Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 4
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
251102.3 (Cont.)
EXHIBIT 1 (Cont.)
04-06
PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE
YES
NO
N/A
3. New leases and/or amendments to existing leases for land,
equipment, or facilities with annual rental payment in excess
of the amounts listed in the instructions, have been entered into
during this cost reporting period.
If "yes", submit a listing of these new leases and/or
amendments to existing leases that have the following
information:
o
A new lease or lease renewal;
o
Parties to the lease;
o
Period covered by the lease;
o
Description of the asset being leased; and
o
Annual charge by the lessor.
NOTE: Providers are required to submit copies of the lease, or
significant extracts, upon request from the intermediary.
4. There have been new capitalized leases entered into during the
current cost reporting period.
If "yes", attach a list of the individual assets by class, the
department assigned to, and respective dollar amounts for all
capitalized leases in accordance with the thresholds discussed
in the instructions.
5. Assets which were subject to §2314 of DEFRA were acquired
during the period.
If "yes", supply a computation of the basis.
6. Provider's capitalization policy changed during cost reporting
period.
If "yes", submit copy.
7. Obligated capital has been placed into use during the cost
reporting period.
If "yes", attach schedule listing each project, the cost of these
projects and the date placed into service for patient care.
11-18
Rev. 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 3076 - Supplemental Cost Report Schedule B For Intermediate Care Facilityfor The Developmentallydisabled (habilitative Or Nursing) Adult Day Services And Related Transportation Cost
Legal
Related Categories
Parent category: Medical