Worksheet B-1

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THE FORUM AT TUCSON
TUCSON, AZ  85712-

Medicare Provider Number: 035199
Cost report status: Settled Without Audit
[Record Code 236504 - 1996]
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COST ALLOCATION - GENERAL SERVICE COSTS
PROVIDER NO:
035199
PERIOD:
FROM 01/01/2004
TO 12/31/2004
 WORKSHEET B - I  
COST CENTER
(Omit Cents)
  
CAP. REL.
BUILDINGS
& FIXTURES
(Square
Feet)
CAP. REL.
MOVABLE
EQUIPMENT
(Square
Feet)
EMPLOYEE
BENEFITS
(Gross
Salaries)
RECONCIL-
IATION
ADMINIS-
TRATIVE
& GENERAL
(Accumulated
Cost)
PLANT OPER.
MAINTENANCE
& REPAIRS
(Square
Feet)
LAUNDRY
& LINEN
SERVICE
(Pounds of
Laundry)
HOUSE
KEEPING
(Hours of
Service)
DIETARY
(Meals
Served)
NURSING
ADMINIS-
TRATION
(Direct
Nursing Hrs.)
CENTRAL
SERVICES
& SUPPLY
(Costed
Requisitions)
PHARMACY
(Costed
Requisitions)
MEDICAL
RECORDS
& LIBRARY
(Time
Spent)
SOCIAL
SERVICE
(Time
Spent)
INTERNS &
RESIDENTS
(Assigned
Time)
OTHER
GENERAL
SERVICE
COST
SUBTOTAL
POST
STEPDOWN
ADJUSTMENTS
TOTAL
  
    0 1 2 3 4A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
  GENERAL SERVICE COST CENTERS                                      
1 Capital-Related Costs - Building & Fixture                                       1
2 Capital-Related Costs - Movable Equipment                                     2
3 Employee Benefits                                   3
4 Administrative and General                               4
5 Plant Operation, Maintenance and Repairs                             5
6 Laundry and Linen Service                           6
7 Housekeeping                         7
8 Dietary                       8
9 Nursing Administration                     9
10 Central Services and Supply                   10
11 Pharmacy                 11
12 Medical Records and Library               12
13 Social Service             13
14 Intern & Residents (Approved Teaching Program)           14
15 Other General Service Cost         15
  INPATIENT ROUTINE SERVICE COST CENTERS                                      
16 Skilled Nursing Facility   ### ### ### ### ### ### ### ### ### ### ### ###     16
17                                         17
18 Nursing Facility       18
18.1 Intermediate Care Facility/ Mentally Retarded       18.1
19 Other Long Term Care       19
20 Other Inpatient Routine Services       20
  ANCILLARY SERVICE COST CENTERS                                      
21 Radiology       21
22 Laboratory       22
23 Intravenous Therapy       23
24 Oxygen (Inhalation) Therapy       24
25 Physical Therapy       25
26 Occupational Therapy       26
27 Speech Pathology       27
28 Electrocardiology       28
29 Medical Supplies Charged to Patients       29
30 Drugs Charged to Patients       30
31 Dental Care - Title XIX only       31
32 Support Surfaces       32
33 Other Ancillary Service Cost       33
  OUTPATIENT SERVICE COST CENTERS                                      
34 Clinic           34
35 R H C       35
36 Other Outpatient Service Cost       36
  OTHER REIMBURSABLE COST CENTERS                                      
37 Administrative and General - HHA       37
38 Skilled Nursing Care - HHA       38
39 Physical Therapy - HHA       39
40 Occupational Therapy - HHA       40
41 Speech Pathology - HHA       41
42 Medical Social Services - HHA       42
43 Home Health Aide - HHA       43
44 Durable Medical Equipment - Rented - HHA       44
45 Durable Medical Equipment - Sold - HHA       45
46 Home Delivered Meals - HHA       46
47 Other Home Health Services - HHA       47
48 Ambulance       48
49 Interns and Residents (Not in Approved Teaching Program)       49
50 Outpatient Rehabilitation Provider       50
51 Other Reimbursable Cost       51
  SPECIAL PURPOSE COST CENTERS                                      
55 Hospice       55
56 Other Special Purpose Cost       56
57 Subtotals       57
  NON REIMBURSABLE COST CENTERS                                      
58 Gift, Flower, Coffee Shops and Canteen       58
59 Barber and Beauty Shop       59
60 Physicians' Private Offices       60
61 Nonpaid Workers       61
62 Patients Laundry       62
63 Other Non Reimbursable Cost       63
64 Cross Foot Adjustments                                       64
65 Negative Cost left                                       65
66 Cost to be Allocated (Per Wkst. B, Part I)         66
67 Unit Cost Multiplier (Wkst. B, Part I)         67
68 Cost to be Allocated (Per Wkst. B, Part II)             68
69 Unit Cost Multiplier (Wkst. B, Part II)             69