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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 SNFdata.com have been marked with an asterisk.

[-] 2010 Format

S001 Worksheet S Parts I, II & III *
Certification and Settlement Summary		 form instructions
S201 Worksheet S-2 Part I
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Idenfitication Data		 form instructions
S202 Worksheet S-2 Part II
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Reimbursement Questionnaire		 form instructions
S301 Worksheet S-3 Part I
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Statistical Data		 form instructions
S302 Worksheet S-3 Parts II and III
SNF Wage Index Information		 form instructions
S304 Worksheet S-3 Part IV
SNF Wage Related Costs		 form instructions
S305 Worksheet S-3 Part V
SNF Reporting of Direct Care Expenditures		 form instructions
S400 Worksheet S-4
SNF-Based Home Health Agency Statistical Data		 form instructions
S500 Worksheet S-5 *
SNF-based Rural Health Clinic Federally Qualified Health Center Statistical Data		 form instructions
S600 Worksheet S-6 *
SNF-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 *
Hospice Identification Data		 form instructions
A000 Worksheet A
Reclassification and Adjustment of Trial Balance of Expenses		 form instructions
A600 Worksheet A-6
Reclassifications		 form instructions
A700 Worksheet A-7
Analysis of Changes During Cost Reporting Period in Capital Asset Balances		 form instructions
A800 Worksheet A-8
Adjustments to Expenses		 form instructions
A810 Worksheet A-8-1
Statement of Costs of Services From Related Organizations and Home Office Cost		 form instructions
A820 Worksheet A-8-2
Provider-Based Physicians Adjustments		 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 Step Down Adjustments		 form instructions
C000 Worksheet C
Ratio of Cost to Charges for Ancillary and Outpatient Cost Centers		 form instructions
D001 Worksheet D Part I
Apportionment of Ancillary and Outpatient Cost		 form instructions
D002 Worksheet D Parts II & III
Apportionment of Ancillary and Outpatient Cost		 form instructions
D101 Worksheet D-1 Parts I & II *
Computation of Inpatient Routine Costs		 form instructions
E001 Worksheet E Part I
Calculation of Reimbursement Settlement Title XVIII		 form instructions
E002 Worksheet E Part II *
Calculation of Reimbursement Settlement for Title V and Title XIX Only		 form instructions
E100 Worksheet E-1 *
Analysis of Payments to Providers for Services Rendered		 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
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 SNF-based Rural Health Clinic / Federally Qualified Health Center Costs		 form instructions
I200 Worksheet I-2 *
Allocation of Overhead to RHC / FQHC Services		 form instructions
I300 Worksheet I-3 *
Calculation of Reimbursement Settlement for RHC / FQHC Services		 form instructions
I400 Worksheet I-4 *
Computation of Pneumococcal and Influenza Vaccine Cost		 form instructions
I500 Worksheet I-5 *
Analysis of Payments to SNF-based Rural Health Clinic and Federally Qualified Health Centers		 form instructions
J101 Worksheet J-1 Part I *
Allocation of General Service Costs to Cost Centers for CMHC		 form instructions
J102 Worksheet J-1 Part II *
Allocation of General Service Costs to Cost Centers for CMHC		 form instructions
J201 Worksheet J-2 Part I *
Computation of CMHC Rehabilitation Costs		 form instructions
J202 Worksheet J-2 Part II *
Apportionment of Cost of CMHC Services Furnished by Shared Departments		 form instructions
J300 Worksheet J-3 *
Calculation of Reimbursement Settlement of Community Mental Health Center Provider Services		 form instructions
J400 Worksheet J-4 *
Analysis of Payments to Provider-based CMHC for Services Rendered to Program Beneficiaries		 form instructions
K000 Worksheet K *
Analysis of Provider-based Hospice Costs		 form instructions
K100 Worksheet K-1 *
Hospice 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 Per Diem Cost		 form instructions
O000 Worksheet O *
Analysis of SNF-based Hospice Costs		 form instructions
O100 Worksheet O-1 *
Analysis of SNF-based Hospice Costs Hospice Continuous Home Care		 form instructions
O200 Worksheet O-2 *
Analysis of SNF-based Hospice Costs Hospice Routine Home Care		 form instructions
O300 Worksheet O-3 *
Analysis of SNF-based Hospice Costs Hospice Inpatient Respite Care		 form instructions
O400 Worksheet O-4 *
Analysis of SNF-based Hospice Costs Hospice General Inpatient Care		 form instructions
O500 Worksheet O-5 *
Cost Allocation - Determination of SNF-based Hospice Net Expenses for Allocation		 form instructions
O601 Worksheet O-6 Part I *
Cost Allocation - SNF-based Hospice General Service Costs		 form instructions
O602 Worksheet O-6 Part II *
Cost Allocation - SNF-based Hospice General Service Cost Statistical Basis		 form instructions
O700 Worksheet O-7 *
Apportionment of SNF-based Hospice Shared Service Costs by Level of Care		 form instructions
O800 Worksheet O-8 *
Calculation of SNF-based Hospice Per Diem Cost		 form instructions

[+] 1996 Format

S200 Worksheet S-2
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Identification Data		 form instructions
S301 Worksheet S-3, Part I
Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Statistical Data		 form instructions
S302 Worksheet S-3, Parts II and III
SNF Wage Index Information		 form instructions
S701 Worksheet S-7, Part I
NHCMQ Demonstration Statistical Data		 form instructions
S702 Worksheet S-7, Part II
PPS Statistical Data		 form instructions
S703 Worksheet S-7, Part III
PPS Statistical Data		 form instructions
S704 Worksheet S-7, Part IV
Prospective Payment for SNF Statistical Data		 form instructions
A000 Worksheet A
Reclassification and Adjustment of Trial Balance of Expenses		 form instructions
A700 Worksheet A-7
Analysis of Changes During Cost Reporting Period in Capital Asset Balances		 form instructions
A800 Worksheet A-8
Adjustments to Expenses		 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 - General Service Costs		 form instructions
C000 Worksheet C
Ratio of Cost to Charges for Ancillary Outpatient Cost Centers		 form instructions
D001 Worksheet D, Part I
Apportionment of Ancillary and Outpatient Cost and Reduction of Therapy Cost		 form instructions
D002 Worksheet D, Part II
Apportionment of Vaccine Cost and Costs for Interns and Residents		 form instructions
E003 Worksheet E, Part III
Calculation of Reimbursement Settlement - SNF Reimbursement Under PPS		 form instructions
G000 Worksheet G
Balance Sheet		 form instructions
G201 Worksheet G-2, Part I
Statement of Patient Revenues and Operating Expenses		 form instructions
G300 Worksheet G-3
Statement of Revenues and Expenses		 form instructions