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11-05

Form CMS-216-94

3390(Cont.)

This report is required by law (42 USC 1395g) and 42CFR 413.20 and 413.24.

FORM APPROVED

Failure to report can result in all payments made during the reporting period

OMB NO. 0938-0102

being deemed overpayments (42 USC 1395g).

ORGAN PROCUREMENT ORGANIZATION

PROVIDER NO.

PERIOD:

WORKSHEET

HISTOCOMPATIBILITY LABORATORY GENERAL

FROM:_______

_______________

DATA AND CERTIFICATION STATEMENT

TO:__________

Intermediary Use Only:

[

] Audited

Date Received ________________

[

] Initial

[

] Re-opened

[

] Desk Reviewed

Intermediary No. ______________

[

] Final

PART I - GENERAL

Check

[

] Electronic filed cost report

Date:

applicable box

[

] Manually submitted cost report

Time:

1 Name:

Medicare Number:

1.01 Street:

P.O. Box:

1.01

1.02 City:

State:

Zip Code:

1.02

2 Name:

Medicare Number:

2.01 Street:

P.O. Box:

2.01

2.02 City:

State:

Zip Code:

2.02

3 Reporting Period: From

Type of Control

Type of Provider

(see instructions)

Participation Date

PART II-CERTIFICATION BY OFFICER OR ADMINISTRATOR OF FACILITY

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY

BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT

UNDER FEDERAL LAW. FUTHERMORE, IF SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED

OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLYOF A KICKBACK OR WERE OTHERWIS

ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATION ACTION, FINES AND/OR IMPRISONMENT MAY RESULT

CERTIFICATION BY OFFICER, ADMINISTRATOR OR DIRECTOR OF ORGANIZATION/LABORATORY

I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Statement of Reimbursable Cost

and the Balance Sheet and Statement of Revenue and Expenses prepared by _____________________________________________

_________________________________________________________________________________________

(name(s) and number(s) for the cost reporting period beginning _____________________ and ending_________________________,

and that to the best of my knowledge and belief, it is a true, correct and complete ststement prepared from the books and records of the

Organization/Laboratory in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws

and regulations regarding the provision of health care services, and that the services identified in this cost report were provided in

compliance with such laws and regulations.

(Signed) ______________________________________________

Officer, Administrator or Director

______________________________________________

Title

______________________________________________

Date

PART III - SETTLEMENT SUMMARY

TITLE XVIII

Organ Acquisition

Tissue Typing

OPO/Lab

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a

valid OMB control number. The valid OMB Control Number for this information collection is 0938-0102. The time required to complete

this information collection is estimated to average 45 hours per response, including the time to review instructions, search existing data

resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form please write to: Centers for Medicare and Medicaid Services, 7500 Security

Boulevard, Baltimor, Maryland 21244-1850.

FORM CMS-216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,

SECTIONS 3302,3302.1 and 3302.2)

Rev. 4

33-303

Form Cms-216-94 - Organ Procurement Organization-Histo-Compatibility Lab Statement Of Reimbursable Costs

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