3690 (Cont.)
BALANCE SHEET (If you are nonproprietary and do not maintain fund-type accounting records, complete the General Fund column only) Assets (Omit cents) CURRENT ASSETS Cash on hand and in banks Temporary investments Notes receivable Accounts receivable Other receivables Allowances for uncollectible notes and accounts receivable Inventory Prepaid expenses Other current assets Due from other funds Total current assets (sum of lines 1-10) FIXED ASSETS Land Land improvements Accumulated depreciation Buildings Accumulated depreciation Leasehold improvements Accumulated depreciation Fixed equipment Accumulated depreciation Automobiles and trucks Accumulated depreciation Major movable equipment Accumulated depreciation Minor equipment depreciable Accumulated depreciation Minor equipment-nondepreciable Total fixed assets (sum of lines 12-20) OTHER ASSETS Investments Deposits on leases Due from owners/officers Other assets Total other assets (sum of lines 22-25) Total assets (sum of lines 11, 21, and 26)
FORM CMS-2552-96
PROVIDER NO.: ______________ Specific Purpose Fund 2 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X PERIOD: FROM ________ TO ___________ Endowment Fund 3 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X WORKSHEET G
06-03
General Fund 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Plant Fund 4 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 1 2 3 4 5 6 7 8 9 10 11 12 13 13.01 14 14.01 15 15.01 16 16.01 17 17.01 18 18.01 19 19.01 20 21 22 23 24 25 26 27
1 2 3 4 5 6 7 8 9 10 11 12 13 13.01 14 14.01 15 15.01 16 16.01 17 17.01 18 18.01 19 19.01 20 21 22 23 24 25 26 27
FORM CMS-2552-96 (6/2003) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3640)
36-600
Rev. 10
10-96
BALANCE SHEET (If you are nonproprietary and do not maintain fund-type accounting records, complete the General Fund column only) Liabilities and Fund Balances (Omit cents) CURRENT LIABILITIES Accounts payable Salaries, wages, and fees payable Payroll taxes payable Notes and loans payable (short term) Deferred income Accelerated payments Due to other funds Other current liabilities Total current liabilities (sum of lines 28 thru 35)
FORM CMS-2552-96
PROVIDER NO.: ______________ Specific Purpose Fund 2 X X X X X X X X PERIOD: FROM ________ TO ___________ Endowment Fund 3 X X X X X X X X
3690 (Cont.)
WORKSHEET G (CONT.)
General Fund 1 X X X X X X X X X
Plant Fund 4 X X X X X X X X 28 29 30 31 32 33 34 35 36
28 29 30 31 32 33 34 35 36
LONG TERM LIABILITIES Mortgage payable Notes payable Unsecured loans Loans from owners .01 Prior to 7/1/66 .02 On or after 7/1/66 41 Other long term liabilities 42 Total long term liabilities (sum of lines 37 thru 41) 43 Total liabilities (sum of lines 36 and 42) 37 38 39 40 CAPITAL ACCOUNTS 44 General fund balance 45 Specific purpose fund 46 Donor created - endowment fund balance - restricted 47 Donor created - endowment fund balance - unrestricted 48 Governing body created - endowment fund balance 49 Plant fund balance - invested in plant 50 Plant fund balance - reserve for plant improvement, replacement, and expansion 51 Total fund balances (sum of lines 44 thru 50) 52 Total liabilities and fund balances (sum of lines 43 and 51)
X X X X X X X X
X X X X X X X X
X X X X X X X X
X X X X X X X X
37 38 39 40.01 40.02 41 42 43
X X X X X X X X X X X X X X X
44 45 46 47 48 49 50 51 52
FORM CMS-2552-96 (6/2003) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3640)
Rev. 1
36-601
10-96
STATEMENT OF CHANGES IN FUND BALANCES
FORM CMS-2552-96
PROVIDER NO.: ______________ SPECIFIC PURPOSE FUND 3 4 PERIOD: FROM _________ TO ___________ ENDOWMENT FUND 5 6
3690 (Cont.)
WORKSHEET G-1
GENERAL FUND 1 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Fund balances at beginning of period Net income (loss) (from Wkst. G-3, line 31) Total (sum of line 1 and line 2) Additions (credit adjustments) (specify)
PLANT FUND 7
8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Total additions (sum of lines 4-9) Subtotal (line 3 plus line 10) Deductions (debit adjustments) (specify)
Total deductions (sum of lines 12-17) Fund balance at end of period per balance sheet (line 11 minus line 18)
FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3640)
Rev. 1
36-602
10-96
STATEMENT OF PATIENT REVENUES AND OPERATING REVENUES
FORM CMS-2552-96
PROVIDER NO.: ______________
3690 (Cont.)
PERIOD: WORKSHEET G-2, FROM _________ PARTS I & II TO ___________
PART I - PATIENT REVENUES INPATIENT REVENUE CENTER 1 1 2 4 5 6 7 8 9 10 11 12 13 14 15 GENERAL INPATIENT ROUTINE CARE SERVICES Hospital Subprovider Swing bed - SNF Swing bed - NF Skilled nursing facility Nursing facility Other long term care Total general inpatient care services (sum of lines 1-8) INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES Intensive care unit Coronary care unit Burn intensive care unit Surgical intensive care unit Other special care (specify) Total intensive care type inpatient hospital services (sum of of lines 10-14) Total inpatient routine care services (sum of lines 9 and 15) Ancillary services Outpatient services Home health agency Ambulance Outpatient rehabilitation providers ASC Hospice X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 2 3 1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 OUTPATIENT TOTAL
16 17 18 19 20 21 22 23 24 25 Total patient revenues (sum of lines 16-24) (transfer column 3 to Wkst. G-3, line 1) PART II - OPERATING EXPENSES
1 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Operating expenses (per Wkst. A, column 3, line 101) Add (specify)
2 X
Total additions (sum of lines 27-32) Deduct (specify)
X
Total deductions (sum of lines 34-38) Total operating expenses (sum of lines 26 and 33 minus line 39) (transfer to Wkst. G-3, line 4)
X X
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3640)
Rev. 1
36-603
3690 (Cont.)
STATEMENT OF REVENUES AND EXPENSES
FORM CMS-2552-96
PROVIDER NO.: ______________ PERIOD: FROM _________ TO ___________ WORKSHEET G-3
10-96
1 2 3 4 5
Description Total patient revenues (from Wkst. G-2, Part I, column 3, line 25) Less contractual allowances and discounts on patients' accounts Net patient revenues (line 1 minus line 2) Less total operating expenses (from Wkst. G-2, Part II, line 40) Net income from service to patients (line 3 minus line 4) OTHER INCOME
X X X X X
1 2 3 4 5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Contributions, donations, bequests, etc Income from investments Revenues from telephone and telegraph service Revenue from television and radio service Purchase discounts Rebates and refunds of expenses Parking lot receipts Revenue from laundry and linen service Revenue from meals sold to employees and guests Revenue from rental of living quarters Revenue from sale of medical and surgical supplies to other than patients Revenue from sale of drugs to other than patients Revenue from sale of medical records and abstracts Tuition (fees, sale of textbooks, uniforms, etc.) Revenue from gifts, flowers, coffee shops, and canteen Rental of vending machines Rental of hospital space Governmental appropriations Other (specify) Total other income (sum of lines 6-24) Total (line 5 plus line 25) Other expenses (specify)
Total other expenses (sum of lines 27-29) Net income (or loss) for the period (line 26 minus line 30)
X X X X X X X X X X X X X X X X X X X X X X X X X X
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
FORM CMS-2552-96 (9/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3640)
36-604
Rev. 1