Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 14
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251102.3 (Cont.)
EXHIBIT 2
04-06
Allocation of Physician
Provider Name:__________________________________________
Compensation: Hours
Provider Number:
Department: ___________________________
Physician Name: ___________________________________________
Cost Reporting Year:
Beginning___________________ Ending ___________________
___
___
Basis of Allocation: Time Study /__/; Other /__/; Describe ______________________________
Services
Total
Hours
1.
Provider Services - Teaching and Supervision of I/R's and other GME Related Functions.
_________________________
1A.
Provider Services - Teaching and Supervision of Allied Health Students
_________________________
1B.
Provider Services - Non Teaching Reimbursable Activities such as Departmental Administration,
Supervision of Nursing, and Technical Staff, Utilization Review, etc.
_________________________
1C.
Provider Services - Emergency Room Physician Availability
_________________________
(Do not include minimum guarantee arrangements for Emergency Room Physicians.)
1D.
Sub-Total - Provider Administrative Services (Lines 1, 1A, 1B, 1C).
_________________________
2.
Physician Services: Medical and Surgical Services
to Individual Patients
_________________________
3.
Non-Reimbursable Activities: Research, Teaching of I/R's in Non-Approved Programs, Teaching
and Supervision of Medical Students, Writing for Medical Journals, etc.
_________________________
4.
Total Hours: (Lines 1D, 2, and 3)
_________________________
5.
Professional Component Percentage (Line 2 / Line 4)
_________________________
6.
Provider Component Percentage - (Line 1D / Line 4)
_________________________
__________________________________________
________________________
Signature: Physician or Physician Department Head
Date
11-28
Rev. 6
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