Worksheet formats are based on information supplied by the Centers for Medicare and Medicaid Services (CMS).  Forms and instructions can be downloaded from the CMS website and are presented here as a convenient reference.

* Worksheets which are not yet available on CostReportData.com have been marked with an asterisk. Please contact us if there is a specific sheet to be requested, as an addition, to those already available.

[-] 2010 Format

S001 Worksheet S Parts I, II & III
Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary
form instructions
S100 Worksheet S-10
Hospital Uncompensated and Indigent Care Data
Worksheet S-10 is used for cost reports with begin date before October 1, 2022.
form instructions
S101 Worksheet S-10 Part I
Hospital Uncompensated and Indigent Care Data
Worksheets S-10 Part I and S-10 Part II are used for cost reports with begin date on or after October 1, 2022.
form instructions
S102 Worksheet S-10 Part II
Hospital Uncompensated and Indigent Care Data - Hospital Data
Worksheets S-10 Part I and S-10 Part II are used for cost reports with begin date on or after October 1, 2022.
form instructions
S201 Worksheet S-2 Part I
Hospital and Hospital Health Care Complex Identification Data
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S202 Worksheet S-2 Part II
Hospital and Hospital Health Care Complex Reimbursement Questionnaire
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S301 Worksheet S-3 Part I
Hospital and Hospital Health Care Complex Statistical Data
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S302 Worksheet S-3 Parts II & III
Hospital Wage Index Information
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S304 Worksheet S-3 Part IV
Hospital Wage Related Costs
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S305 Worksheet S-3 Part V
Hospital Contract Labor and Benefit Cost
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S400 Worksheet S-4
Hospital-based Home Health Agency Statistical Data
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S500 Worksheet S-5
Hospital Renal Dialysis Department Statistical Data
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S600 Worksheet S-6 *
Hospital-based Community Mental Health Center and Other Outpatient Rehabilitation Provider Statistical Data
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S700 Worksheet S-7
Prospective Payment for SNF Statistical Data
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S800 Worksheet S-8 *
Hospital-based Rural Health Clinic / Federally Qualified Health Center Statistical Data
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S900 Worksheet S-9 Parts I-IV *
Hospice Identification Data
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S111 Worksheet S-11 Part I *
Hospital-based FQHC Identification Data
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S112 Worksheet S-11 Part II *
Hospital-based FQHC Consolidated Cost Report Participant Identification Data
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S113 Worksheet S-11 Part III *
Hospital-based FQHC Statistical Data
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A000 Worksheet A
Reclassification and Adjustment of Trial Balance of Expenses
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A600 Worksheet A-6
Reclassifications
form instructions
A701 Worksheet A-7 Parts I, II & III
Reconciliation of Capital Costs Centers
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A800 Worksheet A-8
Adjustments to Expenses
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A81A Worksheet A-8-1 Part A
Statement of Costs of Services from Related Organizations and Home Office Costs
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A81B Worksheet A-8-1 Part B
Interrelationship to Related Organization(s) and/or Home Office
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A820 Worksheet A-8-2
Provider-based Physicians Adjustments
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A830 Worksheet A-8-3 Parts I - VI
Reasonable Cost Determination for Therapy Services Furnished by Outside Suppliers
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B001 Worksheet B Part I
Cost Allocation - General Service Costs
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B002 Worksheet B Part II
Allocation of Capital-related Costs
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B100 Worksheet B-1
Cost Allocation - Statistical Basis
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B200 Worksheet B-2
Post Stepdown Adjustments
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C001 Worksheet C Part I
Computation of Ratio of Costs to Charges
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C002 Worksheet C Part II *
Calculation of Outpatient Service Cost to Charge Ratios Net of Reductions for Medicaid Only
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D001 Worksheet D Part I
Apportionment of Inpatient Routine Service Capital Costs
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D002 Worksheet D Part II
Apportionment of Inpatient Ancillary Service Capital Costs
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D003 Worksheet D Part III
Apportionment of Inpatient Routine Service Other Pass Through Costs
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D004 Worksheet D Part IV
Apportionment of Inpatient/Outpatient Ancillary Service Other Pass Through Costs
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D005 Worksheet D Part V
Apportionment of Medical and Other Health Services Costs
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D101 Worksheet D-1 Part I
Computation of Inpatient Operating Cost - All Provider Components
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D102 Worksheet D-1 Part II
Computation of Inpatient Operating Cost - Hospital and Subproviders Only
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D103 Worksheet D-1 Parts III & IV
Computation of Inpatient Operating Cost - SNF, NF and ICF/IID Only
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D200 Worksheet D-2 Parts 1 - III *
Apportionment of Cost of Services Rendered by Interns and Residents
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D300 Worksheet D-3
Inpatient Ancillary Service Cost Apportionment
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D401 Worksheet D-4 Part I
Computation of Organ Acquisition Costs and Charges for a Transplant Hospital with a Medicare-certified Transplant Program - Routine and Acillary Costs
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D402 Worksheet D-4 Part II
Computation of Organ Acquisition Costs and Charges for a Transplant Hospital with a Medicare-certified Transplant Program - Other Costs
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D403 Worksheet D-4 Parts III & IV
Computation of Organ Acquisition Costs and Charges for a Transplant Hospital with a Medicare-certified Transplant Program - Summary and Statistics
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D501 Worksheet D-5 Part I *
Apportionment of Cost for Physicians' Services in a Teaching Hospital - Reasonable Compensation Computation PE Before June 30,2014
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D502 Worksheet D-5 Part II *
Apportionment of Cost for Physicians' Services in a Teaching Hospital - Apportionment of Costs PE Before June 30,2014
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D503 Worksheet D-5 Part III *
Apportionment of Cost for Physicians' Services in a Teaching Hospital - Reasonable Compensation Computation PE On or after June 30,2014
form instructions
D504 Worksheet D-5 Part IV *
Apportionment of Cost for Physicians' Services in a Teaching Hospital - Apportionment of Costs PE On or after June 30,2014
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D601 Worksheet D-6 Parts I & II
Computation of Cellular Therapy Acquisition Costs
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D603 Worksheet D-6 Part III
Computation of Cellular Therapy Acquisition Costs Summary
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E00A Worksheet E Part A
Calculation of Reimbursement Settlement - Inpatient PPS
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E00B Worksheet E Part B
Calculation of Reimbursement Settlement - Medical and Other Health Services
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E101 Worksheet E-1 Part I *
Analysis of Payments to Providers for Services Rendered
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E102 Worksheet E-1 Part II
Calculation of Reimbursement Settlement for HIT
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E200 Worksheet E-2
Calculation of Reimbursement Settlement - Swing Beds
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E301 Worksheet E-3 Part I
Calculation of Medicare Reimbursement Settlement Under TEFRA
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E302 Worksheet E-3 Part II
Calculation of Medicare Reimbursement Settlement Under IPF PPS
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E303 Worksheet E-3 Part III
Calculation of Medicare Reimbursement Settlement Under IRF PPS
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E304 Worksheet E-3 Part IV
Calculation of Medicare Reimbursement Settlement Under LTCH PPS
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E305 Worksheet E-3 Part V
Calculation of Medicare Reimbursement Settlement for Medicare Part A Services - Cost Reimbursement (CAHs)
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E306 Worksheet E-3 Part VI
Calculation of Medicare Reimbursement Settlement - Title XVIII Part A PPS SNF Services
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E307 Worksheet E-3 Part VII *
Calculation of Medicare Reimbursement Settlement - All Other Health Services for Titles V or Title XIX Services
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E400 Worksheet E-4
Direct Graduate Medical Education (GME) & ESRD Outpatient Direct Medical Education Costs
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E500 Worksheet E-5 *
Outlier Reconciliation at Tentative Settlement
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E950 Worksheet E-95 *
Payment Adjustments for Domestic NIOSH-Approved Surgical N95 Respirators
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G000 Worksheet G
Balance Sheet
form instructions
G100 Worksheet G-1
Statement of Changes in Fund Balances
form instructions
G200 Worksheet G-2 Parts I & II
Statement of Patient Revenues and Operating Expenses
form instructions
G300 Worksheet G-3
Statement of Revenues and Expenses
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H000 Worksheet H
Analysis of Hosptial-based Home Health Agency Costs
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H101 Worksheet H-1 Part I *
Cost Allocation - HHA General Service Cost
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H102 Worksheet H-1 Part II *
Cost Allocation - HHA Statistical Basis
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H201 Worksheet H-2 Part I *
Allocation of General Service Costs to HHA Cost Centers
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H202 Worksheet H-2 Part II *
Allocation of General Service Costs to HHA Cost Centers Statistical Basis
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H300 Worksheet H-3 Parts I & II *
Apportionment of Patient Service Costs
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H400 Worksheet H-4 Parts I & II *
Calculation of HHA Reimbursement Settlement
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H500 Worksheet H-5 *
Analysis of Payments to Hospital-based HHAs for Services Rendered to Program Beneficiaries
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I100 Worksheet I-1 *
Analysis of Renal Dialysis Department Costs
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I200 Worksheet I-2 *
Allocation of Renal Department Costs to Treatment Modalities
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I300 Worksheet I-3 *
Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis
form instructions
I400 Worksheet I-4 *
Computation of Average Cost per Treatment for Outpatient Renal Dialysis
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I500 Worksheet I-5 *
Calculation of Reimbursable Bad Debts - Title XVIII - Part B
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J101 Worksheet J-1 Part I *
Allocation of General Service Costs to Community Mental Health Centers
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J102 Worksheet J-1 Part II *
Allocation of General Service Costs to Community Mental Health Centers - Statistical Basis
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J201 Worksheet J-2 Part I *
Computation of Community Mental Health Center Provider Costs - Apportionment of CMHC Cost Centers
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J202 Worksheet J-2 Part II *
Computation of Community Mental Health Center Provider Costs - Apportionment of Costs Furnished by Shared ospital Departments
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J300 Worksheet J-3 *
Calculation of Reimbursement Settlement Community Mental Health Center Provider Services
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J400 Worksheet J-4 *
Analysis of Payments to Hospital-based Community Mental Health Center for Services Rendered to Program Beneficiaries
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K000 Worksheet K
Analysis of Hospital-based Hospice Costs
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K100 Worksheet K-1
Hospice Compensation Analysis Salaries and Wages
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K200 Worksheet K-2
Hospice Compensation Analysis Employee Benefits (Payroll Related)
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K300 Worksheet K-3
Hospice Compensation Analysis Contracted Services/Purchased Services
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K401 Worksheet K-4 Part I
Cost Allocation - Hospice General Service Cost
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K402 Worksheet K-4 Part II
Cost Allocation - Hospice Statistical Basis
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K501 Worksheet K-5 Part I
Allocation of General Service Costs to Hospice Cost Centers
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K502 Worksheet K-5 Part II
Allocation of General Service Costs to Hospice Cost Centers - Statistical Basis
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K503 Worksheet K-5 Part III
Apportionment of Hospice Shared Services
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K600 Worksheet K-6
Calculation of Hospice per Diem Cost
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L000 Worksheet L Parts I, II & III
Calculation of Capital Payment
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L101 Worksheet L-1 Part I *
Allocation of Allowable Costs for Extraordinary Circumstances
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L102 Worksheet L-1 Part II *
Computation of Program Inpatient Routine Service Capital Costs for Extraordinary Circumstances
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L103 Worksheet L-1 Part III *
Computation of Program Inpatient Ancillary Service Capital Costs for Extraordinary Circumstances
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M100 Worksheet M-1
Analysis of Hospital-based Rural Health Clinic / Federally Qualified Health Center Costs
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M200 Worksheet M-2
Allocation of Overhead to Hospital-based RHC/FQHC Services
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M300 Worksheet M-3
Calculation of Reimbursement Settlement for Hospiital-based RHC/FQHC Services
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M400 Worksheet M-4
Computation of Hospital-based RHC/FQHC Vaccine Cost
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M500 Worksheet M-5
Analysis of Payments to Hospital-based RHC/FQHC Provider for Services Rendered to Program Beneficiaries
form instructions
N100 Worksheet N-1 *
Reclassification and Adjustment of Trial Balance of Expenses for Hospital-based FQHC
form instructions
N200 Worksheet N-2 *
Calculation of Hospital-based FQHC Cost per Visit
form instructions
N300 Worksheet N-3 *
Computation of Hospital-based FQHC Vaccine Cost
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N400 Worksheet N-4 *
Calculation of Hospital-based FQHC Reimbursement Settlement
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N500 Worksheet N-5 *
Analysis of Payments to Hospital-based FQHC for Services Rendered
form instructions
O000 Worksheet O *
Analysis of Hospital-based Hospice Costs
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O100 Worksheet O-1 *
Hospice Continuous Home Care Costs
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O200 Worksheet O-2 *
Hospice Routine Home Care Costs
form instructions
O300 Worksheet O-3 *
Hospice Inpatient Respite Care Costs
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O400 Worksheet O-4 *
Hospice General Inpatient Care Costs
form instructions
O500 Worksheet O-5 *
Cost Allocation - Determination of Hospital-based Hospice Net Expenses for Allocation
form instructions
O601 Worksheet O-6 Part I *
Cost Allocation - Hospital-based Hospice General Service Costs
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O602 Worksheet O-6 Part II *
Cost Allocation - Hospital-based Hospice General Service Costs Statistical Basis
form instructions
O700 Worksheet O-7 *
Apportionment of Hospital-based Hospice Shared Service Costs By Level of Care
form instructions
O800 Worksheet O-8 *
Calculation of Hospital-based Hospice Per Diem Cost
form instructions

[+] 1996 Format

S20 Worksheet S-2
Hospital and Hospital Health Care Complex Identification Data
form instructions
S31 Worksheet S-3, Part I
Hospital and Hospital Health Care Complex Statistical Data
form instructions
S32 Worksheet S-3, Part II
Hospital Wage Index Information - Wage Data
form instructions
S33 Worksheet S-3, Part III
Hospital Wage Index Information - Wage Index Summary
form instructions
S10 Worksheet S-10
Hospital Uncompensated Care Data
form instructions
A00 Worksheet A
Reclassification and Adjustment of Trial Balance of Expenses
form instructions
A71 Worksheet A-7, Parts I & II
Analysis of Changes During Cost Reporting Period in Capital Asset Balance
form instructions
A73 Worksheet A-7, Parts III & IV
Reconciliation of Capital Cost Centers
form instructions
A80 Worksheet A-8
Adjustments to Expenses
form instructions
81A Worksheet A-8-1, Part A
Statement of Costs of Services from Related Organizations and Home Office Costs - Costs and Adjustments
form instructions
81B Worksheet A-8-1, Part B
Statement of Costs of Services from Related Organizations and Home Office Costs - Interrelationships
form instructions
B01 Worksheet B, Part I
Cost Allocation - General Service Costs
form instructions
B10 Worksheet B-1
Cost Allocation - Statistical Basis
form instructions
C01 Worksheet C, Part I
Computation of Ratio of Costs to Charges
form instructions
C02 Worksheet C, Part II
Calculation of Outpatient Service Cost to Charge Ratios Net of Reductions
form instructions
D01 Worksheet D, Part I
Apportionment of Inpatient Routine Service Capital Costs
form instructions
D02 Worksheet D, Part II
Apportionment of Inpatient Ancillary Service Capital Costs
form instructions
D03 Worksheet D, Part III
Apportionment of Inpatient Routine Service Other Pass Through Costs
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D04 Worksheet D, Part IV
Apportionment of Inpatient/Outpatient Ancillary Service Other Pass Through Costs
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D05 Worksheet D, Parts V & VI
Apportionment of Medical, Other Health Services Costs and Vaccine Cost
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D11 Worksheet D-1, Part I
Computation of Inpatient Operating Cost - All Provider Components
form instructions
D12 Worksheet D-1, Part II
Computation of Inpatient Operating Cost - Hospital and Subproviders Only
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D13 Worksheet D-1, Parts III & IV
Computation of Inpatient Operating Cost - SNF, NF, ICF/MR, and Observation Beds
form instructions
D40 Worksheet D-4
Inpatient Ancillary Service Cost Apportionment
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D60 Worksheet D-6, Parts III & IV
Computation of Organ Acquisition Costs and Charges
form instructions
E0A Worksheet E, Part A
Calculation of Reimbursement Settlement - Inpatient Hospital Services Under PPS
form instructions
E0B Worksheet E, Part B
Calculation of Reimbursement Settlement - Medical and Other Health Services
form instructions
E0C Worksheet E, Part C
Calculation of Reimbursement Settlement - Outpatient Ambulatory Surgical Center
form instructions
E0D Worksheet E, Part D
Calculation of Reimbursement Settlement - Outpatient Radiology Services
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E0E Worksheet E, Part E
Calculation of Reimbursement Settlement - Other Outpatient Diagnostic Procedures
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E20 Worksheet E-2
Calculation of Reimbursement Settlement - Swing Beds
form instructions
E31 Worksheet E-3, Part I
Calculation of Medicare Reimbursement Settlement under TEFRA, IRF PPS, LTAC PPS, and IPF PPS
form instructions
E32 Worksheet E-3, Part II
Calculation of Reimbursement Settlement - Medicare Part A Services - Cost Reimbursement
form instructions
E33 Worksheet E-3, Part III
Calculation of Reimbursement Settlement - Title V or Title XIX Services or Title XVIII SNF PPS Only
form instructions
E34 Worksheet E-3, Part IV
Direct Graduate Medical Education (GME) & ESRD Outpatient Direct Medical Education Costs
form instructions
E35 Worksheet E-3, Part V
Calculation of NHCMQ Demonstration Reimbursement Settlement
form instructions
E36 Worksheet E-3, Part VI
Calculation of GME & IME Payments for Redistribution of Unused Residency Slots
form instructions
G00 Worksheet G
Balance Sheet
form instructions
G20 Worksheet G-2, Parts I & II
Statement of Patient Revenues and Operating Revenues
form instructions
G30 Worksheet G-3
Statement of Revenues and Expenses
form instructions
H60 Worksheet H-6
Apportionment of Patient Service Costs [HHA]
form instructions
H70 Worksheet H-7
Calculation of HHA Reimbursement Settlement
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L00 Worksheet L
Calculation of Capital Payment
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M10 Worksheet M-1
Analysis of Provider-Based Rural Health Clinic / Federally Qualified Health Center Costs
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M20 Worksheet M-2
Allocation of Overhead to RHC/FQHC Services
form instructions
M30 Worksheet M-3
Calculation of Reimbursement Settlement for RHC/FQHC Services
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M40 Worksheet M-4
Computation of Pneumococcal and Influenza Vaccine Cost
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M50 Worksheet M-5
Analysis of Payments to Hospital-Based RHC/FQHC Provider for Services Rendered to Program Beneficiaries
form instructions