Worksheet A-8-1
- Return to Cost Report Summary
- Form A810
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1
DIVERSICARE OF ST. THERESA
CINCINATTI, OH 45227
CINCINATTI, OH 45227
Medicare Provider Number: 365946
Cost report status: Settled Without Audit
[Record Code 1169384 - 2010]
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STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME OFFICE COSTS |
Provider CCN: 365946 | PERIOD: FROM 01/01/2016 TO 12/31/2016 |
WORKSHEET A-8-1 | ||||
| PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS | |||||||
| Line No. | Cost Center | Expense Items | Amount Allowable In Cost | Amount Included in Wkst. A., col. 5 | Adjustments ( col. 4 minus col. 5 ) | ||
| 1 | 2 | 3 | 4 | 5 | 6 | ||
| 1 | ### | ### | ### | ### | ### | ### | 1 |
| 2 | ### | ### | ### | ### | ### | ### | 2 |
| 3 | ### | ### | ### | ### | ### | 3 | |
| 4 | ### | ### | ### | ### | ### | 4 | |
| 5 | 5 | ||||||
| 6 | 6 | ||||||
| 7 | 7 | ||||||
| 8 | 8 | ||||||
| 9 | 9 | ||||||
| 10 | TOTALS (sum of lines 1-9) (Transfer column 6, line 10 to Wkst. A-8, col. 3, line 12) | ### | ### | ### | 10 | ||
| PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND / OR HOME OFFICE | |||||||
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish the information requested under Part II of this worksheet. This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that the costs applicable to services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII. |
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| (1) Symbol | Name | Percentage of Ownership | Related Organization(s) | ||||
| Name | Percentage of Ownership | Type of Business | |||||
| 1 | 2 | 3 | 4 | 5 | 6 | ||
| 1 | ### | ### | ### | ### | 1 | ||
| 2 | ### | ### | ### | ### | 2 | ||
| 3 | ### | ### | ### | ### | 3 | ||
| 4 | ### | ### | ### | ### | 4 | ||
| 5 | ### | ### | ### | ### | 5 | ||
| 6 | 6 | ||||||
| 7 | 7 | ||||||
| 8 | 8 | ||||||
| 9 | 9 | ||||||
| 10 | 10 | ||||||
| (1) Use the followings symbols to indicate interrelationship to related organizations: | |||||||
A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider. B. Corporation, partnership or other organization has financial interest in provider. C. Provider has financial interest in corporation, partnership, or other organization. D. Director, officer, administrator or key person of provider or organization. |
E. Individual is director, officer, administrator or key person of provider and related organization. F. Director, officer, administrator or key person of related organization or relative of such person has financial interest in provider. G. Other (financial or non-financial) specify ______________________ _____________________________________________________ |
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| FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4117) | |||||||
| Rev. 7 | 08-16 | ||||||