Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 18
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251102.3 (Cont.)
EXHIBIT 4
04-06
Hospital Emergency Department
Provider Name: ______________________________________________________
Provider-Based Physician
Provider Number: ____________________________________________________
Allowable Unmet Guarantee Amounts
Cost Reporting Year: Beginning _______________ Ending ______________
Under Minimum Guarantee Arrangements:
Geographic Location of Provider: ____________________________________
Data Elements
(City and State)
_
Specialty: _____________________________________
Name of Physician: __________________________________________________
_
Allocation Agreement:
Time - Percentage
Total Hours Worked
A) Professional Services to Individual
Patients (includes inpatients and
employees) and Availability Services
________%
________
B) Supervision & Administrative Services
________%
________
Total
%
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 Outpatient Charges
$______________
Unmet Guarantee Amount
$_____________
Billed Inpatient Charges
$______________
Membership in Professional Associations
$_____________
Imputed Inpatient Charges
$______________
Continuing Medical Education
$_____________
Imputed Outpatient Charges
$______________
Malpractice Insurance Premiums
$_____________
Imputed Employee Charges
$______________
Other
$_____________
Other: _________________
$______________
_________________
$______________
Actual Minimum Guarantee Amount
$_____________
Total Outpatient Charges
$______________
Total Inpatient Charges
$______________
Note: Attach copy of Approved Allocation Agreement
11-32
Rev. 6
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