SNFData - 495363 - 12/2016

FAIRMONT CROSSING
AMHERST, VA 24521

Medicare Provider Number: 495363

Cost report status: Settled Without Audit

[Record Code 1215921 - 2010]

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RECLASSIFICATIONS						Provider CCN: 495363		PERIOD: FROM 01/01/2016 TO 12/31/2016		WORKSHEET A-6
- Select other programs and provider types available
EXPLANATION OF RECLASSIFICATION(S)		CODE (1)	INCREASE				DECREASE
		CODE (1)	COST CENTER	LN NO.	SALARY	NON SALARY	COST CENTER	LN NO.	SALARY	NON SALARY
		1	2	3	4	5	6	7	8	9
1											1
2											2
3											3
4											4
5											5
6											6
7											7
8											8
9											9
10											10
11											11
12											12
13											13
14											14
15											15
16											16
17											17
18											18
19											19
20											20
21											21
22											22
23											23
24											24
25											25
26											26
27											27
28											28
29											29
30											30
31											31
32											32
33											33
34											34
35											35
100	TOTAL RECLASSIFICATIONS (Sum of columns 4 and 5 must equal sum of columns 8 and 9 (2)					###				###	100
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry. (2) Transfer the amounts in columns 4, 5, 8 and 9 to Worksheet A, column 4, lines as appropriate.
FORM CMS-2540-10 (09/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4114)
41-318										Rev. 2

Worksheet A-6