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 Hospice cost report preparation services. Our organization has over 30 years experience in Medicare and state specific Medicaid cost reporting.

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

What this includes: Preparation of your fiscal year end Hospice cost report as required by CMS and your fiscal intermediary. Each Medicare cost report will be completed in compliance with CMS HIM-15 and chapter 38 rules and regulations including submission of the CMS-339 questionnaire and a diskette containing the Medicare cost report ECR files. 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.

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