CMS-287-05 Home Office Cost Statement

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Overview

A1
A2
A3
B
B-1
B-2, PARTS I&II
B-2, Part III
C
D-1
D-2
E
E-1
F PART I
F PART II
F-1, PART I
F-1, PART II
G
I
J

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Sheet 1: A1

08-05				FORM CMS-287-05					3990 (Cont.)
This report is required by law (42 USC 1395g: 42 CFR 413.20(b)).								FORM APPROVED
Failure to report can result in all interim payments made since								OMB NO. 0938-0202
the beginning of the cost report period being deemed overpayments
(42 USC 1395g).
HOME OFFICE COST			Designated Intermediary Use Only				Date Received:		SCHEDULE
STATEMENT				Desk Reviewed					A
				Audited			Intermediary No.		page 1 of 3
GENERAL INFORMATION, CERTIFICATION AND LISTING OF CHAIN COMPONENTS
Part I - General Information
l. Home Office Name:						2. No. Assigned by Designated Intermediary:
						2.01 No. Assigned by CMS:
3. Home Office Address:						4. Chain Operations
						Started On:
5. Contact Person						6. Cost Statement Period:
Name:						From:
Title:						To:
Phone:						7. Was Audited Financial Data used on
						Schedule B?		[ ] Yes [ ] No
8. Type of Chain Organization (check applicable item)
a) voluntary non-profit					b) proprietary/investor-owned			c) governmental
		Church affiliated				Individual			Federal
		Community				Partnership			State
		Private				Corporation			County
		Charitable				Other (specify)			City
		Other (specify)							District
									Other(specify)
9. Key Officers of Home Office (attach listing if necessary)
President
Vice President(s)
Secretary
Treasurer
Controller
Others(specify)
Part II--Certification of Officer of Home Office
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE
BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE,
IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY
OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR
IMPRISONMENT MAY RESULT.
		CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying statement of allowable
Home Office costs (and equity capital if applicable), the allocation thereof to the chain components, and the other supporting
schedules for the period beginning _______, 20__, and ending ____________, 20__. To the best of my knowledge and belief,
they are true and correct statements from the books and records of the Home Office in accordance with applicable instructions,
except as noted (attach a statement with exception if necessary).
							(signed)
							(title)
							(date)
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0202. The time required to complete this information collection is estimated 662 hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3906-3906.2)
Rev. 1									39-103

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Sheet 2: A2

3990 (Cont.)					FORM CMS-287-05						08-05
PART III-- LISTING OF CHAIN HEALTHCARE FACILITY COMPONENTS						Home Office:	Period			SCHEDULE
(Attach additional pages if necessary) (Please indicate all Medicare numbers excluding							From:_____________			A
Sub-Providers, Provider-Based Skilled Nursing Facilities and Home Health Agencies)							To:_________________			page 2 of 3
			Periods Ending During		Date Acquired	Date Sold/Closed	Medicaid	Type of
	Component Name		Home Office Fiscal Year		During the Home	During the Home	Participation	Reimbursement	Medicare	Medicaid
	Health Care Facilities	Medicare No.	From:	To:	Office Fiscal Year	Office Fiscal Year	Yes/No	N, P, T, O	Intermediaries	Intermediaries
	1	2	3	4	5	6	7	8	9	10
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.
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3906.3)
39-104											Rev. 1

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Sheet 3: A3

08-05				FORM CMS-287-05					3990 (Cont.)
PART IV-- LISTING OF OTHER			Home Office:		Period			SCHEDULE
CHAIN COMPONENTS (Attach					From:________________			A
additional pages if necessary)								page 3 of 3
					To:__________________
			Periods Ending During			During the Home Office Fiscal Year
	Component Name		Home Office Fiscal Year			Date		Date
	Other Components		From	To		Acquired		Sold or Closed
	1		2	3		4		5
1									1
2									2
3									3
4									4
5									5
6									6
7									7
8									8
9									9
PART V--LISTING OF REGIONS/DIVISIONS
				Costs Included	Separate Cost			Designated
			Location	in this Cost Statement	Statement Filed			Region/Division
	Name	City	State	Amount	Yes	No		Intermediary
	1	2	3	4	5	6		7
1									1
2									2
3									3
4									4
		DISCLOSURE OF THE HOME OFFICE COST STATEMENT
The home office cost statement is not an integral part of the providers' cost report; therefore,it is not affected by 20 CFR 422.435(c)
which requires disclosure of providers' cost reports. Any request received under the Freedom of Information Act (FOIA) regarding
a home office cost statement will be subjected to a case by case determination of whether to withhold the information in whole or in part.
In most cases, since the home office cost statements contain information the disclosure of which may result in a competitive disadvantage
for many provider chains, the exemption from disclosure provided in 5 USC, Sec. 552(b)(4) will apply.
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 3906.4-3906.5)
Rev. 1									39-105

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Sheet 4: B

3990 (Cont.)				FORM CMS-287-05						08-05
TRIAL BALANCE OF EXPENSES				Home Office:			Period		SCHEDULE
RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS							From:____________________		B
							To:______________________		page 1 of 3
		Expenses per		Reclassified		Net Allowable	Direct	Functional	Pooled
Cost Center Description		Home Office	Reclassifications	Trial Balance	Medicare	Expenses	Allocations	Allocations	Allocations
	(omit cents)	Books	(from Sch.B-1)	(col. 1minus/	Adjustments	(col.3 minus/plus	To Chain	To Chain	(col.5 minus
				plus col.2)	(from Sch.C)	col.4)	Components	Components	cols. 6,7)
		1	2	3	4	5	6	7	8
1.	Old Cap. Rel. Costs--Bldg and Fixtures									1
1.01	Int. Exp.-Old Capital Bldg and Fixtures									1.01
2.	Old Cap. Rel. Costs--Movable Equip.									2
2.01	Int. Exp.-Old Capital Movable Equip.									2.01
3.	Sub-Total (Lines 1 and 2)									3
4	New Cap. Rel. Costs--Bldg and Fixtures									4
4.01	Int. Exp.-New Capital Bldg and Fixtures									4.01
5	New Cap. Rel. Costs--Movable Equip.									5
5.01	Int. Exp.-New Capital Movable Equip.									5.01
6	Sub-Total (Lines 4 and 5)									6
	Other Capital Related Costs
	----------------------------------
7	Insurance Premiums									7
8	Taxes & Licenses (Other than Income)									8
9	Other (Specify)									9
10	Sub-Total (sum of lines 7-9)									10
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)
39-106										Rev. 1
08-05				FORM CMS-287-05						3990 (Cont.)
TRIAL BALANCE OF EXPENSES				Home Office:			Period		SCHEDULE
RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS							From:____________________		B
							To:______________________		page 2 of 3
		Expenses per		Reclassified		Net Allowable	Direct	Functional	Pooled
Cost Center Description		Home Office	Reclassifications	Trial Balance	Medicare	Expenses	Allocations	Allocations	Allocations
	(omit cents)	Books	(from Sch.B-1)	(col. 1minus/	Adjustments	(col.3 minus/plus	To Chain	To Chain	(col.5 minus
				plus col.2)	(from Sch.C)	col.4)	Components	Components	cols. 6,7)
		1	2	3	4	5	6	7	8
	Non-Capital Related Cost
11	Salaries of Officers									11
12	Salaries and Wages of Others									12
13	Payroll Taxes									13
14	Employee Benefits - Payroll Related									14
15	Employee Benefits - Non-Payroll Related									15
16	Profit Sharing/Pension Plans									16
17	Legal Fees									17
18	Auditing and Accounting Fees									18
19	Utilities									19
20	Communications									20
21	Travel and Entertainment									21
22	Transportation									22
23	Cleaning, Office and Adm. Supplies									23
24	Minor Equipment Expensed									24
25	Repairs and Maintenance									25
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)
Rev. 1										39-107
3990 (Cont.)				FORM CMS-287-05						08-05
TRIAL BALANCE OF EXPENSES				Home Office:			Period		SCHEDULE
RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS							From:____________________		B
							To:______________________		page 3 of 3
		Expenses per		Reclassified		Net Allowable	Direct	Functional	Pooled
Cost Center Description		Home Office	Reclassifications	Trial Balance	Medicare	Expenses	Allocations	Allocations	Allocations
	(omit cents)	Books	(from Sch.B-1)	(col. 1minus/	Adjustments	(col.3 minus/plus	To Chain	To Chain	(col.5 minus
				plus col.2)	(from Sch.C)	col.4)	Components	Components	cols. 6,7)
		1	2	3	4	5	6	7	8
	Non Capital Related Cost (Cont.)
26	Dues and Subscriptions									26
27	Contributions									27
28	Insurance Premiums - Non-Cap. Rel.									28
29	Taxes and Licenses - Non-Cap. Rel.									29
30	Interest Expense									30
31	Interest Income									31
32	Other (Specify)									32
33	Other (Specify)									33
34	Other (Specify)									34
35	Other (Specify)									35
36	Sub-Total (sum of lines 11-35)									36
100	Total Exp. (sum of lines 3, 6, 10, 36)									100
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)
39-108										Rev. 1

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Sheet 5: B-1

08-05				FORM CMS-287-05					3990 (Cont.)
				Home Office:		Period:		SCHEDULE
	RECLASSIFICATION OF HOME OFFICE EXPENSES					From:_______________		B-1
						To: ________________
		Code		Increase			Decrease
	Explanation of Reclassification Entry	(1)	Cost Center	Line No.	Amount(2)	Cost Center	Line No.	Amount(2)
		1	2	3	4	5	6	7
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.									18.
	Total Reclassifications (Sum of col.4 must
100	equal sum of col.7)								100
(1) A letter (A,B, etc) must be entered on each line to identify each reclassification entry.
(2) Transfer to Schedule B, column 2, line as appropriate.
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3909)
Rev. 1									39-109

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Sheet 6: B-2, PARTS I&II

3990 (Cont.)				FORM CMS-287-05					08-05
ANALYSIS OF CHANGES DURING COST STATEMENT			Home Office:		PERIOD:
PERIOD IN CAPITAL ASSET BALANCES OF CHAIN					FROM: __________			SCHEDULE B-2
HOME OFFICE WHERE THE CHAIN INCLUDES HOSPITALS					TO: __________			PARTS I & II
SUBJECT TO THE PROSPECTIVE PAYMENT SYSTEM
PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES
				Acquisitions		Disposals		Fully
		Beginning				and	Ending	Depreciated
	Description	Balances	Purchases	Donation	Total	Retirements	Balance	Assets
		1	2	3	4	5	6	7
1.	Land								1.
2.	Land Improvements								2.
3.	Buildings and Fixtures								3.
4.	Building Improvements								4.
5.	Fixed Equipment								5.
6.	Movable Equipment								6.
7.	SUBTOTAL								7.
8.	Reconciling Items								8.
9.	TOTAL (Line 7 minus line 8)								9.
PART II - ANALYSIS OF CHANGES IN NEW CAPITAL ASSET BALANCES
				Acquisitions		Disposals		Fully
		Beginning				and	Ending	Depreciated
	Description	Balances	Purchases	Donation	Total	Retirements	Balance	Assets
		1	2	3	4	5	6	7
1.	Land								1.
2.	Land Improvements								2.
3.	Buildings and Fixtures								3.
4.	Building Improvements								4.
5.	Fixed Equipment								5.
6.	Movable Equipment								6.
7.	SUBTOTAL								7.
8.	Reconciling Items								8.
9.	TOTAL (Line 7 minus line 8)								9.
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3910)
39-110									Rev. 1

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Sheet 7: B-2, Part III

08-05				FORM CMS-287-05						3990 (Cont.)
RECONCILIATION OF CAPITAL COSTS CENTERS				Home Office:		PERIOD:																																																																																																																		STATEMENT OF REVENUE AND EXPENSES									SCHEDULE
						FROM:		SCHEDULE B-2																																																																																																																									I
						TO:		Part III
																																																																																																																													Period
PART III																																																																																																																								Home Office:		Harrod Corporation			From: 10-1-91			To: 9-30-92
			COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL
				Gross Assets					Total (1)
			Capitalized	for Ratio	Ratio			Other Capital-	(Sum of																																																																																																															l. Total operating revenue							$		9,856,982
	Description	Gross Assets	Leases	(Col. 1 - Col. 2)	(See Instructions)	Insurance	Taxes	Related Costs	Columns 5-7)
*		1	2	3	4	5	6	7	8
1	Old Cap. Rel Costs-Bldgs and Fixtures									1																																																																																																														2. Less: Operating expenses
2	Old Cap. Rel. Costs-Movable Equipment									2																																																																																																														(Schedule B, column 1, line 60)							$		(8,598,750)
3	New Cap. Rel Costs-Bldgs and Fixtures									3
4	New Cap. Rel. Costs-Movable Equipment									4
5	Total (Sum of Lines 1-4)									5
																																																																																																																								a. contributions, donations					$	18,450
																																																																																																																								b. income from investments					$	1,125,400
					SUMMARY OF OLD AND NEW CAPITAL																																																																																																																			c. interest income					$	75,600
								Other Capital-	Total (2)																																																																																																															d. purchase discounts					$	25,000
						Insurance	Taxes	Related Costs	(Sum of																																																																																																															e. rebates and refunds of expenses					$	32,600
	Description		Depreciation	Lease	Interest	(From Col. 5)	(From Col. 6)	(From Col. 7)	Columns 9-14)																																																																																																															f. parking lot receipts					$	8,560
*			9	10	11	12	13	14	15																																																																																																															g. rental income					$	1,256,901
1	Old Cap. Rel Costs-Bldgs and Fixtures									1
2	Old Cap. Rel. Costs-Movable Equipment									2
3	New Cap. Rel Costs-Bldgs and Fixtures									3
4	New Cap. Rel. Costs-Movable Equipment									4
5	Total (Sum of Lines 1-4)									5
*	All lines numbers except line 5 are to be consistent with Schedule B line numbers for capital cost centers																																																																																																																							5. Total other income
(1) The sum of the amounts on lines 1 thru 4 must equal the amount on Schedule B, column 2, lines 7-9, net of other capital-related costs directly allocated to components of the chain.
(2) The amounts on lines 1 thru 4 must equal the corresponding amounts on Schedule B, Column 3, lines 1,2,4,5 and 7-9.																																																																																																																								6. Other expenses (specify)					$
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3910)																																																																																																																													$
Rev. 1										39-111
																																																																																																																								8. Net income (loss) for the period (sum of lines 3, 5, 7)							$		#VALUE!
																																																																																																																								FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
																																																																																																																									PUB. 15-II, SECTION 3126)
																																	Chain Components	Base: Sq. Ft.	Sq. Ft.	Sq. Ft.	Sq. Ft.
																																		Building		Building
																																		and	Movable	and	Movable
																																	Health Care Facilities:	Fixtures	Equipment	Fixtures	Equipment
																																	-	1	2	3	4
																																1.	Lisaville Mount Hospital	1,300	1,300	2,000	2,000
																																2.	Canyon Hospital	900	900	1,250	1,250
																																3.	Valley Memorial Hospital	830	830	800	800
																																4.	Sunrise Health Center	750	750	900	900
																																5.	Knollwood Medical Center	925	925	1,630	1,630
																																6.	Oceanside Hospital	850	850	1,450	1,450
																																7.	River Cross Hospital	850	850	960	960
																																8.	Swansonside Hospital	775	775	880	880
																																9.	Distmont Medical Center	935	935	759	759
																																10.	Harvey Lake Hospital	800	800	650	650
																																11.	Irvine City Hospital	900	900	910	910
																																12.	Brownston Nursing Home	850	850	756	756
																																13.	Hunter Valley Home Health	900	900	689	689
																																14.
																																15.
																																16.
																																17.	Total (sum of lines 1-16)	11,565	11,565	13,634	13,634
																																FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3134)
																																FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL		Home Office:	Harrod Corporation	Period	SUPPLEMENTAL
																																COSTS TO CHAIN COMPONENTS---STATISTICS				From: 10-1-91	SCHEDULE F
																																				To: 9-30-92	Part II (Cont'd)
																																			Old Capital		New Capital
																																	Chain Components	Base:	Sq. Ft.		Sq. Ft.
																																		Building		Building
																																		and	Movable	and	Movable
																																	Other Components:	Fixtures	Equipment	Fixtures	Equipment
																																	-	1	2	3	4
																																18.	Harrod Hotel	8,000	500		12,000
																																19.
																																20.
																																21.
																																22.
																																23.
																																24.
																																25.
																																26.	Managed Facilities	8,000	440	2,000	550
																																27.	Total (sum of lines 18-26)	16,000	940	2,000	12,550
FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,																																	Regional Offices:
	SECTION 3121)																																-
																																28.	East Region	3,200	400	750	600
																																29.	West Region	1,600	330	761	700
																																30.
																																31.
																																32.	Total (sum of lines 28-31)	4,800	730	1,511	1,300
																																33.	Total statistics (sum of lines 17, 27 and 32)(A)	32,365	13,235	17,145	27,484		0
																																34.	Cost to be Allocated (B)	Err:520	Err:520	Err:520	Err:520
																																35.	Unit Cost Multiplier (B/A)	Err:520	Err:520	Err:520	Err:520
																																FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3134)

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Sheet 8: C

3990 (Cont.)		FORM CMS-287-05				08-05
	MEDICARE ADJUSTMENTS TO HOME OFFICE EXPENSES				SCHEDULE C
	Home		Period
	Office:		From:		To:
					Cost Center to be
					Adjusted (on
		*			Schedule B, col. 3)
	Description			Line
			Amount	No.	Cost Center
			1	2	3
1.	Federal/State income tax, franchise tax and related					1.
	interest and penalties on late payments
	(CMS Pub. 15-1, secs.2122.2 and 2133)
2.	Donations (See CMS Pub. 15-1, Chapter 6)					2.
3.	Stockholders servicing costs (stock transfers and					3.
	registrations) (CMS Pub 15-1, se. 2134.9)
4.	Acquisition expenses (CMS Pub. 15-1, sec. 2134.11)					4.
5.	Disposal expenses re: non-patient care assets					5.
	or subsidiaries (CMS Pub. 15-1, sec. 2102.3)
6.	Bad Debts (CMS Pub. 15-1, sec. 308)					6.
7.	Life insurance premiums where home office is					7.
	direct/indirect beneficiary (CMS Pub 15-1, sec. 2102.3)
8.	Annual stockholder meeting expenses					8.
	(CMS Pub. 15-1, sec. 2134.9)
9.	Nonhealth care projects (CMS Pub. 15-1, sec. 2102.3)					9.
10.	Noncompetition agreement expenses					10.
	(CMS Pub. 15-1, sec 2105.1/1218.7)
11.	Fund-raising expenses (CMS Pub. 15-1, sec. 2136.2)					11.
12.	Rebates/refunds on expenses (CMS					12.
	Pub. 15-1, sec. 804)
13.	Other (Specify)					13.
14.	Cost of ownership of assets leased from related					14.
	organization in lieu of rent (CMS Pub. 15-1, sec. 700)
15.	Related organizations (from Schedule D, Part B					15.
	col. 5, line 15 (CMS Pub. 15-1, sec. 700)
16.	Value of services of nonpaid					16.
	workers (CMS Pub. 15-1, sec. 700)
17.	Interest on Loans between home office and					17.
	components of the chain (CMS Pub. 15-1,
	sec. 2150.2c) where no exception applies
18.	Costs of corporate acquisitions of					18.
	capital stocks and acquisition and
	development department cost
	(CMS Pub. 15-1, sec. 2150.2B)
19.	Interest on Loans from owners					19.
	(CMS Pub.15-1, sec. 218.2)
20.	Abandoned construction in progress					20.
	cost (CMS Pub. 15-1, sec. 2155)
21	Other (specify)					21
22	Other (specify)					22
23	Other (specify)					23
24	Other (specify)					24
25	Other (specify)					25
26	Other (specify)					26
27	Other (specify)					27
28	Total (sum of lines 1-27)					28
* A. Costs--if cost, including applicable overhead, can be determined.
B. Amount Received--if cost cannot be determined.
FORM CMS-287-05(8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 3911
39-112						Rev. 1

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Sheet 9: D-1

08-05		FORM CMS-287-05				3990 (Cont.)
STATEMENT OF COSTS OF SERVICES					SCHEDULE D
FROM RELATED ORGANIZATIONS					page 1 of 2
			Period
Home
Office:			From:		To:
Part A.		Are there any costs included on Schedule B which resulted
		from transactions with related organizations as defined in
		42 CFR 413.17?
		_________________Yes		___________________	No
		If "YES," complete Parts B and C following.
Part B.
		Costs incurred and adjustment required as a result of
		transactions with related organizations:
		Account and Amount		Amount	Net Adjustment
		(on Schedule B, column 3)		Allowable	(col. 3 minus
	Line	Expense Account	Amount	in Cost	col.4) *
	1	2	3	4	5
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.
100	Total (sum of lines 1-99)					100
	* transfer to column 1 of Schedule C, applicable lines
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3912)
Rev. 1						39-113

---

Sheet 10: D-2

3990 (Cont.)			FORM CMS-287-05			08-05
	STATEMENT OF COSTS OF SERVICES	Home Office:		Period:	SCHEDULE
	FROM RELATED ORGANIZATIONS			From: ______________________________	D
					page 2 of 2
				To: ________________________________
	Part C. Inter-relationship of chain Home Office to related organization:
	Name of Related Organization	Type of Business	Related Through	Explanation of Relationship
			Ownership or Control
	1	2	3	4
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
100						100
FORM CMS-287-05(8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3912)
39-114						Rev. 1

---

Sheet 11: E

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

---

Sheet 12: 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
			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

---

Sheet 13: F PART I

08-05				FORM CMS-287-05						3990 (Cont.)
FUNCTIONAL ALLOCATION OF HOME OFFICE		Home Office:				Period
CAPITAL COSTS TO CHAIN COMPONENTS						From:		SCHEDULE F
						To:		Part 1
				Old Capital				New Capital
	Chain Components
		Building				Building
		and	Interest	Movable	Interest	and	Interest	Movable	Interest
	Health Care Facilities:	Fixtures	Expense	Equipment	Expense	Fixtures	Expense	Equipment	Expense
		1	2.01	2	2.01	3	4.01	4	4.01
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. 15-1, SECTION 3915)
Rev. 1										39-119
3990 (Cont.)				FORM CMS-287-05						08-05
FUNCTIONAL ALLOCATION OF HOME OFFICE		Home Office:				Period
CAPITAL COSTS TO CHAIN COMPONENTS						From:		SCHEDULE F
						To:		Part 1 (Cont'd)
				Old Capital				New Capital
	Chain Components
		Building				Building
		and	Interest	Movable	Interest	and	Interest	Movable	Interest
	Other Components:	Fixtures	Expense	Equipment	Expense	Fixtures	Expense	Equipment	Expense
		1	2.01	2	2.01	3	4.01	4	4.01
19										18.
20										19.
21										20.
22										21.
23										22.
24										23.
25										24.
26										25.
27	Other Managed Facilities									26.
28	Total (sum of lines 19-27)									27.
	Regional Offices:
										28.
29										29.
30										30.
31										31.
32										32.
33	Total (sum of lines 28-32)									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. 15-1, SECTION 3915)
39-120										Rev. 1

---

Sheet 14: F PART II

08-05			FORM CMS-287-05					3990 (Cont.)
FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL			Home Office:		Period
COSTS TO CHAIN COMPONENTS---STATISTICS					From:	SCHEDULE F
					To:	Part II
			Old Capital			New Capital
		Base:
	Chain Components
		Building			Building
		and	Movable	Interest	and	Movable	Interest
	Health Care Facilities:	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense
	-	1	2	2.01	3	4	4.01
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. 15-1, SECTION 3915)
Rev. 1								39-121
3990 (Cont.)			FORM CMS-287-05					08-05
FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL			Home Office:		Period
COSTS TO CHAIN COMPONENTS---STATISTICS					From:	SCHEDULE F
					To:	Part II
			Old Capital			New Capital
		Base:
	Chain Components	Building			Building
		and	Movable	Interest	and	Movable	Interest
	Other Components:	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense
	-	1	2	2.01	3	4	4.01
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 28-31)							33
34	Total statistics (sum of lines 18, 28 and 33) (A)							34
35	Cost to be Allocated (B)							35
36	Unit Cost Multiplier (B/A)							36
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3915)
39-122								Rev. 1

---

Sheet 15: F-1, PART I

08-05						FORM CMS-287-05							3990 (Cont.)
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part I
			Specify:
Chain Components		Medicare										Total
		No.										(cols. 1 thru 9)
	Health Care Facilities:		1	2	3	4	5	6	7	8	9	10
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 3916)
Rev. 1													31-123
3990 (Cont.)						FORM CMS-287-05							08-05
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part I
			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 18-27)												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 3916)
39-124													Rev. 1

---

Sheet 16: F-1, PART II

08-05						FORM CMS-287-05							3990 (Cont.)
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS -STATISTICS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part II
			Base:
Chain Components
												Total
												(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 3916)
Rev. 1													39-125
3990 (Cont.)						FORM CMS-287-05							08-05
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS -STATISTICS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part II
			Base:
Chain Components
												Total
												(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 3916)
39-126													Rev. 1

---

Sheet 17: G

08-05					FORM CMS-287-05								3990 (Cont.)
ALLOCATION OF HOME OFFICE POOLED COSTS BETWEEN						Home Office:		Period			SCHEDULE
HEALTH CARE FACILITIES AND OTHER CHAIN COMPONENTS								From:			G
								To:			PART I & II
	Part I -- Allocation between Health Care Facilities and Other Components
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
		Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
		Total Cost	Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
1.	Health Care Facilities												1
2.	Other Components												2
	Certain Home Office or Region
	Costs Requiring Home Office/
3.	Region overhead allocation												3
4.	Total												4
Part II -- Allocation to Individual Chain Components
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
	Health Care Facilities:	Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
	------------------------------------------		Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
1													1
2													2
3													3
4
5													5
6													6
7													7
8													8
9													9
10													10
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3917)
Rev. 1													39-127
3990 (Cont.)					FORM CMS-287-05								08-05
ALLOCATION OF HOME OFFICE POOLED COSTS BETWEEN						Home Office:		Period			SCHEDULE
HEALTH CARE FACILITIES AND OTHER CHAIN COMPONENTS								From:			G
								To:			PART I & II
Part II -- Allocation to Individual Chain Components (Continued)
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
	Health Care Facilities:	Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
	(Continued)		Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
11													11
12													12
13													13
14													14
15													15
16													16
17													17
18	Total (sum of lines 1-17)												18
	Other Components
	-
19													19
20													20
21													21
22													22
23													23
24													24
25													25
26													26
27													27
28	Total (sum of lines 20-27)												28
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3917)
39-128													Rev. 1
08-05					FORM CMS-287-05								3990 (Cont.)
ALLOCATION OF HOME OFFICE POOLED COSTS BETWEEN						Home Office:		Period			SCHEDULE
HEALTH CARE FACILITIES AND OTHER CHAIN COMPONENTS								From:			G
								To:			PART I & II
Part II -- Allocation to Individual Chain Components (Continued)
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
	Regional Offices:	Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
	-----------------------------		Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
29													29
30													30
31													31
32													32
33	Total (sum of lines 29-32)												33
34	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 3917)
Rev. 1													39-129
																																									0

---

Sheet 18: I

3990 (Cont.)					FORM CMS-287-05					08-05
STATEMENT OF REVENUE AND EXPENSES										SCHEDULE
										I
					Period
Home Office:					From:				To:
l. Total operating revenue								$
2. Less: Operating expenses
(Schedule B, column 1, line 37)								$
3. Operating profit (loss)								$
4. Other income:
a. contributions, donations						$
b. income from investments						$
c. interest income						$
d. purchase discounts						$
e. rebates and refunds of expenses						$
f. parking lot receipts						$
g. rental income						$
h. other (specify)						$
						$
						$
						$
						$
						$
5. Total other income
(sum of item 4 above)								$
6. Other expenses (specify)						$
						$
						$
						$
						$
7. Total other expenses
(sum of item 6 above)								$
8. Net income (loss) for the period (line 3 plus line 5 minus line 7)								$
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECTION 3918)
39-130										Rev. 1

---

Sheet 19: J

08-05			FORM CMS-287-05			3990 (Cont.)
	BALANCE SHEET	Home Office:		Period:	SCHEDULE J
				From:	page 1 of 5
				To:
					Balance
	Assets				Sheet
	(Omit Cents)				Per Books
	Current Assets				1
1	Cash - On Hand & In Bank					1
2	Current Investments					2
3	Notes Receivable					3
4	Accounts Receivable					4
5	Other Receivables (Specify)					5
6	Less:Allowance for Uncollectable Notes and Account Receivable					6
7	Inventory					7
8	Prepaid Expenses					8
9	Other Current Assets (Specify)					9
10	Total Current Assets (Sum of lines 1-9)					10
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
Rev. 1						39-131
3990 (Cont.)			FORM CMS-287-05			08-05
	BALANCE SHEET				SCHEDULE J
					page 2 of 5
					Balance
	Assets				Sheet
	(Omit Cents)				Per Books
	Fixed Assets				1
11	Land					11
12	Land Improvements					12
13	Less: Accumulated Depreciation					13
14	Building					14
15	Less: Accumulated Depreciation					15
16	Leasehold Improvement					16
17	Less: Accumulated Depreciation					17
18	Fixed Equipment					18
19	Less: Accumulated Depreciation					19
20	Motor Vehicles					20
21	Less: Accumulated Depreciation					21
22	Major Movable Equipment					22
23	Less: Accumulated Depreciation					23
24	Minor Equipment - Depreciable					24
25	Less: Accumulated Depreciation					25
26	Minor Equipment - Non-Depreciable					26
27	Other Fixed Assets (Specify)					27
28	Other Fixed Assets (Specify)					28
29	Total Fixed Assets (Sum of lines 11-28)					29
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
39-132						Rev. 1
08-05			FORM CMS-287-05			3990 (Cont.)
	BALANCE SHEET				SCHEDULE J
					page 3 of 5
					Balance
	Assets				Sheet
	(Omit Cents)				Per Books
	Other Assets				1
30	Investments					30
31	Deposits on Leases					31
32	Due from Owners/Officers					32
33	Due from Related Organizations					33
34	Special Funds					34
35	Goodwill					35
36	Construction in Progress					36
37	Other (Specify)					37
38	Total Other Assets (Sum of lines 30-37)					38
39	Total Assets (Sum of lines 10, 29, and 38)					39
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
Rev. 1						39-133
3990 (Cont.)			FORM CMS 287-92			08-05
	BALANCE SHEET				SCHEDULE J
					page 4 of 5
					Balance
	Liabilities and Capital				Sheet
	(Omit Cents)				Per Books
	Liabilities				1
	Current Liabilities:
40	Accounts Payable					40
41	Notes and Loans Payable - Short Term					41
42	Current Portion of Long-Term Debt					42
43	Salaries, Wages and Fees Payable					43
44	Payroll Taxes Payable					44
45	Other Accrued Expenses Payable					45
46	Deferred Income					46
47	Notes and Loans Payable to Related Organization					47
48	Other (Specify)					48
49	Total Current Liabilities (Sum of lines 40-48)					49
	Long Term Liabilities:
50	Mortgage Payable (Long-term Portion)					50
51	Notes Payable - (Long-term Portion)					51
52	Unsecured Loans - (Long-term Portion)					52
53	Loans from Owners					53
54	Other (Specify)					54
55	Total Long-term Liabilities (Sum of lines 50-54)					55
56	Total Liabilities (Sum of lines 49 and 55)					56
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
39-134						Rev. 1
08-05			FORM CMS-287-05			3990 (Cont.)
	BALANCE SHEET	Home Office:		Period:	SCHEDULE J
				From: ______________	page 5 of 5
				To: ________________
					Balance
	Liabilities and Capital				Sheet
	(Omit Cents)				Per Books
	Capital				1
57	Preferred Stock					57
58	Common Stock					58
59	Additional Paid-In Capital					59
60	Retained Earnings - Unrestricted					60
61	Other (Specify)					61
62	Total Capital (Sum of lines 57-61)					62
63	Total Liabilities and Total Capital (Sum of lines 56 and 62)					63
64	Equity in Assets Leased from Related Organizations (Attach supporting Schedules)					64
65	Equity in Related Organizations (attach Supporting Schedules)					65
66	Total Equity Capital (Lines 62 plus/minus 64 and 65)					66
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
Rev. 1						39-135