SNFData - 465163 - 06/2010 - Worksheet G-2, Part I

NORTH CANYON CARE CENTER
BOUNTIFUL, UT 84010

Medicare Provider Number: 465163

Cost report status: Settled Without Audit

[Record Code 418723 - 1996]

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STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES PART I - PATIENT REVENUES		PROVIDER NO: 465163	PERIOD: FROM 07/01/2009 TO 06/30/2010	WORKSHEET G2 PART I
PART I - PATIENT REVENUES
Revenue Center		INPATIENT	OUTPATIENT	TOTAL
Revenue Center		1	2	3
GENERAL INPATIENT ROUTINE CARE SERVICES
1	Skilled Nursing Facility	###		###	1
2					2
3	Nursing facility				3
4	Other long term care				4
5	Total general inpatient care services (Sum of lines 1 - 4)	###		###	5
All Other Care Service
6	Ancillary services	###		###	6
7	Clinic				7
8	Home health agency				8
9					9
10	Ambulance				10
11	Hospice				11
12	Outpatient Rehabilitation Provider				12
13					13
14	Total Patient Revenues (Sum of lines 5 - 13; Transfer column 3 to Worksheet G-3, Line 1)	###		###	14
PART II - OPERATING EXPENSES			1	2
1	Operating Expenses (Per Worksheet A, Col. 3, Line 75)			###	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) (Transfer to Worksheet G-3, Line 4)			###	15