Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

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Overview

EPage1&2
E-1

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Sheet 1: EPage1&2

08-05					FORM CMS 287-05						3990 (Cont.)
DIRECT ALLOCATION OF HOME OFFICE CAPITAL				Home Office:		Period
COSTS TO CHAIN COMPONENTS						From:____________________			SCHEDULE
						To:______________________			E Page 1
			Old Capital		New Capital			Other Capital
	Chain Components		Building		Building
		Medicare	and	Movable	and	Movable			Other	Total
		No.	Fixtures	Equipment	Fixtures	Equipment	Insurance	Taxes	Capital	(cols. 1 thru 7)
			1	2	3	4	5	6	7	8
	Health Care Facilities:
1.											1
2.											2
3.											3
4.											4
5.											5
6.											6
7.											7
8.											8
9.											9
10.											10
11.											11
12.											12
13.											13
14.											14
15.											15
16.											16
17											17
18	Total (sum of lines 1-17)										18
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3913)
Rev. 1											39-115
3990 (Cont.)					FORM CMS 287-05						08-05
DIRECT ALLOCATION OF HOME OFFICE CAPITAL				Home Office:		Period
COSTS TO CHAIN COMPONENTS						From:____________________			SCHEDULE
						To:______________________			E Page 2
			Old Capital		New Capital			Other Capital
	Chain Components		Building		Building
		Medicare	and	Movable	and	Movable			Other	Total
		No.	Fixtures	Equipment	Fixtures	Equipment	Insurance	Taxes	Capital	(cols. 1 thru 7)
			1	2	3	4	5	6	7	8
	Other Components:
	-------------------------
19											19
20											20
21											21
22											22
23											23
24											24
25											25
26											26
27	Other Managed Facilities										27
28	Total (sum of lines 19-27)										28
	Regional Offices:
	-------------------------
29											29
30											30
31											31
32											32
33	Total (sum of lines 29-32)										33
34	Grand Total (sum of lines 18, 28 and 33)										34
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3913)
39-116											Rev. 1

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Sheet 2: E-1

08-05						FORM CMS 287-05							3990 (Cont.)
DIRECT ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS							From:______________________________					SCHEDULE
							To:________________________________					E-1
			Specify:
Chain Components
		Medicare										Total
		No.										(cols. 1 thru 9)
			1	2	3	4	5	6	7	8	9	10
	Health Care Facilities:
	---------------------------
1.													1
2.													2
3.													3
4.													4
5.													5
6.													6
7.													7
8.													8
9.													9
10.													10
11.													11
12.													12
13.													13
14.													14
15.													15
16.													16
17.													17
18	Total (sum of lines 1-17)												18
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3914)
Rev. 1													39-117
3990 (Cont.)						FORM CMS 287-05							08-05
DIRECT ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS							From:______________________________					SCHEDULE
							To:________________________________					E-1 (Cont'd)
			Specify:
Chain Components
		Medicare										Total
		No.										(cols. 1 thru 9)
			1	2	3	4	5	6	7	8	9	10
	Other Components:
	---------------------------
19													19
20													20
21													21
22													22
23													23
24													24
25													25
26													26
27	Other Managed Facilities												27
28	Total (sum of lines 19-27)												28
	Regional Offices:
	---------------------
29													29
30													30
31													31
32													32
33	Total (sum of lines 29-32)												33
34	Grand Total (sum of lines 18, 28 and 33)												34
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3914)
39-118													Rev. 1