SNFData - 495363 - 12/2016 - Worksheet A-8-1

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Form A810
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1

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FAIRMONT CROSSING
AMHERST, VA 24521

Medicare Provider Number: 495363

Cost report status: Settled Without Audit

[Record Code 1215921 - 2010]

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STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME OFFICE COSTS				Provider CCN: 495363	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.
	(1) Symbol	Name	Percentage of Ownership	Related Organization(s)
	(1) Symbol	Name	Percentage of Ownership	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 ______________________ _____________________________________________________
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4117)
Rev. 7						08-16