Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 17
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2504-06
EXHIBIT 3A (Cont.)
1102.3 (Cont.)
Provider Name ______________________________
Provider Number ________________
Name of Physician ___________________________
6. Actual Provider Payments
Supervision and Administration
$_______________
Availability Services
$_______________
Membership in Professional Associations
$_______________
Continuing Medical Education
$_______________
Malpractice (Provider Services Related)
$_______________
Total
$_______________
7. Amount Includable in Allowable Costs:
$_______________
(Lesser of #5 or #6)
8. Allocation of Allowable Costs:
Billed Outpatient Charges
(Emergency Department)
$_______________
Imputed Outpatient and Employee Charges
$_______________
Total Outpatient Charges
$_______________
Imputed Inpatient Charges
$_______________
Billed Inpatient Charges
$_______________
Total Inpatient Charges
$_______________
Total Outpatient and Inpatient Charges
$_______________
Total Outpatient Charges X Allowable Provider Costs = Allowable Part B Costs
Total Charges
___________________ X _________________
= $_______________
Total Inpatient Charges X Allowable Provider Costs = Allowable Part A Costs
Total Charges
______________________ X ____________________ = $__________________
Rev. 6
11-31
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