SNFData - 125045 - 03/2022 - Worksheet A-8-2

HALE ANUENUE RESTORATIVE CARE CENTER
HILO, HI 96720

Medicare Provider Number: 125045

Cost report status: Settled Without Audit

[Record Code 1331156 - 2010]

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PROVIDER - BASED PHYSICIAN ADJUSTMENTS												Provider CCN: 125045		PERIOD: FROM 04/01/2021 TO 03/31/2022		WORKSHEET A-8-2
	Wkst. A Line No.	Cost Center / Physician Identifier	Total Remuneration	Professional Component	Provider Component	R C E Amount	Physician / Provider Component Hours	Unadjusted R C E Limit	5 Percent of Unadjusted R C E Limit	Cost of Memberships & Continuing Education	Provider Component Share of Col. 12	Physician Cost of Malpractice Insurance	Provider Component Share of Col. 14	Adjusted R C E Limit	R C E Disallowance	Adjustment
	1	2	3	4	5	6	7	8	9	12	13	14	15	16	17	18
1	###	###				###											1
2	###	###				###											2
3	###	###				###											3
4	###	###				###											4
5																	5
6																	6
7																	7
8																	8
9																	9
10																	10
11																	11
12																	12
100		TOTAL															100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4118)
08-16																Rev. 7