Hospitals and Health Care Complex Cost Report (CMS-2552-96)

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Overview

G
G1
G2
G3

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Sheet 1: G

4090 (Cont.)		FORM CMS-2552-10				DRAFT
BALANCE SHEET			PROVIDER NO.:	PERIOD:	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type				FROM ________
accounting records, complete the General Fund column only)			______________	TO ___________
			Specific
	Assets	General	Purpose	Endowment	Plant
	(Omit cents)	Fund	Fund	Fund	Fund
		1	2	3	4
	CURRENT ASSETS
1	Cash on hand and in banks					1
2	Temporary investments					2
3	Notes receivable					3
4	Accounts receivable					4
5	Other receivables					5
6	Allowances for uncollectible notes and					6
	accounts receivable
7	Inventory					7
8	Prepaid expenses					8
9	Other current assets					9
10	Due from other funds					10
11	Total current assets (sum of lines 1-10)					11
	FIXED ASSETS
12	Land					12
13	Land improvements					13
14	Accumulated depreciation					14
15	Buildings					15
16	Accumulated depreciation					16
17	Leasehold improvements					17
18	Accumulated depreciation					18
19	Fixed equipment					19
20	Accumulated depreciation					20
21	Automobiles and trucks					21
22	Accumulated depreciation					22
23	Major movable equipment					23
24	Accumulated depreciation					24
25	Minor equipment depreciable					25
26	Accumulated depreciation					26
27	HIT designated Assets					27
28	Accumulated depreciation					28
29	Minor equipment-nondepreciable					29
30	Total fixed assets (sum of lines 12-29)					30
	OTHER ASSETS
31	Investments					31
32	Deposits on leases					32
33	Due from owners/officers					33
34	Other assets					34
35	Total other assets (sum of lines 31-34)					35
36	Total assets (sum of lines 11, 30, and 35)					36
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4040)
40-600						Rev. 1
DRAFT		FORM CMS-2552-10				4090 (Cont.)
BALANCE SHEET			PROVIDER NO.:	PERIOD:	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type				FROM ________	(CONT.)
accounting records, complete the General Fund column only)			______________	TO ___________
	Liabilities and Fund		Specific
	Balances	General	Purpose	Endowment	Plant
	(Omit cents)	Fund	Fund	Fund	Fund
		1	2	3	4
	CURRENT LIABILITIES
37	Accounts payable					37
38	Salaries, wages, and fees payable					38
39	Payroll taxes payable					39
40	Notes and loans payable (short term)					40
41	Deferred income					41
42	Accelerated payments					42
43	Due to other funds					43
44	Other current liabilities					44
45	Total current liabilities (sum of					45
	lines 37 thru 44)
	LONG TERM LIABILITIES
46	Mortgage payable					46
47	Notes payable					47
48	Unsecured loans					48
49	Other long term liabilities					49
50	Total long term liabilities (sum of					50
	lines 46 thru 49)
51	Total liabilities (sum of lines 45 and 50)					51
	CAPITAL ACCOUNTS
52	General fund balance					52
53	Specific purpose fund					53
54	Donor created - endowment fund					54
	balance - restricted
55	Donor created - endowment fund					55
	balance - unrestricted
56	Governing body created - endowment					56
	fund balance
57	Plant fund balance - invested in plant					57
58	Plant fund balance - reserve for plant					58
	improvement, replacement, and expansion
59	Total fund balances (sum of lines 52 thru 58)					59
60	Total liabilities and fund balances (sum of					60
	lines 51 and 59)
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4040)
Rev. 1						40-601

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Sheet 2: G1

4090 (Cont.)			FORM CMS-2552-10							4090 (Cont.)
STATEMENT OF CHANGES IN FUND BALANCES					PROVIDER NO.:		PERIOD:		WORKSHEET G-1
							FROM _________
					______________		TO ___________
		GENERAL FUND		SPECIFIC PURPOSE FUND		ENDOWMENT FUND		PLANT FUND
		1	2	3	4	5	6	7	8
1	Fund balances at beginning of period									1
2	Net income (loss) (from Wkst. G-3, line 31)									2
3	Total (sum of line 1 and line 2)									3
4	Additions (credit adjustments) (specify)									4
5										5
6										6
7										7
8										8
9										9
10	Total additions (sum of lines 4-9)									10
11	Subtotal (line 3 plus line 10)									11
12	Deductions (debit adjustments) (specify)									12
13										13
14										14
15										15
16										16
17										17
18	Total deductions (sum of lines 12-17)									18
19	Fund balance at end of period per balance									19
	sheet (line 11 minus line 18)
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4040)
40-602										Rev. 1

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Sheet 3: G2

DRAFT		FORM CMS-2552-10				4090 (Cont.)
STATEMENT OF PATIENT REVENUES			PROVIDER NO.:	PERIOD:	WORKSHEET G-2,
AND OPERATING EXPENSES				FROM _________	PARTS I & II
			______________	TO ___________
PART I - PATIENT REVENUES
			INPATIENT	OUTPATIENT	TOTAL
	REVENUE CENTER
			1	2	3
	GENERAL INPATIENT ROUTINE CARE SERVICES
1	Hospital					1
2	Subprovider IPF					2
3	Subprovider IRF					3
4	Subprovider (Other)					4
5	Swing bed - SNF					5
6	Swing bed - NF					6
7	Skilled nursing facility					7
8	Nursing facility					8
9	Other long term care					9
10	Total general inpatient care services (sum of lines 1-9)					10
	INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES
11	Intensive care unit					11
12	Coronary care unit					12
13	Burn intensive care unit					13
14	Surgical intensive care unit					14
15	Other special care (specify)					15
16	Total intensive care type inpatient hospital services (sum of					16
	of lines 11-15)
17	Total inpatient routine care services (sum of lines 10 and 16)					17
18	Ancillary services					18
19	Outpatient services					19
20	Home health agency					20
21	Ambulance					21
22	Outpatient rehabilitation providers					22
23	ASC					23
24	Hospice					24
25	Other (specify)					25
26	Total patient revenues (sum of lines 17-25) (transfer column 3 to					26
	Wkst. G-3, line 1)
PART II - OPERATING EXPENSES
				1	2
27	Operating expenses (per Wkst. A, column 3, line 200)					27
28	Add (specify)					28
29						29
30						30
31						31
32						32
33						33
34	Total additions (sum of lines 28-33)					34
35	Deduct (specify)					35
36						36
37						37
38						38
39						39
40	Total deductions (sum of lines 35-39)					40
41	Total operating expenses (sum of lines 27 and 34 minus line 40) (transfer to Wkst. G-3, line 4)					41
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4040)
Rev. 1						40-603

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Sheet 4: G3

4090 (Cont.)		FORM CMS-2552-10			DRAFT
STATEMENT OF REVENUES		PROVIDER NO.:	PERIOD:	WORKSHEET G-3
AND EXPENSES			FROM _________
		______________	TO ___________
	Description
1	Total patient revenues (from Wkst. G-2, Part I, column 3, line 26)				1
2	Less contractual allowances and discounts on patients' accounts				2
3	Net patient revenues (line 1 minus line 2)				3
4	Less total operating expenses (from Wkst. G-2, Part II, line 41)				4
5	Net income from service to patients (line 3 minus line 4)				5
	OTHER INCOME
6	Contributions, donations, bequests, etc				6
7	Income from investments				7
8	Revenues from telephone and telegraph service				8
9	Revenue from television and radio service				9
10	Purchase discounts				10
11	Rebates and refunds of expenses				11
12	Parking lot receipts				12
13	Revenue from laundry and linen service				13
14	Revenue from meals sold to employees and guests				14
15	Revenue from rental of living quarters				15
16	Revenue from sale of medical and surgical supplies to other than patients				16
17	Revenue from sale of drugs to other than patients				17
18	Revenue from sale of medical records and abstracts				18
19	Tuition (fees, sale of textbooks, uniforms, etc.)				19
20	Revenue from gifts, flowers, coffee shops, and canteen				20
21	Rental of vending machines				21
22	Rental of hospital space				22
23	Governmental appropriations				23
24	Other (specify)				24
25	Total other income (sum of lines 6-24)				25
26	Total (line 5 plus line 25)				26
27	Other expenses (specify)				27
28	Total other expenses (sum of lines 26-27)				28
29	Net income (or loss) for the period (line 26 minus line 28)				29
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4040)
40-604					Rev. 1