Worksheet G-3
- Return to Cost Report Summary
- Form G300
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
SPRINGDALE VILLAGE HEALTH CARE
MESA, AZ 85208
MESA, AZ 85208
Medicare Provider Number: 035207
Cost report status: Settled Without Audit
[Record Code 403534 - 1996]
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| STATEMENT OF REVENUES AND EXPENSES | PROVIDER NO: 035207 |
PERIOD: FROM 01/01/2009 TO 12/31/2009 |
WORKSHEET G - 3 |
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| 1 | Total patient revenues (From Wkst. G - 2, Part I, col. 3, line 14) | ### | 1 | ||
| 2 | Less: contractual allowances and discounts on patients accounts | ### | 2 | ||
| 3 | Net patient revenues (Line 1 minus line 2) | ### | 3 | ||
| 4 | Less: total operating expenses (From Worksheet G-2, Part II, line 15) | ### | 4 | ||
| 5 | Net income from service to patients (Line 3 minus 4) | ### | 5 | ||
| 6 | Other income: | 6 | |||
| 7 | Contributions, donations, bequests, etc | 7 | |||
| 8 | Income from investments | 8 | |||
| 9 | Revenues from telephone and telegraph service | 9 | |||
| 10 | Revenue from television and radio service | 10 | |||
| 11 | Purchase discounts | 11 | |||
| 12 | Rebates and refunds of expenses | 12 | |||
| 13 | Parking lot receipts | 13 | |||
| 14 | Revenue from laundry and linen service | 14 | |||
| 15 | Revenue from meals sold to employees and guests | 15 | |||
| 16 | Revenue from rental of living quarters | 16 | |||
| 17 | Revenue from sale of medical and surgical supplies to other than patients | 17 | |||
| 18 | Revenue from sale of drugs to other than patients | 18 | |||
| 19 | Revenue from sale of medical records and abstracts | 19 | |||
| 20 | Tuition (fees, sale of textbooks, uniforms, etc.) | 20 | |||
| 21 | Revenue from gifts, flower, coffee shops, canteen | 21 | |||
| 22 | Rental of vending machines | 22 | |||
| 23 | Rental of skilled nursing space | 23 | |||
| 24 | Governmental appropriations | 24 | |||
| 25 | DIETARY REVENUE | ### | 25 | ||
| 25.01 | BARBER AND BEAUTY | ### | 25.01 | ||
| 25.02 | LAUNDRY INCOME | ### | 25.02 | ||
| 25.03 | TRANSPORTATION | ### | 25.03 | ||
| 25.04 | INTEREST INCOME | ### | 25.04 | ||
| 25.05 | MISCELLANEOUS INCOME | ### | 25.05 | ||
| 25.07 | BEDHOLD | ### | 25.07 | ||
| 25.08 | PHYSICIAN REVENUE | ### | 25.08 | ||
| 25.09 | GERI-PRO INCOME | ### | 25.09 | ||
| 26 | Total other income (Sum of lines 7 - 25) | ### | 26 | ||
| 27 | Total (Line 5 plus line 26) | ### | 27 | ||
| 28 | Other expenses (specify) | 28 | |||
| 29 | 29 | ||||
| 30 | 30 | ||||
| 31 | Total other expenses (Sum of lines 28 - 30) | 31 | |||
| 32 | Net income (or loss) for the period (Line 27 minus line 31) | ### | 32 | ||