Worksheet G-2
- Return to Cost Report Summary
- Form G200
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
BENNETT HEALTHCARE LLC
GOODING, ID 83330
GOODING, ID 83330
Medicare Provider Number: 135134
Cost report status: As Submitted
[Record Code 1382400 - 2010]
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STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES | Provider CCN: 135134 | PERIOD: FROM 01/01/2023 TO 12/31/2023 |
WORKSHEET G - 2 PARTS I & II | ||
PART I - PATIENT REVENUES | |||||
Revenue Center | INPATIENT | OUTPATIENT | TOTAL | ||
1 | 2 | 3 | |||
General Inpatient Routine Care Services | |||||
1 | Skilled nursing facility | ### | ### | 1 | |
2 | Nursing facility | 2 | |||
3 | ICF/IID | 3 | |||
4 | Other long term care | 4 | |||
5 | Total general inpatient care services | ### | ### | 5 | |
(sum of lines 1 - 4) | |||||
All Other Care Service | |||||
6 | Ancillary services | ### | ### | 6 | |
7 | Clinic | 7 | |||
8 | Home health agency | 8 | |||
9 | Ambulance | 9 | |||
10 | RHC/FQHC | 10 | |||
11 | CMHC | 11 | |||
12 | Hospice | 12 | |||
13 | Other (specify) | 13 | |||
14 | Total patient revenues (sum of lines 5 - 13) (transfer to Wkst. G-3, col. 3, line 1 ) | ### | ### | 14 | |
PART II - OPERATING EXPENSES | |||||
1 | Operating Expenses (per Wkst. A, col. 3, line 100) | ### | 1 | ||
2 | Add ( Specify ) | 2 | |||
3 | 3 | ||||
4 | 4 | ||||
5 | 5 | ||||
6 | 6 | ||||
7 | 7 | ||||
8 | Total Additions (sum of lines 2 - 7) | 8 | |||
9 | Deduct (Specify) | 9 | |||
10 | 10 | ||||
11 | 11 | ||||
12 | 12 | ||||
13 | 13 | ||||
14 | Total Deductions (sum of lines 9 - 13) | 14 | |||
15 | Total Operating Expenses (sum of lines 1 and 8, minus line 14) | ### | 15 | ||
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140) | |||||
08-16 | Rev. 7 |