Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 15
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2504-06
EXHIBIT 3
1102.3 (Cont.)
Hospital Emergency Department
Provider Name: ______________________________________________________
Provider-Based Physician
Provider Number: ____________________________________________________
Allowable Availability Service Costs
Cost Reporting Year: Beginning _______________ Ending ______________
Under Hourly Rate or Salary Arrangements
Geographic Location of Provider: ____________________________________
(City & State)
Data Elements
Specialty:____________________________________
Name of Physician: __________________________________________________
Allocation Agreement:
Time - Percentage
Total Hours Worked
Availability Services
________%
_______
Supervision & Administrative Services
________%
_______
Reasonable Compensation Equivalent (RCE) from Table I, Estimate of FTE
$__________________
___
___
RCE Area: Non-Metropolitan /__/; Metropolitan, Less Than One Million /__/;
___
or Metropolitan, Greater Than One Million /__/
Actual Provider Payments:
Total Charges:
Supervision and Administration
$_____________
Billed Inpatient Charges
$______________
Availability Services
$_____________
Billed Outpatient Charges
$______________
Membership in Professional Associations
$_____________
Imputed Inpatient Charges
$______________
Continuing Medical Education
$_____________
Imputed Outpatient Charges
$______________
Malpractice Insurance Premiums
$_____________
Imputed Employee Charges
$______________
Other :
$______________
_________________
$______________
Compensation Based on:
Hourly Rate $_____________ or Salary Basis $___________________
Note: Attach copy of Approved Allocation Agreements
Rev. 6
11-29
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