Print this page and obtain information requested for Hospice Medicare cost report.
  1.  Fax copy of Working trial balance for cost reporting period
2.  Fax copy of PS&R Summary report from intermediary
3.  Fax copy of Worksheet S-1 from prior year Hospice cost report
5.  Fax copy of Worksheet A-7 from prior year Hospice cost report
6.  Fax copy of Worksheet B-1 from prior year Hospice cost report
7.  Fax copy of Worksheet A-8-1 from prior year Hospice cost report

Complete information request below:

Enrollment days Title VIII Title XIX Title XVIII Title XIX  
      Unduplicated Unduplicated  
  Unduplicated  Unduplicated Skilled Nursing Nursing Other
  Medicare Days Medicaid Days Facility Days Facility Days Unduplicated Days
           
Continuous home care _______________ _______________ ________________ _________________ ________________
Routine home care _______________ _______________ ________________ _________________ ________________
Inpatient respite care _______________ _______________ ________________ _________________ ________________
General inpatient care _______________ _______________ ________________ _________________ ________________
 
Description Title XVIII Title XIX Title XVIII Title XIX  
Skilled  
    Nursing Facility Nursing Facility Other
Number of patient receiving Hospice care ___________ ____________ ____________ ___________ ___________
Total number of unduplicated Continuous care hours billed to Medicare ___________   ____________    
Unduplicated census count ___________ ____________ ____________ ___________ ___________
If the Hospice componentized ( or fragmented its A & G service costs enter option '1' or '2' ___________ ____________ ____________ ___________ ___________
 
Are there any related Organization or Home Office costs enter '1' , then '2'  or if none enter -0-          
 ______________
( enter -0- or 1 )
______________
( if '1' enter '2' here
 
  Transportation Miles Number of Miles Driven
by Each Department
  Volunteer Service Coordinator _______________
  Administrative & General Staff _______________
  Inpatient - General Care _______________
  Inpatient Respite Care _______________
  Physician Services  _______________
  Nursing Care _______________
  Physical Therapy _______________
  Occupational Therapy _______________
  Speech Therapy _______________
  Medical Social Services _______________
  Spiritual Counseling _______________
  Dietary Couseling _______________
  Counseling Other _______________
 
Complete the next section if you do not have a prior year HOSPICE Medicare cost report
 
  Data Description - General Info. Data Entry
  Medicare Provider Number _______________
  Facility Name __________________________
  Cost report period from (mm/dd/yyyy) _______________
  Cost report period to (mm/dd/yyyy) _______________
  Street Mailing Address including City & State __________________________
  Zip _______________
  County _______________
  Date Hospice began operation: (mm/dd/yyyy) _______________
  Date Medicare Certified (mm/dd/yyyy) _______________
  Date Medicaid Certified (mm/dd/yyyy) _______________
  Type of Hospice entity control ? ( see choices below ) ______ 1 thru 13
 
  Data Description - General Info. Data Entry
  Medicare Provider Number _______________
  Facility Name __________________________
  Cost report period from (mm/dd/yyyy) _______________
  Cost report period to (mm/dd/yyyy) _______________
  Street Mailing Address including City & State __________________________
  Zip _______________
  County _______________
  Date Hospice began operation: (mm/dd/yyyy) _______________
  Date Medicare Certified (mm/dd/yyyy) _______________
  Date Medicaid Certified (mm/dd/yyyy) _______________
  Type of Hospice entity control?
( see choices below )		 ______ 1 thru 13
 
Entity choices:
1-nonprofit church;  2-nonprofit other;  3-proprietary individual;  4-proprietary corporation;  5-proprietary partnership;  6-properietary other; 7-government federal;  8-governement city;  9-government county; 10-government state;  11-government hospital district; 12-government city;  13-government other
 
  Fixed Asset prior year balances Enter prior year ending amounts
  Land _______________
  Land Improvements _______________
  Buildings & Fixtures _______________
  Leasehold Improvements _______________
  Fixed Equipment _______________
  Moveable Equipment _______________
 
  Department Area's - sq. ft. Enter square footage amounts
  Plant Operation and Maintenance _______________
  Transportation staff _______________
  Volunteer Service Coordination _______________
  Administrative and General _______________
  Inpatient General Care _______________
  Inpatient Respite Care _______________
  Physician Services _______________
  Nursing Care _______________
  Physical Therapy _______________
  Occupational Therapy _______________
  Speech Therapy _______________
  Medical Social Services _______________
  Spiritual Counseling _______________
  Dietary Counseling _______________
  Counseling Other _______________
  Home Health Aide and Homemaker _______________
  Other ___________________
  Drugs, Biologicals and Infusion ___________________
  DME and Oxygen ___________________
  Patient Transportation ___________________
  Imaging Services ___________________
  Labs and Diagnostics ___________________
  Medical Supplies ___________________
  Outpatient Services ___________________
  Radiation Therapy _______________
  Chemotherapy _______________
  Other ___________________
  Bereavement Program Costs ___________________
  Volunteer Program Costs ___________________
  Fundraising ___________________
  Other Program Costs ___________________
 
End of information request form
 
 
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