Worksheet G-2, Part I
- Return to Cost Report Summary
- Form G201
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
SUNSET ESTATES OF EL RENO
EL RENO, OK 73036-
EL RENO, OK 73036-
Medicare Provider Number: 375448
Cost report status: Settled Without Audit
[Record Code 229248 - 1996]
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STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES PART I - PATIENT REVENUES | PROVIDER NO: 375448 |
PERIOD: FROM 01/01/2004 TO 12/31/2004 |
WORKSHEET G2 PART I |
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PART I - PATIENT REVENUES | |||||
Revenue Center | INPATIENT | OUTPATIENT | TOTAL | ||
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 |