 3,647 69,416 014 NURSING ADMINISTRATION 50,666 015 CENTRAL SERVICES & SUPPLY 37,755 720,771 016 PHARMACY 923 11,646 017 MEDICAL RECORDS & LIBRARY 3,709 130,796 INPAT ROUTINE SRVC CNTRS 025 ADULTS & PEDIATRICS 54,262 61,311 69,416 12,124 903 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 037 OPERATING ROOM 69,505 37,033 96,767 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 1,102 1,509 3,830 044 LABORATORY 045 PBP CLINICAL LAB SERVICES 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHARGED 720,771 24,869 056 DRUGS CHARGED TO PATIENTS 11,646 4,427 OUTPAT SERVICE COST CNTRS 061 EMERGENCY 062 OBSERVATION BEDS (NON-DIS SPEC PURPOSE COST CENTERS 095 SUBTOTALS 54,262 177,952 69,416 50,666 720,771 11,646 130,796 NONREIMBURS COST CENTERS 096 GIFT, FLOWER, COFFEE SHOP 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE OFFIC 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENT 102 NEGATIVE COST CENTER 103 TOTAL 54,262 177,952 69,416 50,666 720,771 11,646 130,796 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009)CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COST ALLOCATION - GENERAL SERVICE COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B I I TO 12/31/2009 I PART I SUBTOTAL I&R COST TOTAL COST CENTER POST STEP- DESCRIPTION DOWN ADJ 25 26 27 GENERAL SERVICE COST CNTR 003 NEW CAP REL COSTS-BLDG & 004 NEW CAP REL COSTS-MVBLE E 005 EMPLOYEE BENEFITS 006 ADMINISTRATIVE & GENERAL 008 OPERATION OF PLANT 009 LAUNDRY & LINEN SERVICE 010 HOUSEKEEPING 011 DIETARY 014 NURSING ADMINISTRATION 015 CENTRAL SERVICES & SUPPLY 016 PHARMACY 017 MEDICAL RECORDS & LIBRARY INPAT ROUTINE SRVC CNTRS 025 ADULTS & PEDIATRICS 1,887,947 1,887,947 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 037 OPERATING ROOM 3,160,102 3,160,102 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 115,498 115,498 044 LABORATORY 045 PBP CLINICAL LAB SERVICES 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHARGED 3,352,158 3,352,158 056 DRUGS CHARGED TO PATIENTS 406,938 406,938 OUTPAT SERVICE COST CNTRS 061 EMERGENCY 062 OBSERVATION BEDS (NON-DIS SPEC PURPOSE COST CENTERS 095 SUBTOTALS 8,922,643 8,922,643 NONREIMBURS COST CENTERS 096 GIFT, FLOWER, COFFEE SHOP 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE OFFIC 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENT 102 NEGATIVE COST CENTER 103 TOTAL 8,922,643 8,922,643 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 ALLOCATION OF NEW CAPITAL RELATED COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B I I TO 12/31/2009 I PART III DIR ASSGNED NEW CAP REL C NEW CAP REL C EMPLOYEE BENE ADMINISTRATIV OPERATION OF COST CENTER NEW CAPITAL OSTS-BLDG & OSTS-MVBLE E SUBTOTAL FITS E & GENERAL PLANT DESCRIPTION REL COSTS 0 3 4 4a 5 6 8 GENERAL SERVICE COST CNTR 003 NEW CAP REL COSTS-BLDG & 004 NEW CAP REL COSTS-MVBLE E 005 EMPLOYEE BENEFITS 006 ADMINISTRATIVE & GENERAL 229,421 9,523 238,944 238,944 008 OPERATION OF PLANT 85,178 3,536 88,714 20,120 108,834 009 LAUNDRY & LINEN SERVICE 1,453 010 HOUSEKEEPING 18,929 786 19,715 4,393 2,012 011 DIETARY 20,594 855 21,449 1,357 2,189 014 NURSING ADMINISTRATION 1,357 015 CENTRAL SERVICES & SUPPLY 213,209 8,850 222,059 14,101 22,664 016 PHARMACY 5,214 216 5,430 185 554 017 MEDICAL RECORDS & LIBRARY 20,944 869 21,813 2,992 2,226 INPAT ROUTINE SRVC CNTRS 025 ADULTS & PEDIATRICS 346,235 14,372 360,607 38,451 36,804 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 037 OPERATING ROOM 392,504 16,295 408,799 71,470 41,724 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 6,222 258 6,480 2,798 661 044 LABORATORY 045 PBP CLINICAL LAB SERVICES 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHARGED 69,800 056 DRUGS CHARGED TO PATIENTS 10,467 OUTPAT SERVICE COST CNTRS 061 EMERGENCY 062 OBSERVATION BEDS (NON-DIS SPEC PURPOSE COST CENTERS 095 SUBTOTALS 1,338,450 55,560 1,394,010 238,944 108,834 NONREIMBURS COST CENTERS 096 GIFT, FLOWER, COFFEE SHOP 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE OFFIC 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENTS 102 NEGATIVE COST CENTER 103 TOTAL 1,338,450 55,560 1,394,010 238,944 108,834 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009)CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 ALLOCATION OF NEW CAPITAL RELATED COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B I I TO 12/31/2009 I PART III LAUNDRY & LIN HOUSEKEEPING DIETARY NURSING ADMIN CENTRAL SERVI PHARMACY MEDICAL RECOR COST CENTER EN SERVICE ISTRATION CES & SUPPLY DS & LIBRARY DESCRIPTION 9 10 11 14 15 16 17 GENERAL SERVICE COST CNTR 003 NEW CAP REL COSTS-BLDG & 004 NEW CAP REL COSTS-MVBLE E 005 EMPLOYEE BENEFITS 006 ADMINISTRATIVE & GENERAL 008 OPERATION OF PLANT 009 LAUNDRY & LINEN SERVICE 1,453 010 HOUSEKEEPING 26,120 011 DIETARY 535 25,530 014 NURSING ADMINISTRATION 1,357 015 CENTRAL SERVICES & SUPPLY 5,542 264,366 016 PHARMACY 136 6,305 017 MEDICAL RECORDS & LIBRARY 544 27,575 INPAT ROUTINE SRVC CNTRS 025 ADULTS & PEDIATRICS 1,453 8,999 25,530 325 190 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 037 OPERATING ROOM 10,202 992 20,398 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 162 40 808 044 LABORATORY 045 PBP CLINICAL LAB SERVICES 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHARGED 264,366 5,245 056 DRUGS CHARGED TO PATIENTS 6,305 934 OUTPAT SERVICE COST CNTRS 061 EMERGENCY 062 OBSERVATION BEDS (NON-DIS SPEC PURPOSE COST CENTERS 095 SUBTOTALS 1,453 26,120 25,530 1,357 264,366 6,305 27,575 NONREIMBURS COST CENTERS 096 GIFT, FLOWER, COFFEE SHOP 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE OFFIC 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENTS 102 NEGATIVE COST CENTER 103 TOTAL 1,453 26,120 25,530 1,357 264,366 6,305 27,575 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009)CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 ALLOCATION OF NEW CAPITAL RELATED COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B I I TO 12/31/2009 I PART III SUBTOTAL POST TOTAL COST CENTER STEPDOWN DESCRIPTION ADJUSTMENT 25 26 27 GENERAL SERVICE COST CNTR 003 NEW CAP REL COSTS-BLDG & 004 NEW CAP REL COSTS-MVBLE E 005 EMPLOYEE BENEFITS 006 ADMINISTRATIVE & GENERAL 008 OPERATION OF PLANT 009 LAUNDRY & LINEN SERVICE 010 HOUSEKEEPING 011 DIETARY 014 NURSING ADMINISTRATION 015 CENTRAL SERVICES & SUPPLY 016 PHARMACY 017 MEDICAL RECORDS & LIBRARY INPAT ROUTINE SRVC CNTRS 025 ADULTS & PEDIATRICS 472,359 472,359 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 037 OPERATING ROOM 553,585 553,585 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 10,949 10,949 044 LABORATORY 045 PBP CLINICAL LAB SERVICES 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHARGED 339,411 339,411 056 DRUGS CHARGED TO PATIENTS 17,706 17,706 OUTPAT SERVICE COST CNTRS 061 EMERGENCY 062 OBSERVATION BEDS (NON-DIS SPEC PURPOSE COST CENTERS 095 SUBTOTALS 1,394,010 1,394,010 NONREIMBURS COST CENTERS 096 GIFT, FLOWER, COFFEE SHOP 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE OFFIC 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENTS 102 NEGATIVE COST CENTER 103 TOTAL 1,394,010 1,394,010 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COST ALLOCATION - STATISTICAL BASIS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B-1 I I TO 12/31/2009 I COST CENTER NEW CAP REL C NEW CAP REL C EMPLOYEE BENE ADMINISTRATIV OPERATION OF DESCRIPTION OSTS-BLDG & OSTS-MVBLE E FITS E & GENERAL PLANT (SQUARE (SQUARE (GROSS S RECONCIL- ( ACCUM. (SQUARE FEET ) FEET )ALARIES ) IATION COST ) FEET ) 3 4 5 6a.00 6 8 GENERAL SERVICE COST 003 NEW CAP REL COSTS-BLD 30,547 004 NEW CAP REL COSTS-MVB 30,547 005 EMPLOYEE BENEFITS 2,624,309 006 ADMINISTRATIVE & GENE 5,236 5,236 443,790 -1,898,056 7,024,587 008 OPERATION OF PLANT 1,944 1,944 41,837 591,496 23,367 009 LAUNDRY & LINEN SERVI 42,719 010 HOUSEKEEPING 432 432 22,835 129,162 432 011 DIETARY 470 470 39,881 470 014 NURSING ADMINISTRATIO 32,667 39,888 015 CENTRAL SERVICES & SU 4,866 4,866 69,093 414,548 4,866 016 PHARMACY 119 119 5,430 119 017 MEDICAL RECORDS & LIB 478 478 87,953 478 INPAT ROUTINE SRVC CN 025 ADULTS & PEDIATRICS 7,902 7,902 566,108 1,130,417 7,902 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST C 037 OPERATING ROOM 8,958 8,958 1,385,915 2,101,061 8,958 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 142 142 62,064 82,263 142 044 LABORATORY 045 PBP CLINICAL LAB SERV 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHAR 2,052,050 056 DRUGS CHARGED TO PATI 307,719 OUTPAT SERVICE COST C 061 EMERGENCY 062 OBSERVATION BEDS (NON SPEC PURPOSE COST CEN 095 SUBTOTALS 30,547 30,547 2,624,309 -1,898,056 7,024,587 23,367 NONREIMBURS COST CENT 096 GIFT, FLOWER, COFFEE 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE O 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENT 102 NEGATIVE COST CENTER 103 COST TO BE ALLOCATED 1,338,450 55,560 580,088 1,898,056 751,319 (WRKSHT B, PART I) 104 UNIT COST MULTIPLIER 43.816087 .221044 .270202 (WRKSHT B, PT I) 1.818837 32.152994 105 COST TO BE ALLOCATED (WRKSHT B, PART II) 106 UNIT COST MULTIPLIER (WRKSHT B, PT II) 107 COST TO BE ALLOCATED 238,944 108,834 (WRKSHT B, PART III 108 UNIT COST MULTIPLIER .034015 (WRKSHT B, PT III) 4.657594 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(7/2009)CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COST ALLOCATION - STATISTICAL BASIS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET B-1 I I TO 12/31/2009 I COST CENTER LAUNDRY & LIN HOUSEKEEPING DIETARY NURSING ADMIN CENTRAL SERVI PHARMACY MEDICAL RECOR DESCRIPTION EN SERVICE ISTRATION CES & SUPPLY DS & LIBRARY (PATIENT (SQUARE (PATIENT (NURSING HOURS(COSTED R(COSTED REQ(PATIENT R DAYS ) FEET )DAYS ) )EQUIS. )UISITION )EVENUE ) 9 10 11 14 15 16 17 GENERAL SERVICE COST 003 NEW CAP REL COSTS-BLD 004 NEW CAP REL COSTS-MVB 005 EMPLOYEE BENEFITS 006 ADMINISTRATIVE & GENE 008 OPERATION OF PLANT 009 LAUNDRY & LINEN SERVI 521 010 HOUSEKEEPING 22,935 011 DIETARY 470 521 014 NURSING ADMINISTRATIO 76,448 015 CENTRAL SERVICES & SU 4,866 100 016 PHARMACY 119 100 017 MEDICAL RECORDS & LIB 478 42,438,277 INPAT ROUTINE SRVC CN 025 ADULTS & PEDIATRICS 521 7,902 521 18,294 292,924 026 INTENSIVE CARE UNIT ANCILLARY SRVC COST C 037 OPERATING ROOM 8,958 55,877 31,397,365 038 RECOVERY ROOM 040 ANESTHESIOLOGY 041 RADIOLOGY-DIAGNOSTIC 142 2,277 1,242,777 044 LABORATORY 045 PBP CLINICAL LAB SERV 049 RESPIRATORY THERAPY 050 PHYSICAL THERAPY 055 MEDICAL SUPPLIES CHAR 100 8,068,960 056 DRUGS CHARGED TO PATI 100 1,436,251 OUTPAT SERVICE COST C 061 EMERGENCY 062 OBSERVATION BEDS (NON SPEC PURPOSE COST CEN 095 SUBTOTALS 521 22,935 521 76,448 100 100 42,438,277 NONREIMBURS COST CENT 096 GIFT, FLOWER, COFFEE 096 01 SHELLED SPACE 097 RESEARCH 098 PHYSICIANS' PRIVATE O 099 NONPAID WORKERS 101 CROSS FOOT ADJUSTMENT 102 NEGATIVE COST CENTER 103 COST TO BE ALLOCATED 54,262 177,952 69,416 50,666 720,771 11,646 130,796 (WRKSHT B, PART I) 104 UNIT COST MULTIPLIER 7.758971 .662751 116.460000 (WRKSHT B, PT I) 104.149712 133.236084 7,207.710000 .003082 105 COST TO BE ALLOCATED (WRKSHT B, PART II) 106 UNIT COST MULTIPLIER (WRKSHT B, PT II) 107 COST TO BE ALLOCATED 1,453 26,120 25,530 1,357 264,366 6,305 27,575 (WRKSHT B, PART III 108 UNIT COST MULTIPLIER 1.138871 .017751 63.050000 (WRKSHT B, PT III) 2.788868 49.001919 2,643.660000 .000650 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(07/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COMPUTATION OF RATIO OF COSTS TO CHARGES I 15-0172 I FROM 1/ 1/2009 I WORKSHEET C I I TO 12/31/2009 I PART I WKST A COST CENTER DESCRIPTION WKST B, PT I THERAPY TOTAL RCE TOTAL LINE NO. COL. 27 ADJUSTMENT COSTS DISALLOWANCE COSTS 1 2 3 4 5 INPAT ROUTINE SRVC CNTRS 25 ADULTS & PEDIATRICS 1,887,947 1,887,947 1,887,947 26 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 3,160,102 3,160,102 3,160,102 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 115,498 115,498 115,498 44 LABORATORY 45 PBP CLINICAL LAB SERVICES 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED 3,352,158 3,352,158 3,352,158 56 DRUGS CHARGED TO PATIENTS 406,938 406,938 406,938 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DIS 702,861 702,861 702,861 OTHER REIMBURS COST CNTRS 101 SUBTOTAL 9,625,504 9,625,504 9,625,504 102 LESS OBSERVATION BEDS 702,861 702,861 702,861 103 TOTAL 8,922,643 8,922,643 8,922,643 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(07/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COMPUTATION OF RATIO OF COSTS TO CHARGES I 15-0172 I FROM 1/ 1/2009 I WORKSHEET C I I TO 12/31/2009 I PART I WKST A COST CENTER DESCRIPTION INPATIENT OUTPATIENT TOTAL COST OR TEFRA INPAT- PPS INPAT- LINE NO. CHARGES CHARGES CHARGES OTHER RATIO IENT RATIO IENT RATIO 6 7 8 9 10 11 INPAT ROUTINE SRVC CNTRS 25 ADULTS & PEDIATRICS 292,924 292,924 26 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 7,506,974 23,890,391 31,397,365 .100649 .100649 .100649 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 137,112 1,105,665 1,242,777 .092935 .092935 .092935 44 LABORATORY 45 PBP CLINICAL LAB SERVICES 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED 3,730,052 4,338,908 8,068,960 .415439 .415439 .415439 56 DRUGS CHARGED TO PATIENTS 305,741 1,130,510 1,436,251 .283333 .283333 .283333 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DIS 200,745 55,798 256,543 2.739740 2.739740 2.739740 OTHER REIMBURS COST CNTRS 101 SUBTOTAL 12,173,548 30,521,272 42,694,820 102 LESS OBSERVATION BEDS 103 TOTAL 12,173,548 30,521,272 42,694,820 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(09/1997) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I I TO 12/31/2009 I PART I TITLE XVIII, PART A PPS ------------- OLD CAPITAL ------------- ------------- NEW CAPITAL -------------- WKST A COST CENTER DESCRIPTION CAPITAL REL SWING BED REDUCED CAP CAPITAL REL SWING BED REDUCED CAP LINE NO. COST (B, II) ADJUSTMENT RELATED COST COST (B,III) ADJUSTMENT RELATED COST 1 2 3 4 5 6 INPAT ROUTINE SRVC CNTRS 25 ADULTS & PEDIATRICS 472,359 472,359 26 INTENSIVE CARE UNIT 101 TOTAL 472,359 472,359 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(09/1997) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I I TO 12/31/2009 I PART I TITLE XVIII, PART A PPS WKST A COST CENTER DESCRIPTION TOTAL INPATIENT OLD CAPITAL INPAT PROGRAM NEW CAPITAL INPAT PROGRAM LINE NO. PATIENT DAYS PROGRAM DAYS PER DIEM OLD CAP CST PER DIEM NEW CAP CST 7 8 9 10 11 12 INPAT ROUTINE SRVC CNTRS 25 ADULTS & PEDIATRICS 830 188 569.11 106,993 26 INTENSIVE CARE UNIT 101 TOTAL 830 188 106,993 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(09/1996) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART II I 15-0172 I I TITLE XVIII, PART A HOSPITAL PPS WKST A COST CENTER DESCRIPTION OLD CAPITAL NEW CAPITAL TOTAL INPAT PROGRAM OLD CAPITAL LINE NO. RELATED COST RELATED COST CHARGES CHARGES CST/CHRG RATIO COSTS 1 2 3 4 5 6 ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 553,585 31,397,365 1,049,450 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 10,949 1,242,777 42,315 44 LABORATORY 45 PBP CLINICAL LAB SERVICES 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED 339,411 8,068,960 957,473 56 DRUGS CHARGED TO PATIENTS 17,706 1,436,251 43,645 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DIS 175,854 256,543 OTHER REIMBURS COST CNTRS 101 TOTAL 1,097,505 42,401,896 2,092,883 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(09/1996) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART II I 15-0172 I I TITLE XVIII, PART A HOSPITAL PPS WKST A COST CENTER DESCRIPTION NEW CAPITAL LINE NO. CST/CHRG RATIO COSTS 7 8 ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM .017632 18,504 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC .008810 373 44 LABORATORY 45 PBP CLINICAL LAB SERVICES 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED .042064 40,275 56 DRUGS CHARGED TO PATIENTS .012328 538 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DIS .685476 OTHER REIMBURS COST CNTRS 101 TOTAL 59,690 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(11/1998) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF INPATIENT ROUTINE I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D SERVICE OTHER PASS THROUGH COSTS I I TO 12/31/2009 I PART III TITLE XVIII, PART A PPS WKST A COST CENTER DESCRIPTION NONPHYSICIAN MED EDUCATN SWING BED TOTAL TOTAL PER DIEM LINE NO. ANESTHETIST COST ADJ AMOUNT COSTS PATIENT DAYS 1 2 3 4 5 6 INPAT ROUTINE SRVC CNTRS 25 ADULTS & PEDIATRICS 830 26 INTENSIVE CARE UNIT 101 TOTAL 830 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(11/1998) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF INPATIENT ROUTINE I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D SERVICE OTHER PASS THROUGH COSTS I I TO 12/31/2009 I PART III TITLE XVIII, PART A WKST A COST CENTER DESCRIPTION INPATIENT INPAT PROGRAM LINE NO. PROG DAYS PASS THRU COST 7 8 25 ADULTS & PEDIATRICS 188 26 INTENSIVE CARE UNIT 101 TOTAL 188 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(07/2009) APPORTIONMENT OF INPATIENT ANCILLARY SERVICE I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 OTHER PASS THROUGH COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART IV I 15-0172 I I TITLE XVIII, PART A HOSPITAL PPS WKST A COST CENTER DESCRIPTION NONPHYSICIAN MED ED NRS MED ED ALLIED MED ED ALL BLOOD CLOT FOR LINE NO. ANESTHETIST SCHOOL COST HEALTH COST OTHER COSTS HEMOPHILIACS 1 1.01 2 2.01 2.02 2.03 ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 44 LABORATORY 45 PBP CLINICAL LAB SERVICES 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED 56 DRUGS CHARGED TO PATIENTS OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DIS OTHER REIMBURS COST CNTRS 101 TOTAL Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(07/2009) CONTD APPORTIONMENT OF INPATIENT ANCILLARY SERVICE I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 OTHER PASS THROUGH COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART IV I 15-0172 I I TITLE XVIII, PART A HOSPITAL PPS WKST A COST CENTER DESCRIPTION TOTAL O/P PASS THRU TOTAL RATIO OF COST O/P RATIO OF INPAT PROG INPAT PROG LINE NO. COSTS COSTS CHARGES TO CHARGES CST TO CHARGES CHARGE PASS THRU COST 3 3.01 4 5 5.01 6 7 ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 31,397,365 1,049,450 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 1,242,777 42,315 44 LABORATORY 45 PBP CLINICAL LAB SERVICES 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED 8,068,960 957,473 56 DRUGS CHARGED TO PATIENTS 1,436,251 43,645 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DIS 256,543 OTHER REIMBURS COST CNTRS 101 TOTAL 42,401,896 2,092,883 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(07/2009) CONTD APPORTIONMENT OF INPATIENT ANCILLARY SERVICE I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 OTHER PASS THROUGH COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART IV I 15-0172 I I TITLE XVIII, PART A HOSPITAL PPS WKST A COST CENTER DESCRIPTION OUTPAT PROG OUTPAT PROG OUTPAT PROG OUTPAT PROG COL 8.01 COL 8.02 LINE NO. CHARGES D,V COL 5.03 D,V COL 5.04 PASS THRU COST * COL 5 * COL 5 8 8.01 8.02 9 9.01 9.02 ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 6,202,945 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 425,714 44 LABORATORY 45 PBP CLINICAL LAB SERVICES 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED 1,361,511 56 DRUGS CHARGED TO PATIENTS 326,415 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DIS 50,035 OTHER REIMBURS COST CNTRS 101 TOTAL 8,366,620 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/2004) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES & VACCINE COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART V I 15-0172 I I TITLE XVIII, PART B HOSPITAL Cost/Charge Cost/Charge Outpatient Outpatient Other Ratio (C, Pt I, Ratio (C, Pt Ambulatory Radialogy Outpatient col. 9) II, col. 9) Surgical Ctr Diagnostic Cost Center Description 1 1.02 2 3 4 (A) ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM .100649 .100649 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC .092935 .092935 44 LABORATORY 45 PBP CLINICAL LAB SERVICES-PRGM ONLY 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED TO PATIENTS .415439 .415439 56 DRUGS CHARGED TO PATIENTS .283333 .283333 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DISTINCT PART) 2.739740 2.739740 101 SUBTOTAL 102 CRNA CHARGES 103 LESS PBP CLINIC LAB SVCS- PROGRAM ONLY CHARGES 104 NET CHARGES ____________________________________________________________________________________________________________________________________ (A) WORKSHEET A LINE NUMBERS (1) REPORT NON HOSPITAL AND NON SUBPROVIDER COMPONENTS COST FOR THE PERIOD HERE (SEE INSTRUCTIONS) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/2004) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES & VACCINE COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART V I 15-0172 I I TITLE XVIII, PART B HOSPITAL All Other (1) PPS Services Non-PPS PPS Services Outpatient FYB to 12/31 Services 1/1 to FYE Ambulatory Surgical Ctr Cost Center Description 5 5.01 5.02 5.03 6 (A) ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 6,202,945 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 425,714 44 LABORATORY 45 PBP CLINICAL LAB SERVICES-PRGM ONLY 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED TO PATIENTS 1,361,511 56 DRUGS CHARGED TO PATIENTS 326,415 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DISTINCT PART) 50,035 101 SUBTOTAL 8,366,620 102 CRNA CHARGES 103 LESS PBP CLINIC LAB SVCS- PROGRAM ONLY CHARGES 104 NET CHARGES 8,366,620 ____________________________________________________________________________________________________________________________________ (A) WORKSHEET A LINE NUMBERS (1) REPORT NON HOSPITAL AND NON SUBPROVIDER COMPONENTS COST FOR THE PERIOD HERE (SEE INSTRUCTIONS) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/2004) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES & VACCINE COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART V I 15-0172 I I TITLE XVIII, PART B HOSPITAL Outpatient Other All Other PPS Services Non-PPS Radialogy Outpatient FYB to 12/31 Services Diagnostic Cost Center Description 7 8 9 9.01 9.02 (A) ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 624,320 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 39,564 44 LABORATORY 45 PBP CLINICAL LAB SERVICES-PRGM ONLY 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED TO PATIENTS 565,625 56 DRUGS CHARGED TO PATIENTS 92,484 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DISTINCT PART) 137,083 101 SUBTOTAL 1,459,076 102 CRNA CHARGES 103 LESS PBP CLINIC LAB SVCS- PROGRAM ONLY CHARGES 104 NET CHARGES 1,459,076 ____________________________________________________________________________________________________________________________________ (A) WORKSHEET A LINE NUMBERS (1) REPORT NON HOSPITAL AND NON SUBPROVIDER COMPONENTS COST FOR THE PERIOD HERE (SEE INSTRUCTIONS) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/2004) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES & VACCINE COSTS I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D I COMPONENT NO: I TO 12/31/2009 I PART V I 15-0172 I I TITLE XVIII, PART B HOSPITAL PPS Services Hospital I/P Hospital I/P 1/1 to FYE Part B Charges Part B Costs Cost Center Description 9.03 10 11 (A) ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC 44 LABORATORY 45 PBP CLINICAL LAB SERVICES-PRGM ONLY 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED TO PATIENTS 56 DRUGS CHARGED TO PATIENTS OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DISTINCT PART) 101 SUBTOTAL 102 CRNA CHARGES 103 LESS PBP CLINIC LAB SVCS- PROGRAM ONLY CHARGES 104 NET CHARGES ____________________________________________________________________________________________________________________________________ (A) WORKSHEET A LINE NUMBERS (1) REPORT NON HOSPITAL AND NON SUBPROVIDER COMPONENTS COST FOR THE PERIOD HERE (SEE INSTRUCTIONS) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/2004) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COMPUTATION OF INPATIENT OPERATING COST I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D-1 I COMPONENT NO: I TO 12/31/2009 I PART I I 15-0172 I I TITLE XVIII PART A HOSPITAL PPS PART I - ALL PROVIDER COMPONENTS 1 INPATIENT DAYS 1 INPATIENT DAYS (INCLUDING PRIVATE ROOM AND SWING BED DAYS, EXCLUDING NEWBORN) 830 2 INPATIENT DAYS (INCLUDING PRIVATE ROOM, EXCLUDING SWING-BED AND NEWBORN DAYS) 830 3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 830 5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF COST REPORTING PERIOD (IF CALENDAR YEAR, ENTER 0 ON THIS LINE) 7 TOTAL SWING-BED NF TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 8 TOTAL SWING-BED NF TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF COST REPORTING PERIOD (IF CALENDAR YEAR, ENTER 0 ON THIS LINE) 9 TOTAL INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE PROGRAM 188 (EXCLUDING SWING-BED AND NEWBORN DAYS) 10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD (IF CALENDAR YEAR, ENTER 0 ON THIS LINE) 12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V & XIX ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLE V & XIX ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD (IF CALENDAR YEAR, ENTER 0 ON THIS LINE) 14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE PROGRAM (EXCLUDING SWING-BED DAYS) 15 TOTAL NURSERY DAYS (TITLE V OR XIX ONLY) 16 NURSERY DAYS (TITLE V OR XIX ONLY) SWING-BED ADJUSTMENT 17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 1,887,947 22 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 26 TOTAL SWING-BED COST (SEE INSTRUCTIONS) 27 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 1,887,947 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 GENERAL INPATIENT ROUTINE SERVICE CHARGES (EXCLUDING SWING-BED CHARGES) 292,924 29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 30 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 292,924 31 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO 6.445177 32 AVERAGE PRIVATE ROOM PER DIEM CHARGE 33 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 352.92 34 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL 35 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL 36 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT 37 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST AND PRIVATE ROOM 1,887,947 COST DIFFERENTIAL Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/2004) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COMPUTATION OF INPATIENT OPERATING COST I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D-1 I COMPONENT NO: I TO 12/31/2009 I PART II I 15-0172 I I TITLE XVIII PART A HOSPITAL PPS PART II - HOSPITAL AND SUBPROVIDERS ONLY 1 PROGRAM INPATIENT OPERATING COST BEFORE PASS THROUGH COST ADJUSTMENTS 38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 2,274.63 39 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 427,630 40 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM 41 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 427,630 TOTAL TOTAL AVERAGE PROGRAM PROGRAM I/P COST I/P DAYS PER DIEM DAYS COST 1 2 3 4 5 42 NURSERY (TITLE V & XIX ONLY) INTENSIVE CARE TYPE INPATIENT HOSPITAL UNITS 43 INTENSIVE CARE UNIT 44 CORONARY CARE UNIT 45 BURN INTENSIVE CARE UNIT 46 SURGICAL INTENSIVE CARE UNIT 47 OTHER SPECIAL CARE 1 48 PROGRAM INPATIENT ANCILLARY SERVICE COST 519,697 49 TOTAL PROGRAM INPATIENT COSTS 947,327 PASS THROUGH COST ADJUSTMENTS 50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE SERVICES 106,993 51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ANCILLARY SERVICES 59,690 52 TOTAL PROGRAM EXCLUDABLE COST 166,683 53 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL RELATED, NONPHYSICIAN 780,644 ANESTHETIST, AND MEDICAL EDUCATION COSTS TARGET AMOUNT AND LIMIT COMPUTATION 54 PROGRAM DISCHARGES 55 TARGET AMOUNT PER DISCHARGE 56 TARGET AMOUNT 57 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND TARGET AMOUNT 58 BONUS PAYMENT 58.01 LESSER OF LINES 53/54 OR 55 FROM THE COST REPORTING PERIOD ENDING 1996, UPDATED AND COMPOUNDED BY THE MARKET BASKET 58.02 LESSER OF LINES 53/54 OR 55 FROM PRIOR YEAR COST REPORT, UPDATED BY THE MARKET BASKET 58.03 IF LINES 53/54 IS LESS THAN THE LOWER OF LINES 55, 58.01 OR 58.02 ENTER THE LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS (LINE 53) ARE LESS THAN EXPECTED COSTS (LINES 54 x 58.02), OR 1 PERCENT OF THE TARGET AMOUNT (LINE 56) OTHERWISE ENTER ZERO. 58.04 RELIEF PAYMENT 59 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT 59.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LINE 59 / LINE 54) (LTCH ONLY) 59.02 PROGRAM DISCHARGES PRIOR TO JULY 1 59.03 PROGRAM DISCHARGES AFTER JULY 1 59.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS) 59.05 REDUCED INPATIENT COST PER DISCHARGE FOR DISCHARGES PRIOR TO JULY 1 (SEE INSTRUCTIONS) (LTCH ONLY) 59.06 REDUCED INPATIENT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1 (SEE INSTRUCTIONS) (LTCH ONLY) 59.07 REDUCED INPATIENT COST PER DISCHARGE (SEE INSTRUCTIONS) (LTCH ONLY) 59.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTRUCTIONS) PROGRAM INPATIENT ROUTINE SWING BED COST 60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD (SEE INSTRUCTIONS) 61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER DECEMBER 31 OF THE COST REPORTING PERIOD (SEE INSTRUCTIONS) 62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 63 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(05/2004) CONTD I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 COMPUTATION OF INPATIENT OPERATING COST I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D-1 I COMPONENT NO: I TO 12/31/2009 I PART III I 15-0172 I I TITLE XVIII PART A HOSPITAL PPS PART III - SKILLED NURSING FACILITY, NURSINGFACILITY & ICF/MR ONLY 1 66 SKILLED NURSING FACILITY/OTHER NURSING FACILITY/ICF/MR ROUTINE SERVICE COST 67 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 68 PROGRAM ROUTINE SERVICE COST 69 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM 70 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS 71 CAPITAL-RELATED COST ALLOCATED TO INPATIENT ROUTINE SERVICE COSTS 72 PER DIEM CAPITAL-RELATED COSTS 73 PROGRAM CAPITAL-RELATED COSTS 74 INPATIENT ROUTINE SERVICE COST 75 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS 76 TOTAL PROGRAM ROUTINE SERVICE COSTS FOR COMPARISON TO THE COST LIMITATION 77 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION 78 INPATIENT ROUTINE SERVICE COST LIMITATION 79 REASONABLE INPATIENT ROUTINE SERVICE COSTS 80 PROGRAM INPATIENT ANCILLARY SERVICES 81 UTILIZATION REVIEW - PHYSICIAN COMPENSATION 82 TOTAL PROGRAM INPATIENT OPERATING COSTS PART IV - COMPUTATION OF OBSERVATION BED COST 83 TOTAL OBSERVATION BED DAYS 309 84 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 2,274.63 85 OBSERVATION BED COST 702,861 COMPUTATION OF OBSERVATION BED PASS THROUGH COST COLUMN 1 TOTAL OBSERVATION BED ROUTINE DIVIDED BY OBSERVATION PASS THROUGH COST COST COLUMN 2 BED COST COST 1 2 3 4 5 86 OLD CAPITAL-RELATED COST 1,887,947 702,861 87 NEW CAPITAL-RELATED COST 472,359 1,887,947 .250197 702,861 175,854 88 NON PHYSICIAN ANESTHETIST 1,887,947 702,861 89 MEDICAL EDUCATION 1,887,947 702,861 89.01 MEDICAL EDUCATION - ALLIED HEA 89.02 MEDICAL EDUCATION - ALL OTHER Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96(07/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 INPATIENT ANCILLARY SERVICE COST APPORTIONMENT I 15-0172 I FROM 1/ 1/2009 I WORKSHEET D-4 I COMPONENT NO: I TO 12/31/2009 I I 15-0172 I I TITLE XVIII, PART A HOSPITAL PPS WKST A COST CENTER DESCRIPTION RATIO COST INPATIENT INPATIENT LINE NO. TO CHARGES CHARGES COST 1 2 3 INPAT ROUTINE SRVC CNTRS 25 ADULTS & PEDIATRICS 105,812 26 INTENSIVE CARE UNIT ANCILLARY SRVC COST CNTRS 37 OPERATING ROOM .100649 1,049,450 105,626 38 RECOVERY ROOM 40 ANESTHESIOLOGY 41 RADIOLOGY-DIAGNOSTIC .092935 42,315 3,933 44 LABORATORY 45 PBP CLINICAL LAB SERVICES-PRGM ONLY 49 RESPIRATORY THERAPY 50 PHYSICAL THERAPY 55 MEDICAL SUPPLIES CHARGED TO PATIENTS .415439 957,473 397,772 56 DRUGS CHARGED TO PATIENTS .283333 43,645 12,366 OUTPAT SERVICE COST CNTRS 61 EMERGENCY 62 OBSERVATION BEDS (NON-DISTINCT PART) 2.739740 OTHER REIMBURS COST CNTRS 101 TOTAL 2,092,883 519,697 102 LESS PBP CLINIC LABORATORY SERVICES - PROGRAM ONLY CHARGES 103 NET CHARGES 2,092,883 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (12/2008) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 CALCULATION OF REIMBURSEMENT SETTLEMENT I 15-0172 I FROM 1/ 1/2009 I WORKSHEET E I COMPONENT NO: I TO 12/31/2009 I PART A I 15-0172 I I PART A - INPATIENT HOSPITAL SERVICES UNDER PPS HOSPITAL DESCRIPTION 1 1.01 DRG AMOUNT 1 OTHER THAN OUTLIER PAYMENTS OCCURRING PRIOR TO OCTOBER 1 1.01 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER OCTOBER 1 629,623 AND BEFORE JANUARY 1 1.02 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER JAN 1 MANAGED CARE PATIENTS 1.03 PAYMENTS PRIOR TO MARCH 1ST OR OCTOBER 1ST 1.04 PAYMENTS ON OR AFTER OCTOBER 1 AND PRIOR TO JANUARY 1 1.05 PAYMENTS ON OR AFTER JANUARY 1ST BUT BEFORE 4/1 / 10/1 1.06 ADDITIONAL AMOUNT RECEIVED OR TO BE RECEIVED (SEE INSTR) 1.07 PAYMENTS FOR DISCHARGES ON OR AFTER APRIL 1, 2001 THROUGH SEPTEMBER 30, 2001. 1.08 SIMULATED PAYMENTS FROM PS&R ON OR AFTER APRIL 1, 2001 THROUGH SEPTEMBER 30, 2001. 2 OUTLIER PAYMENTS FOR DISCHARGES OCCURRING PRIOR TO 10/1/97 2.01 OUTLIER PAYMENTS FOR DISCHARGES OCCURRING ON OR AFTER 3,964 OCTOBER 1, 1997 (SEE INSTRUCTIONS) 3 BED DAYS AVAILABLE DIVIDED BY # DAYS IN COST RPTG PERIOD 11.19 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3.01 NUMBER OF INTERNS & RESIDENTS FROM WKST S-3, PART I 3.02 INDIRECT MEDICAL EDUCATION PERCENTAGE (SEE INSTRUCTIONS) 3.03 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3.04 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PROGRAMS FOR THE MOST RECENT COST REPORTING PERIOD ENDING ON OR BEFORE 12/31/1996. 3.05 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PROGRAMS WHICH MEET THE CRITERIA FOR AN ADD-ON TO THE CAP FOR NEW PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) 3.06 ADJUSTED FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PROGRAMS FOR AFFILIATED PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) FOR CR PERIODS ENDING ON OR AFTER 7/1/2005 E-3 PT 6 LN 15 PLUS LN 3.06 3.07 SUM OF LINES 3.04 THROUGH 3.06 (SEE INSTRUCTIONS) 3.08 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PROGRAMS IN THE CURRENT YEAR FROM YOUR RECORDS 3.09 FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1,ENTER THE PERCENTAGE OF DISCHARGES OCCURRING PRIOR TO OCTOBER 1. 3.10 FOR COST REPORTING PERIODS BEGINNING BEFORE OCTOBER 1, ENTER THE PERCENTAGE OF DISCHARGES OCCURRING ON OR AFTER OCTOBER 1 3.11 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.09 3.12 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.10 3.13 FTE COUNT FOR RESIDENTS IN DENTAL AND PODIATRIC PROGRAMS. 3.14 CURRENT YEAR ALLOWABLE FTE (SEE INSTRUCTIONS) 3.15 TOTAL ALLOWABLE FTE COUNT FOR THE PRIOR YEAR, IF NONE BUT PRIOR YEAR TEACHING WAS IN EFFECT ENTER 1 HERE 3.16 TOTAL ALLOWABLE FTE COUNT FOR THE PENULTIMATE YEAR IF THAT YEAR ENDED ON OR AFTER SEPTEMBER 30, 1997, OTHERWISE ENTER ZERO. IF THERE WAS NO FTE COUNT IN THIS PERIOD BUT PRIOR YEAR TEACHING WAS IN EFFECT ENTER 1 HERE 3.17 SUM OF LINES 3.14 THRU 3.16 DIVIDED BY THE NUMBER OF THOSE LINES IN EXCESS OF ZERO (SEE INSTRUCTIONS). 3.18 CURRENT YEAR RESIDENT TO BED RATIO (LN 3.17 DIVIDED BY LN 3) 3.19 PRIOR YEAR RESIDENT TO BED RATIO (SEE INSTRUCTIONS) 3.20 FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 1997, ENTER THE LESSER OF LINES 3.18 OR 3.19 (SEE INST) 3.21 IME PAYMENTS FOR DISCHARGES OCCURRING PRIOR TO OCT 1 3.22 IME PAYMENTS FOR DISCHARGES OCCURRING ON OR AFTER OCT 1, BUT BEFORE JANUARY 1 (SEE INSTRUCTIONS) 3.23 IME PAYMENTS FOR DISCHARGES OCCURRING ON OR AFTER JANUARY 1 SUM OF LINES PLUS E-3, PT 3.21 - 3.23 VI, LINE 23 3.24 SUM OF LINES 3.21 THROUGH 3.23 (SEE INSTRUCTIONS). DISPROPORTIONATE SHARE ADJUSTMENT 4 PERCENTAGE OF SSI RECIPIENT PATIENT DAYS TO MEDICARE PART A PATIENT DAYS (SEE INSTRUCTIONS) 4.01 PERCENTAGE OF MEDICAID PATIENT DAYS TO TOTAL DAYS REPORTED ON WORKSHEET S-3, PART I 4.02 SUM OF LINES 4 AND 4.01 4.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE (SEE INSTRUC) 4.04 DISPROPORTIONATE SHARE ADJUSTMENT (SEE INSTRUCTIONS) ADDITIONAL PAYMENT FOR HIGH PERCENTAGE OF ESRD BENEFICIARY DISCHARGES 5 TOTAL MEDICARE DISCHARGES ON WKST S-3, PART I EXCLUDING DISCHARGES FOR DRGs 302, 316, 317 OR MS-DRGS 652, 682 - 685.(SEE INSTRUCTIONS) 5.01 TOTAL ESRD MEDICARE DISCHARGES EXCLUDING DRGs 302, 316, 317 OR MS-DRGS 652 AND 682 - 685. (SEE INSTRUCTIONS) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (12/2008) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 CALCULATION OF REIMBURSEMENT SETTLEMENT I 15-0172 I FROM 1/ 1/2009 I WORKSHEET E I COMPONENT NO: I TO 12/31/2009 I PART A I 15-0172 I I PART A - INPATIENT HOSPITAL SERVICES UNDER PPS HOSPITAL DESCRIPTION 1 1.01 5.02 DIVIDE LINE 5.01 BY LINE 5 (IF LESS THAN 10%, YOU DO NOT QUALIFY FOR ADJUSTMENT) 5.03 TOTAL MEDICARE ESRD INPATIENT DAYS EXCLUDING DRGs 302, 316, 317, OR MS-DRGS 652, 682-685. (SEE INSTRUCTIONS) 5.04 RATIO OF AVERAGE LENGTH OF STAY TO ONE WEEK 5.05 AVERAGE WEEKLY COST FOR DIALYSIS TREATMENTS (SEE INSTRUC) 5.06 TOTAL ADDITIONAL PAYMENT 6 SUBTOTAL (SEE INSTRUCTIONS) 633,587 7 HOSPITAL SPECIFIC PAYMENTS (TO BE COMPLETED BY SCH AND MDH, SMALL RURAL HOSPITALS ONLY, SEE INSTRUCTIONS) 7.01 HOSPITAL SPECIFIC PAYMENTS (TO BE COMPLETED BY SCH AND MDH, SMALL RURAL HOSPITALS ONLY, SEE INSTRUCTIONS FY BEG. 10/1/2000) 8 TOTAL PAYMENT FOR INPATIENT OPERATING COSTS SCH AND MDH 633,587 ONLY (SEE INSTRUCTIONS) 9 PAYMENT FOR INPATIENT PROGRAM CAPITAL 141,681 10 EXCEPTION PAYMENT FOR INPATIENT PROGRAM CAPITAL (WORKSHEET L, PART IV, SEE INSTRUCTIONS) 11 DIRECT GRADUATE MEDICAL EDUCATION PAYMENT (FROM WORKSHEET E-3, PART IV, SEE INSTRUCTIONS) 11.01 NURSING AND ALLIED HEALTH MANAGED CARE PAYMENT 11.02 SPECIAL ADD-ON PAYMENTS FOR NEW TECHNOLOGIES 12 NET ORGAN ACQUISITION COST 13 COST OF TEACHING PHYSICIANS 14 ROUTINE SERVICE OTHER PASS THROUGH COSTS 15 ANCILLARY SERVICE OTHER PASS THROUGH COSTS 16 TOTAL 775,268 17 PRIMARY PAYER PAYMENTS 897 18 TOTAL AMOUNT PAYABLE FOR PROGRAM BENEFICIARIES 774,371 19 DEDUCTIBLES BILLED TO PROGRAM BENEFICIARIES 78,944 20 COINSURANCE BILLED TO PROGRAM BENEFICIARIES 21 REIMBURSABLE BAD DEBTS (SEE INSTRUCTIONS) 21.01 ADJUSTED REIMBURSABLE BAD DEBTS (SEE INSTRUCTIONS) 21.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES 22 SUBTOTAL 695,427 23 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVIDER TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 24 OTHER ADJUSTMENTS (SPECIFY) 24.98 CREDIT FOR MANUFACTURER REPLACED MEDICAL DEVICES 24.99 OUTLIER RECONCILIATION ADJUSTMENT 25 AMOUNTS APPLICABLE TO PRIOR COST REPORTING PERIODS RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 26 AMOUNT DUE PROVIDER 695,427 27 SEQUESTRATION ADJUSTMENT 28 INTERIM PAYMENTS 605,299 28.01 TENTATIVE SETTLEMENT (FOR FISCAL INTERMEDIARY USE ONLY) 29 BALANCE DUE PROVIDER (PROGRAM) 90,128 30 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT ITEMS) IN ACCORDANCE WITH CMS PUB. 15-II, SECTION 115.2. ----- FI ONLY ------------ 50 OPERATING OUTLIER AMOUNT FROM WKS E, A, L2.01 51 CAPITAL OUTLIER AMOUNT FROM WKS L, I, L3.01 52 OPERATING OUTLIER RECONCILIATION AMOUNT (SEE INSTRUCTIONS) 53 CAPITAL OUTLIER RECONCILIATION AMOUNT (SEE INSTRUCTIONS) 54 THE RATE USED TO CALCULATE THE TIME VALUE OF MONEY 55 TIME VALUE OF MONEY (SEE INSTRUCTIONS) 56 CAPITAL TIME VALUE OF MONEY (SEE INSTRUCTIONS) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (07/2009) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 CALCULATION OF REIMBURSEMENT SETTLEMENT I 15-0172 I FROM 1/ 1/2009 I WORKSHEET E I COMPONENT NO: I TO 12/31/2009 I PART B I 15-0172 I I PART B - MEDICAL AND OTHER HEALTH SERVICES HOSPITAL 1 MEDICAL AND OTHER SERVICES (SEE INSTRUCTIONS) 1.01 MEDICAL AND OTHER SERVICES RENDERED ON OR AFTER APRIL 1, 1,459,076 2001 (SEE INSTRUCTIONS). 1.02 PPS PAYMENTS RECEIVED INCLUDING OUTLIERS. 1,912,555 1.03 ENTER THE HOSPITAL SPECIFIC PAYMENT TO COST RATIO. 1.04 LINE 1.01 TIMES LINE 1.03. 1.05 LINE 1.02 DIVIDED BY LINE 1.04. 1.06 TRANSITIONAL CORRIDOR PAYMENT (SEE INSTRUCTIONS) 1.07 ENTER THE AMOUNT FROM WORKSHEET D, PART IV, (COLS 9, 9.01, 9,02) LINE 101. 2 INTERNS AND RESIDENTS 3 ORGAN ACQUISITIONS 4 COST OF TEACHING PHYSICIANS 5 TOTAL COST (SEE INSTRUCTIONS) COMPUTATION OF LESSER OF COST OR CHARGES REASONABLE CHARGES 6 ANCILLARY SERVICE CHARGES 7 INTERNS AND RESIDENTS SERVICE CHARGES 8 ORGAN ACQUISITION CHARGES 9 CHARGES OF PROFESSIONAL SERVICES OF TEACHING PHYSICIANS. 10 TOTAL REASONABLE CHARGES CUSTOMARY CHARGES 11 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS 12 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(e). 13 RATIO OF LINE 11 TO LINE 12 14 TOTAL CUSTOMARY CHARGES (SEE INSTRUCTIONS) 15 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 16 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 17 LESSER OF COST OR CHARGES (FOR CAH SEE INSTRUC) 17.01 TOTAL PROSPECTIVE PAYMENT (SUM OF LINES 1.02, 1.06 AND 1.07) 1,912,555 COMPUTATION OF REIMBURSEMENT SETTLEMENT 18 DEDUCTIBLES AND COINSURANCE (SEE INSTRUCTIONS) 18.01 DEDUCTIBLES AND COINSURANCE RELATING TO AMOUNT ON 443,492 LINE 17.01 (SEE INSTRUCTIONS) 19 SUBTOTAL (SEE INSTRUCTIONS) 1,469,063 20 SUM OF AMOUNTS FROM WORKSHEET E PARTS C, D & E (SEE INSTR.) 21 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 22 ESRD DIRECT MEDICAL EDUCATION COSTS 23 SUBTOTAL 1,469,063 24 PRIMARY PAYER PAYMENTS 11,041 25 SUBTOTAL 1,458,022 REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES) 26 COMPOSITE RATE ESRD 27 BAD DEBTS (SEE INSTRUCTIONS) 27.01 ADJUSTED REIMBURSABLE BAD DEBTS (SEE INSTRUCTIONS) 27.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES 28 SUBTOTAL 1,458,022 29 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVIDER TERMINATION OR A DECREASE IN PROGRAM UTILIZATION. 30 OTHER ADJUSTMENTS (SPECIFY) 30.99 OTHER ADJUSTMENTS (MSP-LCC RECONCILIATION AMOUNT) 31 AMOUNTS APPLICABLE TO PRIOR COST REPORTING PERIODS RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS. 32 SUBTOTAL 1,458,022 33 SEQUESTRATION ADJUSTMENT (SEE INSTRUCTIONS) 34 INTERIM PAYMENTS 1,458,022 34.01 TENTATIVE SETTLEMENT (FOR FISCAL INTERMEDIARY USE ONLY) 35 BALANCE DUE PROVIDER/PROGRAM 36 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT ITEMS) IN ACCORDANCE WITH CMS PUB. 15-II, SECTION 115.2 TO BE COMPLETED BY CONTRACTOR 50 ORIGINAL OUTLIER AMOUNT (SEE INSTRUCTIONS) 51 OUTLIER RECONCILIATION AMOUNT (SEE INSTRUCTIONS) 52 THE RATE USED TO CALCULATE THE TIME VALUE OF MONEY 53 TIME VALUE OF MONEY (SEE INSTRUCTIONS) 54 TOTAL (SUM OF LINES 51 AND 53) Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (11/1998) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED I 15-0172 I FROM 1/ 1/2009 I WORKSHEET E-1 I COMPONENT NO: I TO 12/31/2009 I I 15-0172 I I TITLE XVIII HOSPITAL DESCRIPTION INPATIENT-PART A P A R T B MM/DD/YYYY AMOUNT MM/DD/YYYY AMOUNT 1 2 3 4 1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 605,299 1,458,022 2 INTERIM PAYMENTS PAYABLE ON INDIVIDUAL BILLS, NONE NONE EITHER SUBMITTED OR TO BE SUBMITTED TO THE INTERMEDIARY, FOR SERVICES RENDERED IN THE COST REPORTING PERIOD. IF NONE, WRITE "NONE" OR ENTER A ZERO. 3 LIST SEPARATELY EACH RETROACTIVE LUMP SUM ADJUSTMENT AMOUNT BASED ON SUBSEQUENT REVISION OF THE INTERIM RATE FOR THE COST REPORTING PERIOD. ALSO SHOW DATE OF EACH PAYMENT. IF NONE, WRITE "NONE" OR ENTER A ZERO. (1) ADJUSTMENTS TO PROVIDER .01 ADJUSTMENTS TO PROVIDER .02 ADJUSTMENTS TO PROVIDER .03 ADJUSTMENTS TO PROVIDER .04 ADJUSTMENTS TO PROVIDER .05 ADJUSTMENTS TO PROGRAM .50 ADJUSTMENTS TO PROGRAM .51 ADJUSTMENTS TO PROGRAM .52 ADJUSTMENTS TO PROGRAM .53 ADJUSTMENTS TO PROGRAM .54 SUBTOTAL .99 NONE NONE 4 TOTAL INTERIM PAYMENTS 605,299 1,458,022 TO BE COMPLETED BY INTERMEDIARY 5 LIST SEPARATELY EACH TENTATIVE SETTLEMENT PAYMENT AFTER DESK REVIEW. ALSO SHOW DATE OF EACH PAYMENT. IF NONE, WRITE "NONE" OR ENTER A ZERO. (1) TENTATIVE TO PROVIDER .01 TENTATIVE TO PROVIDER .02 TENTATIVE TO PROVIDER .03 TENTATIVE TO PROGRAM .50 TENTATIVE TO PROGRAM .51 TENTATIVE TO PROGRAM .52 SUBTOTAL .99 NONE NONE 6 DETERMINED NET SETTLEMENT SETTLEMENT TO PROVIDER .01 90,128 AMOUNT (BALANCE DUE) SETTLEMENT TO PROGRAM .02 BASED ON COST REPORT (1) 7 TOTAL MEDICARE PROGRAM LIABILITY 695,427 1,458,022 NAME OF INTERMEDIARY: INTERMEDIARY NO: SIGNATURE OF AUTHORIZED PERSON: ___________________________________________________ DATE: ___/___/___ ____________________________________________________________________________________________________________________________________ (1) ON LINES 3, 5 AND 6, WHERE AN AMOUNT IS DUE PROVIDER TO PROGRAM, SHOW THE AMOUNT AND DATE ON WHICH THE PROVIDER AGREES TO THE AMOUNT OF REPAYMENT, EVEN THOUGH TOTAL REPAYMENT IS NOT ACCOMPLISHED UNTIL A LATER DATE. Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (06/2003) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 BALANCE SHEET I 15-0172 I FROM 1/ 1/2009 I I I TO 12/31/2009 I WORKSHEET G GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND ASSETS FUND 1 2 3 4 CURRENT ASSETS 1 CASH ON HAND AND IN BANKS 211,914 2 TEMPORARY INVESTMENTS 3 NOTES RECEIVABLE 4 ACCOUNTS RECEIVABLE 1,342,141 5 OTHER RECEIVABLES 6 LESS: ALLOWANCE FOR UNCOLLECTIBLE NOTES & ACCOUNTS RECEIVABLE 7 INVENTORY 390,776 8 PREPAID EXPENSES 96,562 9 OTHER CURRENT ASSETS 262,620 10 DUE FROM OTHER FUNDS 11 TOTAL CURRENT ASSETS 2,304,013 FIXED ASSETS 12 LAND 850,190 12.01 13 LAND IMPROVEMENTS 768,719 13.01 LESS ACCUMULATED DEPRECIATION 14 BUILDINGS 7,396,260 14.01 LESS ACCUMULATED DEPRECIATION 15 LEASEHOLD IMPROVEMENTS 15.01 LESS ACCUMULATED DEPRECIATION 16 FIXED EQUIPMENT 16.01 LESS ACCUMULATED DEPRECIATION 17 AUTOMOBILES AND TRUCKS 17.01 LESS ACCUMULATED DEPRECIATION 18 MAJOR MOVABLE EQUIPMENT 3,746,721 18.01 LESS ACCUMULATED DEPRECIATION -1,207,787 19 MINOR EQUIPMENT DEPRECIABLE 19.01 LESS ACCUMULATED DEPRECIATION 20 MINOR EQUIPMENT-NONDEPRECIABLE 21 TOTAL FIXED ASSETS 11,554,103 OTHER ASSETS 22 INVESTMENTS 23 DEPOSITS ON LEASES 24 DUE FROM OWNERS/OFFICERS 6,534 25 OTHER ASSETS 65,372 26 TOTAL OTHER ASSETS 71,906 27 TOTAL ASSETS 13,930,022 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (06/2003) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 BALANCE SHEET I 15-0172 I FROM 1/ 1/2009 I I I TO 12/31/2009 I WORKSHEET G GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND LIABILITIES AND FUND BALANCE FUND 1 2 3 4 CURRENT LIABILITIES 28 ACCOUNTS PAYABLE 786,663 29 SALARIES, WAGES & FEES PAYABLE 135,753 30 PAYROLL TAXES PAYABLE 31 NOTES AND LOANS PAYABLE (SHORT TERM) 2,705,000 32 DEFERRED INCOME 33 ACCELERATED PAYMENTS 34 DUE TO OTHER FUNDS 35 OTHER CURRENT LIABILITIES 349,905 36 TOTAL CURRENT LIABILITIES 3,977,321 LONG TERM LIABILITIES 37 MORTGAGE PAYABLE 7,387,674 38 NOTES PAYABLE 1,000,000 39 UNSECURED LOANS 40.01 LOANS PRIOR TO 7/1/66 40.02 ON OR AFTER 7/1/66 41 OTHER LONG TERM LIABILITIES 42 TOTAL LONG-TERM LIABILITIES 8,387,674 43 TOTAL LIABILITIES 12,364,995 CAPITAL ACCOUNTS 44 GENERAL FUND BALANCE 1,565,027 45 SPECIFIC PURPOSE FUND 46 DONOR CREATED- ENDOWMENT FUND BALANCE- RESTRICTED 47 DONOR CREATED- ENDOWMENT FUND BALANCE- UNRESTRICT 48 GOVERNING BODY CREATED- ENDOWMENT FUND BALANCE 49 PLANT FUND BALANCE-INVESTED IN PLANT 50 PLANT FUND BALANCE- RESERVE FOR PLANT IMPROVEMENT, REPLACEMENT AND EXPANSION 51 TOTAL FUND BALANCES 1,565,027 52 TOTAL LIABILITIES AND FUND BALANCES 13,930,022 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (09/1996) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 STATEMENT OF CHANGES IN FUND BALANCES I 15-0172 I FROM 1/ 1/2009 I WORKSHEET G-1 I I TO 12/31/2009 I GENERAL FUND SPECIFIC PURPOSE FUND 1 2 3 4 1 FUND BALANCE AT BEGINNING 77,900 OF PERIOD 2 NET INCOME (LOSS) 1,415,084 3 TOTAL 1,492,984 ADDITIONS (CREDIT ADJUSTMENTS) (SPECIFY) 4 ADDITIONS (CREDIT ADJUSTM 72,044 5 6 7 8 9 10 TOTAL ADDITIONS 72,044 11 SUBTOTAL 1,565,028 DEDUCTIONS (DEBIT ADJUSTMENTS) (SPECIFY) 12 DEDUCTIONS (DEBIT ADJUSTM 1 13 14 15 16 17 18 TOTAL DEDUCTIONS 1 19 FUND BALANCE AT END OF 1,565,027 PERIOD PER BALANCE SHEET ENDOWMENT FUND PLANT FUND 5 6 7 8 1 FUND BALANCE AT BEGINNING OF PERIOD 2 NET INCOME (LOSS) 3 TOTAL ADDITIONS (CREDIT ADJUSTMENTS) (SPECIFY) 4 ADDITIONS (CREDIT ADJUSTM 5 6 7 8 9 10 TOTAL ADDITIONS 11 SUBTOTAL DEDUCTIONS (DEBIT ADJUSTMENTS) (SPECIFY) 12 DEDUCTIONS (DEBIT ADJUSTM 13 14 15 16 17 18 TOTAL DEDUCTIONS 19 FUND BALANCE AT END OF PERIOD PER BALANCE SHEET Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (09/1996) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES I 15-0172 I FROM 1/ 1/2009 I WORKSHEET G-2 I I TO 12/31/2009 I PARTS I & II PART I - PATIENT REVENUES REVENUE CENTER INPATIENT OUTPATIENT TOTAL 1 2 3 GENERAL INPATIENT ROUTINE CARE SERVICES 1 00 HOSPITAL 292,924 292,924 4 00 SWING BED - SNF 5 00 SWING BED - NF 9 00 TOTAL GENERAL INPATIENT ROUTINE CARE 292,924 292,924 INTENSIVE CARE TYPE INPATIENT HOSPITAL SVCS 10 00 INTENSIVE CARE UNIT 15 00 TOTAL INTENSIVE CARE TYPE INPAT HOSP 16 00 TOTAL INPATIENT ROUTINE CARE SERVICE 292,924 292,924 17 00 ANCILLARY SERVICES 11,679,879 30,465,474 42,145,353 18 00 OUTPATIENT SERVICES 200,745 55,798 256,543 24 00 25 00 TOTAL PATIENT REVENUES 12,173,548 30,521,272 42,694,820 PART II-OPERATING EXPENSES 26 00 OPERATING EXPENSES 9,927,691 ADD (SPECIFY) 27 00 ADD (SPECIFY) 28 00 29 00 30 00 31 00 32 00 33 00 TOTAL ADDITIONS DEDUCT (SPECIFY) 34 00 DEDUCT (SPECIFY) 35 00 36 00 37 00 38 00 39 00 TOTAL DEDUCTIONS 40 00 TOTAL OPERATING EXPENSES 9,927,691 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (09/1996) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 STATEMENT OF REVENUES AND EXPENSES I 15-0172 I FROM 1/ 1/2009 I WORKSHEET G-3 I I TO 12/31/2009 I DESCRIPTION 1 TOTAL PATIENT REVENUES 42,694,820 2 LESS: ALLOWANCES AND DISCOUNTS ON PATIENT'S ACCTS 31,904,270 3 NET PATIENT REVENUES 10,790,550 4 LESS: TOTAL OPERATING EXPENSES 9,927,691 5 NET INCOME FROM SERVICE TO PATIENTS 862,859 OTHER INCOME 6 CONTRIBUTIONS, DONATIONS, BEQUESTS, ETC. 7 INCOME FROM INVESTMENTS 119,147 8 REVENUE FROM TELEPHONE AND TELEGRAPH SERVICE 9 REVENUE FROM TELEVISION AND RADIO SERVICE 10 PURCHASE DISCOUNTS 514 11 REBATES AND REFUNDS OF EXPENSES 12 PARKING LOT RECEIPTS 13 REVENUE FROM LAUNDRY AND LINEN SERVICE 14 REVENUE FROM MEALS SOLD TO EMPLOYEES AND GUESTS 15 REVENUE FROM RENTAL OF LIVING QUARTERS 16 REVENUE FROM SALE OF MEDICAL & SURGICAL SUPPLIES TO OTHER THAN PATIENTS 17 REVENUE FROM SALE OF DRUGS TO OTHR THAN PATIENTS 18 REVENUE FROM SALE OF MEDICAL RECORDS & ABSTRACTS 19 TUITION (FEES, SALE OF TEXTBOOKS, UNIFORMS, ETC) 20 REVENUE FROM GIFTS,FLOWER, COFFEE SHOP & CANTEEN 21 RENTAL OF VENDING MACHINES 22 RENTAL OF HOSPITAL SPACE 23 GOVERNMENTAL APPROPRIATIONS 24 RENTAL INCOME-PSP 859,512 25 TOTAL OTHER INCOME 979,173 26 TOTAL 1,842,032 OTHER EXPENSES 27 BAD DEBT EXPENSE 426,948 28 29 30 TOTAL OTHER EXPENSES 426,948 31 NET INCOME (OR LOSS) FOR THE PERIOD 1,415,084 Health Financial Systems MCRIF32 FOR PHYSICIANS MEDICAL CENTER IN LIEU OF FORM CMS-2552-96 (2/2006) I PROVIDER NO: I PERIOD: I PREPARED 6/ 4/2010 CALCULATION OF CAPITAL PAYMENT I 15-0172 I FROM 1/ 1/2009 I WORKSHEET L I COMPONENT NO: I TO 12/31/2009 I PARTS I-IV I 15-0172 I I TITLE XVIII, PART A HOSPITAL PART I - FULLY PROSPECTIVE METHOD 1 CAPITAL HOSPITAL SPECIFIC RATE PAYMENTS CAPITAL FEDERAL AMOUNT 2 CAPITAL DRG OTHER THAN OUTLIER 3 CAPITAL DRG OUTLIER PAYMENTS PRIOR TO 10/01/1997 3 .01 CAPITAL DRG OUTLIER PAYMENTS AFTER 10/01/1997 INDIRECT MEDICAL EDUCATION ADJUSTMENT 4 TOTAL INPATIENT DAYS DIVIDED BY NUMBER OF DAYS .00 IN THE COST REPORTING PERIOD 4 .01 NUMBER OF INTERNS AND RESIDENTS .00 (SEE INSTRUCTIONS) 4 .02 INDIRECT MEDICAL EDUCATION PERCENTAGE .00 4 .03 INDIRECT MEDICAL EDUCATION ADJUSTMENT (SEE INSTRUCTIONS) 5 PERCENTAGE OF SSI RECEIPIENT PATIENT DAYS TO .00 MEDICARE PART A PATIENT DAYS 5 .01 PERCENTAGE OF MEDICAID PATIENT DAYS TO TOTAL .00 DAYS REPORTED ON S-3, PART I 5 .02 SUM OF 5 AND 5.01 .00 5 .03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE .00 5 .04 DISPROPORTIONATE SHARE ADJUSTMENT 6 TOTAL PROSPECTIVE CAPITAL PAYMENTS PART II - HOLD HARMLESS METHOD 1 NEW CAPITAL 2 OLD CAPITAL 3 TOTAL CAPITAL 4 RATIO OF NEW CAPITAL TO OLD CAPITAL .000000 5 TOTAL CAPITAL PAYMENTS UNDER 100% FEDERAL RATE 6 REDUCTION FACTOR FOR HOLD HARMLESS PAYMENT 7 REDUCED OLD CAPITAL AMOUNT 8 HOLD HARMLESS PAYMENT FOR NEW CAPITAL 9 SUBTOTAL 10 PAYMENT UNDER HOLD HARMLESS PART III - PAYMENT UNDER REASONABLE COST 1 PROGRAM INPATIENT ROUTINE CAPITAL COST 106,993 2 PROGRAM INPATIENT ANCILLARY CAPITAL COST 59,690 3 TOTAL INPATIENT PROGRAM CAPITAL COST 166,683 4 CAPITAL COST PAYMENT FACTOR 85 5 TOTAL INPATIENT PROGRAM CAPITAL COST 141,681 PART IV - COMPUTATION OF EXCEPTION PAYMENTS 1 PROGRAM INPATIENT CAPITAL COSTS 2 PROGRAM INPATIENT CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES 3 NET PROGRAM INPATIENT CAPITAL COSTS 4 APPLICABLE EXCEPTION PERCENTAGE .00 5 CAPITAL COST FOR COMPARISON TO PAYMENTS 6 PERCENTAGE ADJUSTMENT FOR EXTRAORDINARY .00 CIRCUMSTANCES 7 ADJUSTMENT TO CAPITAL MINIMUM PAYMENT LEVEL FOR EXTRAORDINARY CIRCUMSTANCES 8 CAPITAL MINIMUM PAYMENT LEVEL 9 CURRENT YEAR CAPITAL PAYMENTS 10 CURRENT YEAR COMPARISON OF CAPITAL MINIMUM PAYMENT LEVEL TO CAPITAL PAYMENTS 11 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL OVER CAPITAL PAYMENT 12 NET COMPARISON OF CAPITAL MINIMUM PAYMENT LEVEL TO CAPITAL PAYMENTS 13 CURRENT YEAR EXCEPTION PAYMENT 14 CARRYOVER OF ACCUMULATED CAPITAL MINUMUM PAYMENT LEVEL OVER CAPITAL PAYMENT FOR FOLLOWING PERIOD 15 CUR YEAR ALLOWABLE OPERATING AND CAPITAL PAYMENT 16 CURRENT YEAR OPERATING AND CAPITAL COSTS 17 CURRENT YEAR EXCEPTION OFFSET AMOUNT (SEE INSTRUCTIONS) ***FINGERPRINT Line 1 TqpZxV4e5i:QheT:6TTigjqOseQoD0 ***FINGERPRINT Line 2 IcnZP0CiVOPunf2hu9a9tqoFbC1exy ***FINGERPRINT Line 3 0mqq23rQLb02TRrN