SNFData - 025018 - 12/2013 - Worksheet A-8-2

PROVIDENCE TRANSITIONAL CARE CENTER
ANCHORAGE, AK 99503

Medicare Provider Number: 025018

Cost report status: Settled Without Audit

[Record Code 1074617 - 2010]

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PROVIDER - BASED PHYSICIAN ADJUSTMENTS												Provider CCN: 025018		PERIOD: FROM 01/01/2013 TO 12/31/2013		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