Please Print, Complete and Fax to: 1-832-237-1042

Thank you for giving National Cost Report the opportunity to provide you with a proposal for our Home Health Agency cost report preparation services. Our organization has over 30 years experience in Medicare and state specific Medicaid cost reporting and 8 years experience in HHA cost reporting.

Preparation of one (1) Medicare HHA cost report…………………………………………….$ 2,500.00

What this includes: Preparation of your fiscal year end Home Health Agency cost report as required by CMS and your fiscal intermediary. Each HHA cost report will be completed in compliance with CMS HIM-15 and PPS rules and regulations including submission of the CMS-339 questionnaire. This service also includes answering of desk review and field audit questions as they relate to the cost report preparation for a period not less than twelve months from the date of cost report submission. This service also includes a mid-year HHA information request, each year, to follow-up and ensure that proper documents, are being gathered and will be available to cost report preparer to submit a timely filed cost report.

Fees are exclusive of travel expenses and are due and payable within 30 days of invoice date.

Should an ownership change occur during this contract period, the entire contract fee is due and payable.

I have received the above proposal and acknowledge that it is acceptable. I hereby request and authorize the National Cost Report to begin work immediately on the items noted above. If this bid is acceptable, please sign below and fax to our Houston office at 832-237-1042.

Upon fax receipt of signed contract, we will fax you our Texas Medicaid Cost Report information request packet.

Sincerely,

John E. Peterson, Jr.
CPA