Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 25
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2504-06
EXHIBIT 6 (Cont.)
1102.3 (Cont.)
Part II - Other Wage Related Cost
List below detail for each wage related cost that exceeds the 1% threshold. Each wage
related cost listed below must be recognized as a wage related cost in conformity with
published criteria and instructions.
________________________________________________ $_______________________
________________________________________________ $_______________________
TOTAL OTHER WAGE RELATED COST
$__________________________________
Part III - WAGE RELATED COST RECONCILIATION TO FRINGE BENEFITS REPORTED
IN THE COST REPORT
DESCRIPTION
COST PER MEDICARE
COST PER GAAP
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
___________________________
$____________________
$___________________
Rev. 6
11-39
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