Worksheet Formats

Worksheet formats are based on information supplied by the Centers for Medicare and Medicaid Studies (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.

[+] 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
form instructions
S201 Worksheet S-2 PART I
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX IDENTIFICATION DATA
form instructions
S202 Worksheet S-2 PART II
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX REIMBURSEMENT QUESTIONNAIRE
form instructions
S301 Worksheet S-3 PART I
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA
form instructions
S302 Worksheet S-3 PART II & III
HOSPITAL WAGE INDEX INFORMATION
form instructions
S304 Worksheet S-3 PART IV
HOSPITAL WAGE RELATED COSTS
form instructions
S305 Worksheet S-3 PART V
HOSPITAL CONTRACT LABOR AND BENEFIT COST
form instructions
S400 Worksheet S-4
HOSPITAL-BASED HOME HEALTH AGENCY STATISTICAL DATA
form instructions
S500 Worksheet S-5
HOSPITAL RENAL DIALYSIS DEPARTMENT STATISTICAL DATA
form instructions
S600 Worksheet S-6 *
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND OTHER OUTPATIENT REHABILITATION PROVIDER STATISTICAL DATA
form instructions
S700 Worksheet S-7
PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA
form instructions
S800 Worksheet S-8 *
HOSPITAL-BASED RURAL HEALTH CLINIC/ FEDERALLY QUALIFIED HEALTH CENTER STATISTICAL DATA
form instructions
S900 Worksheet S-9 PARTS I-IV *
HOSPICE IDENTIFICATION DATA
form instructions
S111 Worksheet S-11 Part I *
HOSPITAL-BASED FQHC IDENTIFICATION DATA
form instructions
S112 Worksheet S-11 Part II *
HOSPITAL-BASED FQHC CONSOLIDATED COST REPORT PARTICIPANT IDENTIFICATION DATA
form instructions
S113 Worksheet S-11 Part III *
HOSPITAL-BASED FQHC STATISTICAL DATA
form instructions
A000 Worksheet A
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
form instructions
A600 Worksheet A6
RECLASSIFICATIONS
form instructions
A701 Worksheet A-7 PARTS I,II & III
RECONCILIATION OF CAPITAL COSTS CENTERS
form instructions
A800 Worksheet A-8
ADJUSTMENTS TO EXPENSES
form instructions
A81A Worksheet A-8-1 PART A
STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME OFFICE COSTS
form instructions
A81B Worksheet A-8-1 PART B
INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:
form instructions
A820 Worksheet A-8-2
PROVIDER-BASED PHYSICIANS ADJUSTMENTS
form instructions
A830 Worksheet A-8-3 PARTS I,II & III
REASONABLE COST DETERMINATION FOR THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS
form instructions
B001 Worksheet B PART I
COST ALLOCATION - GENERAL SERVICE COSTS
form instructions
B002 Worksheet B PART II
ALLOCATION OF CAPITAL-RELATED COSTS
form instructions
B100 Worksheet B-1
COST ALLOCATION - STATISTICAL BASIS
form instructions
B200 Worksheet B-2
POST STEPDOWN ADJUSTMENTS
form instructions
C001 Worksheet C PART I
COMPUTATION OF RATIO OF COSTS TO CHARGES
form instructions
C002 Worksheet C PART II *
CALCULATION OF OUTPATIENT SERVICE COST TO CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY
form instructions
D001 Worksheet D PART I
APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS
form instructions
D002 Worksheet D PART II
APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS
form instructions
D003 Worksheet D PART III
APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS
form instructions
D004 Worksheet D PART IV
APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS
form instructions
D005 Worksheet D PART V
APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS
form instructions
D101 Worksheet D-1 PART I
COMPUTATION OF INPATIENT OPERATING - ALL PROVIDER COMPONENTS
form instructions
D102 Worksheet D-1 PART II
COMPUTATION OF INPATIENT OPERATING - HOSPITAL AND SUBPROVIDERS ONLY
form instructions
D103 Worksheet D-1 PART III & IV
COMPUTATION OF INPATIENT OPERATING COST - SKILLED NURSING FACILITY, OTHER NURSING FACILITY. AND ICT/MR ONLY
form instructions
D200 Worksheet D-2 PARTS 1-III *
APPORTIONMENT OF COST OF SERVICES RENDERED BY INTERNS AND RESIDENTS
form instructions
D300 Worksheet D-3
INPATIENT ANCILLARY SERVICE COST APPORTIONMENT
form instructions
D401 Worksheet D-4 PART I
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS
form instructions
D402 Worksheet D-4 PART II
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS
form instructions
D403 Worksheet D-4 PART III & IV
COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS
form instructions
D501 Worksheet D-5 PART I *
APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS - REASONABLE COMPENSATION EQUIVALENT COMPUTATION
form instructions
D502 Worksheet D-5 PART II *
APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS - APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSI
form instructions
D503 Worksheet D-5 PART III *
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL - REASONABLE COMPENSATION EQUIVALENT COMPUTATION FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
form instructions
D504 Worksheet D-5 PART IV *
APPORTIONMENT OF COST FOR PHYSICIANS' SERVICES IN A TEACHING HOSPITAL FOR COST REPORTING PERIODS ENDING ON OR AFTER JUNE 30, 2014
form instructions
E00A Worksheet E PART A
CALCULATION OF REIMBURSEMENT SETTLEMENT
form instructions
E00B Worksheet E PART B
CALCULATION OF REIMBURSEMENT SETTLEMENT
form instructions
E101 Worksheet E-1 PART I *
ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED
form instructions
E102 Worksheet E-1 PART II
CALCULATION OF REIMBURSEMENT SETTLEMENT FOR HIT
form instructions
E200 Worksheet E-2
CALCULATION OF REIMBURSEMENT SETTLEMENT - SWING BEDS
form instructions
E301 Worksheet E-3 PART I
CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER - TEFRA
form instructions
E302 Worksheet E-3 PART II
CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS
form instructions
E303 Worksheet E-3 PART III
CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IRF PPS
form instructions
E304 Worksheet E-3 PART IV
CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER LTCH PPS
form instructions
E305 Worksheet E-3 PART V
CALCULATION OF REIMBURSEMENT SETTLEMENT FOR MEDICARE PART A SERVICES - COST REIMBURSEMENT (CAHs)
form instructions
E306 Worksheet E-3 PART VI
CALCULATION OF REIMBURSEMENT SETTLEMEMENT - ALL OTHER HEALTH SERVICES FOR TITLE XVIII PART A PPS SNF SERVICES
form instructions
E307 Worksheet E-3 PART VII *
CALCULATION OF REIMBURSEMENT - ALL OTHER HEALTH SERIVCES FOR TITLES V OR TITLE XIX SERVICES
form instructions
E400 Worksheet E-4
DIRECT GRADUATE MEDICAL EDUCATION (GME) & ESRD OUTPATIENT DIRECT MEDICAL EDUCATION COSTS
form instructions
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
form instructions
H000 Worksheet H
ANALYSIS OF PROVIDER-BASED HOME HEALTH AGENCY COSTS
form instructions
H101 Worksheet H-1 PART I *
COST ALLOCATION - HHA GENERAL SERVICE COST
form instructions
H102 Worksheet H-1 PART II *
COST ALLOCATION - HHA STATISTICAL BASIS
form instructions
H201 Worksheet H-2 PART I *
ALLOCATION OF GENERAL SERVICE COSTS TO HHA COST CENTERS
form instructions
H202 Worksheet H-2 PART II *
ALLOCATION OF GENERAL SERVICE COSTS TO HHA COST CENTERS STATISTICAL BASIS
form instructions
H300 Worksheet H-3 Parts I & II *
APPORTIONMENT OF PATIENT SERVICE COSTS
form instructions
H400 Worksheet H-4 Parts I & II *
CALCULATION OF HHA REIMBURSEMENT SETTLEMENT
form instructions
H500 Worksheet H-5 *
ANALYSIS OF PAYMENTS TO PROVIDER- BASED HHAs FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES
form instructions
I100 Worksheet I-1 *
ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS
form instructions
I200 Worksheet I-2 *
ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES
form instructions
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
form instructions
I500 Worksheet I-5 *
CALCULATION OF REIMBURSABLE BAD DEBTS - TITLE XVIII - PART B
form instructions
J101 Worksheet J-1 Part I *
ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTERS
form instructions
J102 Worksheet J-1 Part II *
ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTERS - STATISTICAL BASIS
form instructions
J201 Worksheet J-2 Part I *
COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS
form instructions
J202 Worksheet J-2 Part II *
COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS
form instructions
J300 Worksheet J-3 *
CALCULATION OF REIMBURSEMENT SETTLEMENT COMMUNITY MENTAL HEALTH CENTER PROVIDER SERVICES
form instructions
J400 Worksheet J-4 *
ANALYSIS OF PAYMENTS TO HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES
form instructions
K000 Worksheet K
ANALYSIS OF PROVIDER-BASED HOSPICE COSTS
form instructions
K100 Worksheet K-1
HOSICE COMPENSATION ANALYSIS SALARIES AND WAGES
form instructions
K200 Worksheet K-2
HOSPICE COMPENSATION ANALYSIS EMPLOYEE BENEFITS (PAYROLL RELATED)
form instructions
K300 Worksheet K-3
HOSPICE COMPENSATION ANALYSIS CONTRACTED SERVICES/PURCHASED SERVICES
form instructions
K401 Worksheet K-4 Part I
COST ALLOCATION - HOSPICE GENERAL SERVICE COST
form instructions
K402 Worksheet K-4 Part II
COST ALLOCATION - HOSPICE STATISTICAL BASIS
form instructions
K501 Worksheet K-5 Part I
ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS
form instructions
K502 Worksheet K-5 Part II
ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS
form instructions
K503 Worksheet K-5 Part III
APPORTIONMENT OF HOSPICE SHARED SERVICES
form instructions
K600 Worksheet K-6
CALCULATION OF HOSPICE PER DIEM COST
form instructions
L000 Worksheet L PARTS I, II & III
CALCULATION OF CAPITAL PAYMENT
form instructions
L101 Worksheet L-1 Part I *
ALLOCATION OF ALLOWABLE COSTS FOR EXTRAORDINARY CIRCUMSTANCES
form instructions
L102 Worksheet L-1 Part II *
COMPUTATION OF PROGRAM INPATIENT ROUTINE SERVICE CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES
form instructions
L103 Worksheet L-1 Part III *
COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES
form instructions
M100 Worksheet M-1
ANALYSIS OF PROVIDER-BASED RURAL HEALTH CLINIC/ FEDERALLY QUALIFIED HEALTH CENTER COSTS
form instructions
M200 Worksheet M-2
ALLOCATION OF OVERHEAD TO RHC/FQHC SERVICES
form instructions
M300 Worksheet M-3
CALCULATION OF REIMBURSEMENT SETTLEMENT FOR RHC/FQHC SERVICES
form instructions
M400 Worksheet M-4
COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA VACCINE COST
form instructions
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 PNEUMOCOCCAL AND INFLUENZA VACCINE COST
form instructions
N400 Worksheet N-4 *
CALCULATION OF HOSPITAL-BASED FQHC REIMBURSEMENT SETTLEMENT
form instructions
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
form instructions
O100 Worksheet O-1 *
HOSPICE CONTINUOUS HOME CARE
form instructions
O200 Worksheet O-2 *
HOSPICE ROUTINE HOME CARE
form instructions
O300 Worksheet O-3 *
HOSPICE INPATIENT RESPITE CARE
form instructions
O400 Worksheet O-4 *
HOSPICE GENERAL INPATIENT CARE
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
form instructions
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
form instructions
D04 Worksheet D, Part IV
Apportionment of Inpatient/Outpatient Ancillary Service Other Pass Through Costs
form instructions
D05 Worksheet D, Parts V & VI
Apportionment of Medical, Other Health Services Costs and Vaccine Cost
form instructions
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
form instructions
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
form instructions
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
form instructions
E0E Worksheet E, Part E
Calculation of Reimbursement Settlement - Other Outpatient Diagnostic Procedures
form instructions
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
form instructions
L00 Worksheet L
Calculation of Capital Payment
form instructions
M10 Worksheet M-1
Analysis of Provider-Based Rural Health Clinic / Federally Qualified Health Center Costs
form instructions
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
form instructions
M40 Worksheet M-4
Computation of Pneumococcal and Influenza Vaccine Cost
form instructions
M50 Worksheet M-5
Analysis of Payments to Hospital-Based RHC/FQHC Provider for Services Rendered to Program Beneficiaries
form instructions

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