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									                   Freestanding Outpatient Surgical Center (FOSC)
                Financial, Utilization, and Services Data 2006 - Instructions
    1      MDH requires the use of the electronic spreadsheet in completing the formset as many of the fields are
           automatically calculated for you and have built in audits that will save you time and reduce the
           possibility of errors. Please e-mail the completed formset to MDH at amy.camp@health.state.mn.us
           when complete.

    2      Report all data according to your facility’s 2006 fiscal year. If you change your fiscal year, you may
           report required information for a period up to 13 months in one report. Please note that you must report
           information for all time periods. If the fiscal year change results in a time period of more than 13
           months, you must complete an additional report. (Minnesota Rules, part 4650.0113, subp. 2.)

    3      You are required to complete all items of the report unless it is specifically noted as optional. These
           optional items have been added to get a more accurate picture of your facility for research purposes. It
           is to your advantage to provide this additional data.


    4      Leave data accounts blank when they are not applicable to your facility. Use a zero only when the
           amount is zero. If data are unavailable, please note as such on the page of the account line.

    5      Whenever reasonably possible, a surgical center must report actual numbers in all categories. If it is not
           reasonably possible to report actual information, the surgical center may estimate using reasonable
           methods. When an entry is an estimate, please identify it as an estimate. Note that, upon request, the
           surgical center must provide a written explanation of the method used for the estimate. (Minnesota
           Rules, part 4650.0112, subpart 1c.)


    6      In some instances two different accounts will require identical information. When this occurs, it is
           referenced on each account line (e.g. both Account 0600 and Account 0790 are Total Operating
           Expense).

    7      Round all financial data to the nearest dollar .

    8      [Bracket] accounts that are negative, such as contractual adjustments and uncollectibles.

    9      Please disregard the order of the account numbers. These are for MDH recording purposes only and do
           not reflect any priority to the data items on the form.


    10     Many enhancements have been added to this years' version to assist you in completion of the formset.
           A drop down box located in the upper left part of the screen lists several ‘key’ accounts. You can jump
           directly to a specific account by selecting it in the box.

    11     Additional Formatting within the formset:
               a      Audits have been added and will show as RED text to the right of the potential error.
               b      Tips throughout the formset are highlighted in YELLOW.
               c      Many hyperlinks also appear throughout the formset for ease of navigation.
               d      All items in the formset are REQUIRED unless otherwise noted.


                                             start of formset




                                                                                                                    Minnesota Department of Health
Fiscal Year 2006                                                                                              phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                      page 1 of 15                                         hccis@health.state.mn.us
           Freestanding Outpatient Surgical Center (FOSC)
                          Financial, Utilization, and Services Data 2006
Complete this page, print it and have it signed. Indicate any changes or corrections to data shown.

Surgical Center Facility Identification

                                             This is the unique ID assigned to your facility for the HCCIS data collection.
                         HCCIS ID
                                             Please click on the HCCIS ID link, select your ID from the list, and enter it here.

           Surgical Center Name #N/A                                                  NPI                    #N/A

                          Address #N/A

                             City #N/A
                           County #N/A
                            State #N/A

                         Zip Code #N/A                                                              Fiscal Year

                                                                                   2006 Fiscal Year End
                 Facility Phone # #N/A
                                                                                                   Date
                                                                                           # of Months in
                    Facility Fax # #N/A
                                                                                          Reporting Year

            Administrator's Name #N/A

             Administrator's Title #N/A

            Administrator's e-mail #N/A

                    CFO's Name #N/A

        FOSC Web Site Address #N/A

                                                                                            Check Type of Affiliation(s):
                                                  Affiliations
                                                                                    Owned       Managed     Leased          N/A

                                    #N/A                                             #N/A         #N/A       #N/A

                                    #N/A                                             #N/A         #N/A       #N/A




                                                                                       Please VERIFY Type of Affiliation

This certification must be signed by an officer of the outpatient surgical center such as the Administrator, CEO, or
CFO. The signed copy of this page must be either faxed or mailed to MDH.
Certification Statement: I hereby certify that I have examined the accompanying Annual Report and to the best of my
knowledge, the information contained in this report is accurate.

              Signed:

     Printed or Typed:                                                                              Date:

             Position:



                                                                                                          Minnesota Department of Health
Fiscal Year 2006                                                                                    phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)               page 2 of 15                                       hccis@health.state.mn.us
   #N/A

Contact Information

Preparer

  Name of Person completing this
                                 #N/A                           Title     #N/A
                           form

                Organization Name #N/A

Address (if different than Surgical
                                    #N/A                        e-mail    #N/A
                           Center)
    City (if different than Surgical                            Direct
                                     #N/A                                 #N/A
                            Center)                             Phone #
 County (if different than Surgical
                                    #N/A                        Fax #     #N/A
                           Center)
   State (if different than Surgical
                                     #N/A
                            Center)
          Zip Code (if different than
                                      #N/A
                  Surgical Center)

Courtesy Contact 1

           Courtesy Contact Name #N/A                           Title     #N/A

                Organization Name #N/A

                           Address #N/A                         e-mail    #N/A

                                                                Direct
                               City #N/A                                  #N/A
                                                                Phone #

                           County) #N/A                         Fax #     #N/A

                              State #N/A

                          Zip Code #N/A

Courtesy Contact 2

           Courtesy Contact Name #N/A                           Title     #N/A

                Organization Name #N/A

                           Address #N/A                         e-mail    #N/A

                                                                Direct
                               City #N/A                                  #N/A
                                                                Phone #

                           County) #N/A                         Fax #     #N/A

                              State #N/A

                          Zip Code #N/A




                                                                                   Minnesota Department of Health
Fiscal Year 2006                                                             phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)   page 3 of 15                            hccis@health.state.mn.us
   #N/A

Section 1: Services and Capacity                                         FY 2006

7300       Number of Surgical Patient Registrations

7301       Number of Operating Rooms

7460       Number of Procedure Rooms* - Optional

                                                                                    Average reported statewide is
7302       Average Number of Hours Open Per Week
                                                                                    between 30 and 60 hours.



Section 2: Non-Surgical Procedures or Services. Does your facility
                                                                     Yes       No
provide the following services?

7303       Radiology procedures (CPT codes 70000 to 79999)


           Laboratory or pathology procedures (CPT codes 80000 to
7304
           89000)

           Medical procedures such as check-ups, immunizations,
7305
           minor injury repair, etc. (CPT codes 90000 to 99199)

                                                                                    This item is required to be
7306       Other (Please Specify)
                                                                                    completed




                                                                                              Minnesota Department of Health
Fiscal Year 2006                                                                        phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)            page 4 of 15                              hccis@health.state.mn.us
   #N/A

                                                                                                         Grey shaded cells
Section 3: Procedure Summary                                                      FY 2006                will be calculated
                                                                                                         for you

State the procedure name, CPT code number, and frequency of the ten procedures that were performed
most frequently at the facility during 2006 fiscal year. List procedures descending from most to least
frequently performed. Use only one CPT code per line.

                                                                                     Number of
                                                     CPT Code          Modifier
                   Procedure Name                                                    Procedures
                                                 (one code per line)   (if any)
                                                                                     Performed

    1)

    2)

    3)

    4)

    5)

    6)

    7)

    8)

    9)

    10)

                                                                                                       *Although these 2
   7307    All other Procedures Performed* - Optional                                                - questions are
                                                                                                       optional, providing
                                                                                                       this data gives a
                                                                                                       more accurate
                                                                                                       picture with which
   7308    Total Procedures* - Optional                                                                to analyze the
                                                                                                       industry.




                                                                                                      Minnesota Department of Health
Fiscal Year 2006                                                                                phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)               page 5 of 15                                   hccis@health.state.mn.us
   #N/A

                                                                                              Grey shaded cells will be
Section 4: Employee Classification of FTEs                                   FY 2006
                                                                                              calculated for you
Full-time equivalent employee (FTE) means an employee or any combination of employees
that are paid by the facility for 2,080 hours of employment per year.

2034       Total Physician FTEs

2031       Total RN FTEs

2032       Total LPN FTEs

2131       Total Nurse Anesthetist FTEs

2134       Total X-ray Technician FTEs

2135       Total Lab Technologist/Technician FTEs

           Total All Other Personnel FTEs (health and non-health
2138
           related)
                                                                                              Required item. Please review
2040       Total Outpatient Surgical Center FTEs                                       0.00
                                                                                              instructions.




Section 5: Physicians with Staff Privileges                                  FY 2006

                                                                                              Required item. Please review
4530       Total Number of Physicians with Staff Privileges
                                                                                              instructions.




                                                                                                        Minnesota Department of Health
Fiscal Year 2006                                                                                  phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                page 6 of 15                                    hccis@health.state.mn.us
   #N/A

                                                                                                Grey shaded cells will be
Section 6: Natural Expense Summary* - Optional                                 FY 2006
                                                                                                calculated for you
*Although some of this section is optional, providing this data gives a more accurate picture   Round all financial data to the
with which to analyze the industry.                                                             nearest dollar

     0601 Salaries and Wages

     0602 Employee Benefits

     0604 Purchased Services

     0608 Supplies

     0615 Interest Expense

     0616 Depreciation

     0618 Property Taxes

                                                                                                Required item. Please review
     0621 Provision for Bad Debts
                                                                                                instructions.

     0625 Malpractice Expenses

     0623 MinnesotaCare Tax

     0619 Other Expenses

                                                                                                Required item. Please review instructions
     0600 Total Operating Expenses (ties to 0790)                       $                 -
                                                                                                (cell is not locked).




                                                                                                          Minnesota Department of Health
Fiscal Year 2006                                                                                    phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                 page 7 of 15                                     hccis@health.state.mn.us
   #N/A

                                                                                          Grey shaded cells will be
Section 7: Patient Care Charges                                             FY 2006
                                                                                          calculated for you
                                                                                          Required item. Please review
0740       Total Charges from Patient Care (ties to 0850)
                                                                                          instructions.
                                                                                          Round all financial data to the
Section 8: Primary Payer Charge Summary                                     FY 2006
                                                                                          nearest dollar
This section now includes both Managed Care and Non-Managed Care charges to be
reported on the same payer lines.

7448       Medicare Patient Charges                                                       Audit Check

7449       MA/GAMC/MinnesotaCare Patient Charges                        $             -

7450       MA Patient Charges                                                             Enter total
                                                                                          MA/GAMC/MinnesotaCare
                                                                                          Charges in 7449 if detail for
7451       GAMC Patient Charges
                                                                                          7450, 7451, and 7452 are not
                                                                                          available (cell E92 is NOT
7452       MinnesotaCare Patient Charges                                                  locked).

           Commercial Insurers, Nonprofit Health Plans, Private (Non-
7453
           Public Program) Patient Charges


0852       Individual (Self-Pay) Patient Charges

           Other Payer Patient Charges (Champus, Workman's
0847                                                                    $             -
           Comp., Auto, etc.)

0850       Total Patient Charges (ties to 0740)                         $             -




                                                                                          Grey shaded cells will be
Section 9: Primary Payer Adjustments and Uncollectibles                     FY 2006
                                                                                          calculated for you
This section now includes both Managed Care and Non-Managed Care adjustments to be        Round all financial data to the
reported on the same payer lines.                                                         nearest dollar
                                                                                          This should be a negative
7454       Medicare Adjustments
                                                                                          number
                                                                                          This should be a negative
7455       MA/GAMC/MinnesotaCare Adjustments                            $             -
                                                                                          number

7456       MA Adjustments                                                                 Enter total
                                                                                          MA/GAMC/MinnesotaCare
                                                                                          Adjustments in 7455 if detail for
7457       GAMC Adjustments
                                                                                          7456, 7457, and 7458 are not
                                                                                          available (cell E104 is NOT
7458       MinnesotaCare Adjustments                                                      locked).

           Commercial Insurers, Nonprofit Health Plans, Private (Non-                     This should be a negative
7459
           Public Program) Adjustments                                                    number
                                                                                          This should be a negative
0762       Charity Care Adjustments
                                                                                          number
           Other Adjustments and Uncollectibles (Champus,                                 This should be a negative
0751                                                                    $             -
           Workman's Comp., Auto, etc.)                                                   number
                                                                                          This should be a negative
0760       Total Adjustments & Uncollectibles
                                                                                          number

                                                                                                    Minnesota Department of Health
Fiscal Year 2006                                                                              phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)              page 8 of 15                                  hccis@health.state.mn.us
   #N/A

                                                                                                 Grey shaded cells will be
Section 10: Net Patient Revenue                                                 FY 2006
                                                                                                 calculated for you
                                                                                                 Please check that Adjustments
0750       Net Patient Revenue (0740+0760)                                                       are reported as a negative
                                                                                                 number
                                                                                                 Round all financial data to the
Section 11: Other Operating Revenue* - Optional                                 FY 2006
                                                                                                 nearest dollar
*Although this section is optional, providing this data gives a more accurate picture with
which to analyze the industry.

0770       Total Other Operating Revenue

Section 12: Operating Income* - Optional                                        FY 2006

*Although some of this section is optional, providing this data gives a more accurate picture
with which to analyze the industry.

0780       Total Operating Revenue (0750+0770)                            $                  -

                                                                                                 Required item. Please review
0790       Total Operating Expenses (ties to 0600)                        $                  -
                                                                                                 instructions.

0700       Income/Loss from Facility Operations                           $                  -

Section 13: Non-Operating Revenue* - Optional                                   FY 2006

*Although this section is optional, providing this data gives a more accurate picture with
which to analyze the industry.

0820       Total Non-Operating Revenue

Section 14: Non-Operating Expense* - Optional                                   FY 2006

*Although this section is optional, providing this data gives a more accurate picture with
which to analyze the industry.

0830       Total Non-Operating Expense

Section 15: Revenue in Excess of Expense* - Optional                            FY 2006

*Although this section is optional, providing this data gives a more accurate picture with
which to analyze the industry.

0831       Extraordinary Items; Gain/(Loss)

0834       Net Income Before Income Tax (0700+0820-0830+0831)             $                  -

0837       Income Tax

0800       Revenue in Excess of Expense (0834-0837)                       $                  -




                                                                                                           Minnesota Department of Health
Fiscal Year 2006                                                                                     phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                  page 9 of 15                                     hccis@health.state.mn.us
   #N/A

Section 16: Charity Care                                                     Yes          No

           Does your Surgical Center have a Charity Care Policy? If                                 Please review amount reported in
   7309
           yes, please attach.                                                                      line 0762.



Section 17: Ownership Relationships: Please ATTACH A DIAGRAM depicting all
major OWNERSHIP RELATIONSHIPS in your facility's overall "corporate family" as
described below.
           Corporations that your facility now owns all or part of, and all those corporations'
 A.)
           parents and subsidiaries;
           Corporations that now own all or part of your facility, and all of those corporations'
 B.)
           parents and subsidiaries;
           It is not necessary to include ownership relationships of less than 5 percent, or to
 C.)
           identify non-corporate owners by name.




                                                                                                              Minnesota Department of Health
Fiscal Year 2006                                                                                        phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                 page 10 of 15                                        hccis@health.state.mn.us
   #N/A

Completion and submission of this page is required by Minnesota Rules, Chapter
4650.0112, subpart 3.
Pursuant to Minnesota Statutes, section 62J.321, subdivision 5, the information provided in
the sections on this page is classified as non-public .



                                                                                               Round all financial data to the
Section 18: Administrative Expenses                                             FY 2006
                                                                                               nearest dollar
Record all direct and indirect expenses in the following category. Include portions of 0637,
0650 and 0655 where applicable.                                                                The sum of Sections 19 and 20
                                                                                               are usually greater than or
0630       Total Administrative Expenses                                                       equal to the amount reported
                                                                                               on line 0630. Please verify
                                                                                               your data.


Section 19: Cost of Regulatory and Compliance Reporting                         FY 2006        Audit Check


                                                                                               Required item. Please review
0637       Total Cost of Regulatory and Compliance Reporting
                                                                                               instructions.




Section 20: MIS and Occupancy Expenses                                          FY 2006

                                                                                               Required item. Please review
0650       Total Management Information Systems Expenses
                                                                                               instructions.
                                                                                               Required item. Please review
0655       Total Plant, Equipment and Occupancy Expenses
                                                                                               instructions.


           Please complete this page before submitting to MDH.

                       start of formset        audit check




                                                                                                         Minnesota Department of Health
Fiscal Year 2006                                                                                   phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                 page 11 of 15                                   hccis@health.state.mn.us
Items on this worksheet are for your reference and to be used as an aid in completing the formset. If your reported amounts do not fall within the stated
ranges, you may be contacted by MDH for corrections.
                                                                               Reported                         If nothing shows in this column, your data has
Contractual Adjustment percentage of Charges                                                  Contractural %
                                                                               Amounts                                      passed the initial audits
7448      Medicare Patient Charges                                           $              -
7454      Medicare Adjustments                                               $              -

7449       MA/GAMC/MinnesotaCare Patient Charges                               $              -
7455       MA/GAMC/MinnesotaCare Adjustments                                   $              -

           Commercial Insurers, Nonprofit Health Plans, Private (Non-Public
7153       Program) Patient Charges                                            $              -
           Commercial Insurers, Nonprofit Health Plans, Private (Non-Public
7459       Program) Adjustments                                                $              -

0852       Individual (Self-Pay) Patient Charges                               $              -
0762       Charity Care Adjustments                                            $              -

           Other Payer Patient Charges (Champus, Workman's Comp., Auto,
0847       etc.)                                                               $              -
           Other Adjustments and Uncollectibles (Champus, Workman's
0751       Comp., Auto, etc.)                                                  $              -

0850       Total Patient Charges (ties to 0740)                                $              -
0760       Total Adjustments & Uncollectibles                                  $              -

                                                                                   Reported                    If nothing shows in this column, your data has
Administrative Expense % of Total Operating Expense                                               % of Total
                                                                                   Amounts                     passed the initial audits
0630       Administrative Expense                                              $              -
                                                                                                               This is required data.
0600       Total Operating Expense                                             $              -




                                                                                                                                        Minnesota Department of Health
Fiscal Year 2006                                                                                                                  phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                                page 12 of 15                                                  hccis@health.state.mn.us
Definitions of codes used on the 2006 FOSC formset
Code       Label                                 Definition
0621       Provision for Bad Debts               The provision for actual or expected doubtful accounts resulting from the extension of credit.
                                                 This line should tie to the Provision for Bad Debts on the income statement of the surgical
                                                 center’s audited financial statements (unless charity care is included in this line on your
                                                 financial statement). Per Minnesota Rules chapter 4650.0116, in determining whether to
                                                 classify charity care as bad debt expense, the facility must consider the following points: A.
                                                 The facility must presume that the patient is able and willing to pay until and unless the
                                                 facility has reason to consider this a charity care case under its charity care policy and the
                                                 facility classifies this as a charity care case; and B. The facility includes as bad debt expense
                                                 unpaid deductibles, co-insurance, co-payments, and non-covered services and any other
                                                 unpaid patient responsibilities.

0762       Charity Care Adjustments              The total dollar amount that would have been charged by a facility for rendering free or
                                                 discounted care to persons who cannot afford to pay and for which the facility did not expect
                                                 payment. For purposes of reporting under Minnesota Rules, chapter 4650.0112, charity care
                                                 adjustments are included in adjustments and uncollectibles. To determine what meets the
                                                 requirements for reporting Charity Care on this report, see Minnesota Rules chapter
                                                 4650.0115. Note: Charity care allowances should include all Hill Burton obligations.
                                                 Charity care is a required field in the FOSC and cannot be reported in 0621 Bad Debt
                                                 Expense.


0630       Total Administrative Expenses         The sum of the following expenses:
                                                  Admitting, patient billing, and collections: All of the costs related to inpatient and
                                                 outpatient admission or registration, whether scheduled or non-scheduled; the scheduling of
                                                 admission times; insurance verification, including coordination of benefits; preparing and
                                                 submitting claim forms; and cashiering, credit, and collection functions.
                                                  Accounting and financial reporting: All costs related to fiscal services, such as general
                                                 accounting, budgeting, cost accounting, payroll accounting, accounts payable, and plant,
                                                 equipment, and inventory accounting.
                                                  Quality assurance and utilization management program or activity: All costs associated
                                                 with any activities or programs established for the purpose of quality of care evaluation and
                                                 utilization management. Activities include quality assurance, development of practice
                                                 protocols, utilization review, peer review, provider credentialing, and all other medical care
                                                 evaluation activities.
                                                  Community and wellness education: All the costs related to wellness programs, health
                                                 promotion, community education classes, support groups, and other outreach programs and
                                                 health screening included in a specific community or wellness education cost center or
                                                 reclassified from other cost centers. Community and wellness education expenses does not
                                                 include patient education programs.
                                                  Promotion and marketing: All costs related to marketing, promotion, and advertising
                                                 activities such as billboards, yellow page listing, cost of materials, advertising agency fees,
                                                 marketing representative wages and fringe benefits, travel, and other expenses allocated to
                                                 the promotion and marketing activities. Promotion and marketing expenses does not include
                                                 costs charged to other departments within the hospital.
                                                  Taxes, fees, and assessments: The direct payments made to government agencies
                                                 including property taxes; medical care surcharge; MinnesotaCare tax; unrelated business
                                                 income taxes; any assessments imposed by local, state, or federal jurisdiction; all fees
                                                 associated with the facility's new or renewal certification with state or federal regulatory
                                                 agencies, including fees associated with joint Commission on Accreditation of Healthcare
                                                 Organizations (JCAHO) accreditation; and any fees or fines paid to government agencies for
                                                 examinations related to regulation.
                                                  Malpractice: All costs of malpractice including malpractice insurance, self-insurance
                                                 expenses including program administration, and malpractice losses not covered by insurance,
                                                 including deductibles and malpractice attorney fees.




                                                                                                                   Minnesota Department of Health
Fiscal Year 2006                                                                                             phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)              page 13 of 15                                               hccis@health.state.mn.us
Definitions of codes used on the 2006 FOSC formset
Code       Label                                     Definition
                                                      Other administrative expenses: All costs for the overall operation of the facility
                                                     associated with management, administration, and legal staff functions, including the costs of
                                                     governing boards, executive wages and benefits, auxiliary and other volunteer groups,
                                                     purchasing, telecommunications, printing and duplicating, receiving and storing, and
                                                     personnel management. Other administrative expenses includes all wages and benefits,
                                                     donations and support, direct and in-kind, for the purpose of lobbying and influencing policy
                                                     makers and legislators, including membership dues, and all expenses associated with public
                                                     policy development, such as response to rulemaking and interaction with government agency
                                                     personnel including attorney fees for reviewing and analyzing governmental policies. Other
                                                     administrative expenses does not include the costs of public relations included in promotion
                                                     and marketing expenses, the costs of legal staff already allocated to other functions, or the
                                                     costs of medical records, social services, and nursing administration.

0637       Total Cost of Regulatory and Compliance   All costs of the facility associated with, or directly incurred in the preparation and
           Reporting                                 submission of financial, statistical, or other utilization, satisfaction, or quality reports, or
                                                     summary plan descriptions that are required by federal, state, and local agencies. This would
                                                     include Federal Ambulatory Surgery Association (FASA) and Accreditation Association for
                                                     Ambulatory Health Care, Inc. (AAAHC). The portion of Account 0637 that is administrative
                                                     expenses is to be reported in Account 0630 and included in the total of Account 0637.



0650       Total Management Information Systems      All costs related to maintaining and operating the data processing system of the facility,
           Expenses                                  including such functions as admissions, medical records, patient charges, decision support
                                                     systems, and fiscal services. The portion of Account 0650 that is administrative expenses is
                                                     to be reported in Account 0630 and included in the total of Account 0650.

0655       Total Plant, Equipment and Occupancy      All costs related to plant, equipment, and occupancy expenses, including maintenance,
           Expenses                                  repairs, and engineering expenses, building rent and leases, equipment rent and leases, and
                                                     utilities. Plant, equipment, and occupancy expenses include interest expenses and
                                                     depreciation. . The portion of Account 0655 that is administrative expenses is to be reported
                                                     in Account 0630 and included in the total of Account 0655.

NPI        National Provider Identifier              Enter this number if you have been assigned an NPI from the Centers for Medicare &
                                                     Medicaid Services (CMS). See
                                                     http://new.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp for more information.




                                                                                                                      Minnesota Department of Health
Fiscal Year 2006                                                                                                phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                  page 14 of 15                                              hccis@health.state.mn.us
2006 HCCIS Freestanding Outpatient
Surgical Center (FOSC) List

HCCIS ID   Surgical Center Name                          City
  334      Minnesota Eye Institute Surgery Center        ALEXANDRIA
  323      Bemidji Same Day Surgery                      BEMIDJI
  308      Mn Eye Laser and Surgery Center               BLOOMINGTON
  349      TRIA Orthpaedic Center ASC LLC                BLOOMINGTON
  347      Brainerd Lakes Surgery Center                 BRAINERD
  356      MINNESOTA VALLEY SURGERY CTR                  BURNSVILLE
  325      North Metro Endoscopy Center                  COON RAPIDS
  306      Dakota Clinic Ltd.                            DETROIT LAKES
  318      Lakewalk Surgery Center Inc.                  DULUTH
  324      Pavilion Surgery Center, LLC                  DULUTH
  345      South East Metro Endoscopy Center             EAGAN
  305      HealthSouth Centennial Lakes Surgery Center   EDINA
  311      Gastrointestinal Diagnostic Center            EDINA
  322      McCannel Eye Surgery, LLC                     EDINA
  329      Orthopaedic Institute Surgery Center          EDINA
  343      Edina Surgery Center                          EDINA
  344      Minnesota Surgery Center, Ltd.                EDINA
  354      COSMETIC CARE CENTER                          EDINA
  319      South Central Surgical Center, LLC            FAIRMONT
  316      MN Orthopaedic Surgery Center, LLC            FRIDLEY
  321      Minneapolis Eye Center                        GOLDEN VALLEY
  353      Lakewood Surgery Center                       GRAND RAPIDS
  314      High Pointe Surgery Center                    LAKE ELMO
  327      Mankato Surgery Center                        MANKATO
  348      Mankato Clinic Endoscopy Center               MANKATO
  301      Maplewood Surgery Center                      MAPLEWOOD
  317      East Metro Endoscopy Center                   MAPLEWOOD
  350      MN Eye Laser & Surgery Center LLC             MAPLEWOOD
  330      Riverside Endoscopy Center LLC                MINNEAPOLIS
  300      Children's Health Care - West                 MINNETONKA
  346      Prairie Surgicenter                           MORRIS
  304      WestHealth Inc.                               PLYMOUTH
  332      West Metro Endoscopy Center                   PLYMOUTH
  352      ILBNC Special Procedures                      PLYMOUTH
  326      Center for Outpatient Surgery                 SARTELL
  302      St. Cloud Surgical Center                     ST. CLOUD
  312      Midsota Surgical Suites PA                    ST. CLOUD
  331      St. Cloud Center for Ophthalmic Surgery       ST. CLOUD
  328      Center for Diagnostic Imaging                 ST. LOUIS PARK
  303      Landmark Surgery Center                       ST. PAUL
  355      ASSOCIATED EYE CARE AMB SURG                  STILLWATER
  313      Dakota Clinic Ltd.                            THIEF RIVER FALLS
  309      Willmar Surgery Center, LLP                   WILLMAR
  351      Family Surgery Center, LLC                    WILLMAR
  320      Woodbury Ambulatory Surgery Center            WOODBURY
  333      Midwest Surgery Center                        WOODBURY




                                                                                                   Minnesota Department of Health
Fiscal Year 2006                                                                             phone 651-201-3575/fax 651-201-5179
Freestanding Outpatient Surgical Center (FOSC)                               page 15 of 15               hccis@health.state.mn.us

								
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