Form Dhcs 3076 - Supplemental Cost Report Schedule B For Intermediate Care Facilityfor The Developmentallydisabled (Habilitative Or Nursing) Adult Day Services And Related Transportation Cost

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SUPPLEMENTAL COST REPORT SCHEDULE B
FOR
INTERMEDIATE CARE FACILITYFOR THE DEVELOPMENTALLY DISABLED
(HABILITATIVE OR NURSING)
ADULT DAY SERVICES AND RELATED TRANSPORTATION COST
INCOMPLETE, INACCURATE OR ALTERED SCHEDULES WILL NOT BE ACCEPTED
Provider Name:
Medi-Cal National Provider Identifier (NPI):
Fiscal Period Year:
Reporting Period Begin Date:
Reporting Period End Date:
Contact Person:
Mailing Address:
Phone:
Date Submitted:
Title:
E-mail Address:
Line 1
Adult Day Services Medi-Cal Participant Days
Line 2
Adult Day Services Revenue
$
Line 3
Direct Costs*
$
Line 4
Regional Center’s Administrative Cost**
$
Line 5
ICF/DDs Administrative Costs***
$
Line 6
Quality Assurance Fees Associated with Adult
$
Day Services****
Line 7
Total Adult Day Services Cost
$
(note: the c ost should match revenue)
*Direct costs of providing the day program treatment and transportation costs
**Regional Center’s administrative costs in making disbursements on behalf of the ICF/DD’s provider for these services
***ICF/DD’s administrative costs for staff responsible for performing the duties related to Adult Day Services
****Quality Assurance fee paid associated with Adult Day Services and related transportation
DHCS 3076-Supp B (01/2016)

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