Form Cms-2552-10 - Cost Allocation - Hospital-Based Hospice General Service Costs

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11-16
FORM CMS-2552-10
4090 (Cont.)
COST ALLOCATION - HOSPITAL-BASED HOSPICE GENERAL SERVICE COSTS
PROVIDER CCN: ___________
PERIOD:
WORKSHEET O-6
HOSPICE CCN: ___________
FROM ____________________
PART I
TO ____________________
CAP REL
CAP REL
EMPLOYEE
ADMINIS-
PLANT
LAUNDRY
HOUSE-
DIETARY
TOTAL
BLDG
MVBLE
BENEFITS
TRATIVE &
OP &
& LINEN
KEEPING
EXPENSES
& FIX
EQUIP
DEPARTMENT
SUBTOTAL
GENERAL
MAINT
Descriptions
0
1
2
3
3A
4
5
6
7
8
GENERAL SERVICE COST CENTERS
1
Cap Rel Costs-Bldg & Fixt
1
2
Cap Rel Costs-Mvble Equip
2
3
Employee Benefits
3
4
Administrative & General
4
5
Plant Operation and Maintenance
5
6
Laundry & Linen Service
6
7
Housekeeping
7
8
Dietary
8
9
Nursing Administration
9
10
Routine Medical Supplies
10
11
Medical Records
11
12
Staff Transportation
12
13
Volunteer Service Coordination
13
14
Pharmacy
14
15
Physician Administrative Services
15
16
Other General Service
16
17
Patient/Residential Care Services
17
LEVEL OF CARE
50
Hospice Continuous Home Care
50
51
Hospice Routine Home Care
51
52
Hospice Inpatient Respite Care
52
53
Hospice General Inpatient Care
53
NONREIMBURSABLE COST CENTERS
60
Bereavement Program
60
61
Volunteer Program
61
62
Fundraising
62
63
Hospice/Palliative Medicine Fellows
63
64
Palliative Care Program
64
65
Other Physician Services
65
66
Residential Care
66
67
Advertising
67
68
Telehealth/Telemonitoring
68
69
Thrift Store
69
70
Nursing Facility Room & Board
70
71
Other Nonreimbursable
71
99
Negative Cost Center
99
100
Total
100
FORM CMS-2552-10 (11-2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4072.3)
Rev. 10
40-677

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