Intravenous Therapy for Licensed Practical Nurse - Excel

Document Sample
Intravenous Therapy for Licensed Practical Nurse - Excel Powered By Docstoc
					                                                                     SCHEDULE- I


HOSPITAL'S TAX ID NUMBER __________
PROCESSING DATE _________________
START OF FISCAL YEAR __________________
END OF FISCAL YEAR ________________
HOSPITAL NAME ______________________
NAME OF PARENT COMPANY _______________________
NUMBER OF DAYS IN FISCAL YEAR __________________
PROVIDER ID NUMBER _____________________
CAMPUSES INCLUDED IN THIS FILING _____________________________
VENDOR ________________________________
TYPE OF HOSPITAL __________ ACUTE ____________ NON-ACUTE
TYPE OF NON-ACUTE ______ REHAB _____CHRONIC _____CHRONIC/REHAB _____ PSYCHIATRIC _____ OTHER



SCHEDULE I                                         GENERAL INFORMATION


DHCFP-403 VERSION 2005


HOSPITAL NAME
ADDRESS



MAIN TELEPHONE NUMBER


CHAIRMAN, BOARD OF TRUSTEES
ADDRESS




CHIEF EXECUTIVE OFFICER
TITLE
TELEPHONE NUMBER
FAX NUMBER




                                                                         Page 1
                                                                SCHEDULE- I


CHIEF FINANCIAL OFFICER
TITLE
TELEPHONE NUMBER
FAX NUMBER




PERSON TO BE CONTACTED REGARDING QUESTIONS ABOUT THIS REPORT:
NAME
TITLE
TELEPHONE NUMBER
FAX NUMBER




                                                                  Page 2
                                                                  COVER-SCH-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ____________


SCHEDULE II             SUMMARY SCHEDULE


DHCFP-403 VERSION 2005

        OVERHEAD
     1 BUILDING AND FIXED EQUIPMENT DEPRECIATION
     2 CAPITAL LEASES - AMORTIZATION ON BUILDING AND FIXED EQUIPMENT
     3 INTEREST - LONG TERM
     4 AMORTIZATION OF BOND ISSUE COSTS
     5 SUBTOTAL
     6 FRINGE BENEFITS
     7 ADMINISTRATION
     8 PURCHASING
     9 GENERAL ACCOUNTING
     10 PATIENT ACCOUNTS & INPATIENT ADMITTING
     11 INSURANCE - PROFESSIONAL MALPRACTICE
     12 INSURANCE - HOSPITAL MALPRACTICE
     13 INSURANCE - OTHER
     14 INTEREST - SHORT TERM
     15 SUBTOTAL
     16 PLANT MAINTENANCE AND REPAIRS
     17 PLANT OPERATIONS
     18 SECURITY
     19 PARKING
     20 LICENSES AND TAXES (OTHER THAN INCOME)
     21 SUBTOTAL
     22 LAUNDRY AND LINEN
     23 HOUSEKEEPING
     24 CAFETERIA
     25 DIETARY SERVICES
     26 MAINTENANCE OF PERSONNEL
     27 NURSING ADMINISTRATION




                                                                       Page 3
                                             COVER-SCH-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ____________


SCHEDULE II               SUMMARY SCHEDULE


DHCFP-403 VERSION 2005

     28 INSERVICE EDUCATION (NURSING)
     29 SUBTOTAL
     30 NURSING FLOAT
     31 RN & LPN EDUCATION
     32 MEDICAL STAFF - TEACHING
     33 MEDICAL STAFF - ADMINISTRATION
     34 SUBTOTAL
     35 POST GRADUATE MEDICAL EDUCATION
     36 CENTRAL SERVICE AND SUPPLIES
     37 PHARMACY
     38 MEDICAL RECORDS
     39 MEDICAL CARE REVIEW
     40 SOCIAL SERVICES
     41 CENTRAL PATIENT TRANSPORTATION
     42 OTHER OVERHEAD
     43 SUBTOTAL OVERHEAD


        ANCILLARY CARE SERVICES
     44 SURGERY
     45 LABOR AND DELIVERY
     46 RECOVERY ROOM
     47 ANESTHESIOLOGY
     48 INTRAVENOUS THERAPY
     49 MEDICAL SUPPLIES - SPECIAL
     50 DRUGS - SPECIAL
     51 LABORATORY
     52 BLOOD
     53 BLOOD PROCESSING AND STORAGING




                                                Page 4
                                            COVER-SCH-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ____________


SCHEDULE II              SUMMARY SCHEDULE


DHCFP-403 VERSION 2005

     54 ELECTROCARDIOLOGY (EKG)
     55 CARDIAC CATHERIZATION LABORATORY
     56 DIAGNOSTIC RADIOLOGY
     57 THERAPEUTIC RADIOLOGY
     58 COMPUTERIZED TOMOGRAPHY
     59 NUCLEAR MEDICINE
     60 RESPIRATORY THERAPY
     61 PULMONARY FUNCTION TESTING
     62 ELECTROENCEPHALOGRAPHY (EEG)
     63 ELECTROMYOGRAPHY
     64 PHYSICAL THERAPY
     65 OCCUPATIONAL THERAPY
     66 SPEECH - LANGUAGE THERAPY
     67 RECREATIONAL THERAPY
     68 AUDIOLOGY
     69 PSYCHOLOGY/PSYCHIATRY
     70 RENAL DIALYSIS
     71 ORGAN ACQUISITION
     72 AMBULANCE
     73
     74
     75
     76
     77
     78 SUBTOTAL ANCILLARY


          ROUTINE INPATIENT CARE SERVICES
     79 MEDICAL & SURGICAL ACUTE




                                               Page 5
                                             COVER-SCH-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ____________


SCHEDULE II             SUMMARY SCHEDULE


DHCFP-403 VERSION 2005

     80 PEDIATRIC ACUTE
     81 OBSTETRIC ACUTE
     82 PSYCHIATRIC ACUTE
     83 VENTILATOR UNIT
     84 SKILLED NURSING FACILITIES
     85
     86
     87
     88 SUBTOTAL ACUTE
     89 MEDICAL & SURGICAL INTENSIVE CARE
     90 CORONARY INTENSIVE CARE
     91 NEONATAL INTENSIVE CARE
     92
     93
     94
     95
     96
     97 SUBTOTAL INTENSIVE CARE
     98 NEWBORN NURSERY
     99 CHRONIC AND REHABILITATION
    100 SUBTOTAL ROUTINE INPATIENT CARE


          ROUTINE AMBULATORY CARE SERVICES
    101 EMERGENCY SERVICES
    102 CLINIC OR AMBULATORY SERVICES
    103 SATELLITE CLINIC SERVICES
    104 AMBULATORY SURGERY SERVICES
    105 AMBULATORY RENAL DIALYSIS SERVICES




                                                Page 6
                                                                    COVER-SCH-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ____________


SCHEDULE II             SUMMARY SCHEDULE


DHCFP-403 VERSION 2005

    106 HOME DIALYSIS SERVICES
    107 PSYCHIATRY
    108 HOME HEALTH SERVICES
    109 OBSERVATION BEDS
    110 PRIVATE REFERRALS
    111 HOSPITAL LICENSED HEALTH CENTER(S)
    112
    113
    114 SUBTOTAL ROUTINE AMBULATORY SERVICES


    115 TOTAL PATIENT CARE (LINES 78+100+114)
    116 TOTAL PATIENT CARE AND OVERHEAD (LINES 43+115)


          NON-PATIENT CARE
    117 NON-PATIENT ANCILLARY
    118 RESEARCH
    119 OTHER NON-PATIENT
    120 SUBTOTAL NON-PATIENT


    121 RECOVERY OF EXPENSES (SCHEDULE VII, COLUMN 3, LINE 50)
    122 TOTAL PATIENT AND NON-PATIENT (LINES 116+120+121)
    123 PROVISION FOR BAD DEBT
  123.01 GROSS UNCOMPENSATED CARE POOL ASSESSMENT
    124 TOTAL PATIENT, NON-PATIENT, PROVISION FOR BAD DEBTS AND GROSS UNCOMPENSATED CARE POOL ASSESSMENT ( LINES 122+123+123.01)




                                                                        Page 7
                                                                   SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II      SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                  (2)                  (3)                   (4)               (5)                (6)                   (7)
                                         EXPENSE            DIRECT             EXPENSE              EXPENSE               PATIENT SER.              PATIENT SER.
                                         BEFORE             EXPENSE                AFTER             AFTER                    EXPENSE BY            EXPENSE BY
                                         RECLASS.                              STEPDOWN             STEPDOWN                     DEPT.                  DEPT.
                                                                                   EXCL CAP          INCL CAP           EXCL CAP              INCL CAP
                                        (SCH IX,C8)        (SCH IX,C12)       (SCH XIV,C25)        (SCH XV,C25)        (SCH XVII,L37)        (SCH XVIII,L37)
                OVERHEAD
              1 DEP                                                           xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              2 LEASE                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              3 INT-LT                                                        xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              4 AMOR.BOND ISSUE COSTS                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              5 SUB                     xxxxxxxxxxxxxxxx                      xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              6 FRINGE                                                        xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              7 ADM                                                           xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              8 PURCH                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
              9 GEN.ACCT.                                                     xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          10 PAT.ACCT                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          11 INS-PROF                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          12 INS-HOSP                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          13 INS-OTHER                                                        xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          14 INT-ST                                                           xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          15 SUB                        xxxxxxxxxxxxxxxx                      xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          16 PL MAINT                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          17 PL OP                                                            xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          18 SEC                                                              xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          19 PARK                                                             xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          20 LIC                                                              xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          21 SUB                        xxxxxxxxxxxxxxxx                      xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          22 LAUND                                                            xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          23 HSKP                                                             xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx




                                                                          Page 8
                                                                   SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II   SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                  (2)                  (3)                   (4)               (5)                (6)                   (7)
                                         EXPENSE            DIRECT             EXPENSE              EXPENSE               PATIENT SER.              PATIENT SER.
                                         BEFORE             EXPENSE                AFTER             AFTER                    EXPENSE BY            EXPENSE BY
                                         RECLASS.                              STEPDOWN             STEPDOWN                     DEPT.                  DEPT.
                                                                                   EXCL CAP          INCL CAP           EXCL CAP              INCL CAP
                                        (SCH IX,C8)        (SCH IX,C12)       (SCH XIV,C25)        (SCH XV,C25)        (SCH XVII,L37)        (SCH XVIII,L37)
          24 CAFE                                                             xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          25 DIET                                                             xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          26 MAINT PER                                                        xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          27 NURS ADM                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          28 INSVC ED                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          29 SUB                        xxxxxxxxxxxxxxxx                      xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          30 NURS FL                                       xxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          31 RN+LPN                                                           xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          32 MED-TEACH                                                        xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          33 MED-ADM                                                          xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          34 SUB                        xxxxxxxxxxxxxxxx                      xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          35 POST GRAD                                                        xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          36 CENT SER                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          37 PHARM                                                            xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          38 MED REC                                                          xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          39 MED CARE                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          40 SOC SER                                                          xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          41 CENT TRAN                                     xxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          42 OTHER OH                                                         xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
          43 SUBTOTAL OH                                                      xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx


              ANCILLARY CARE SERVICES
          44 SURG
          45 LABOR




                                                                          Page 9
                                                             SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II   SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                 (2)             (3)            (4)             (5)            (6)                 (7)
                                        EXPENSE       DIRECT          EXPENSE        EXPENSE           PATIENT SER.            PATIENT SER.
                                        BEFORE        EXPENSE         AFTER           AFTER                EXPENSE BY          EXPENSE BY
                                        RECLASS.                      STEPDOWN       STEPDOWN                 DEPT.                DEPT.
                                                                      EXCL CAP        INCL CAP       EXCL CAP            INCL CAP
                                       (SCH IX,C8)   (SCH IX,C12)    (SCH XIV,C25)   (SCH XV,C25)   (SCH XVII,L37)      (SCH XVIII,L37)
          46 REC RM
          47 ANEST
          48 IV THER
          49 MED SUP
          50 DRUG
          51 LAB
          52 BLOOD
          53 BL PROC
          54 EKG
          55 CARD CATH
          56 DIAG RAD
          57 THER RAD
          58 CT SCAN
          59 NUC MED
          60 RESP THER
          61 PULM
          62 EEG
          63 ELEC
          64 PHY THER
          65 OCC THER
          66 SPEECH
          67 REC THER
          68 AUD
          69 PSYCH




                                                                Page 10
                                                                       SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                           (2)             (3)            (4)             (5)            (6)                 (7)
                                                  EXPENSE       DIRECT          EXPENSE        EXPENSE           PATIENT SER.            PATIENT SER.
                                                  BEFORE        EXPENSE         AFTER           AFTER                EXPENSE BY          EXPENSE BY
                                                  RECLASS.                      STEPDOWN       STEPDOWN                 DEPT.                DEPT.
                                                                                EXCL CAP        INCL CAP       EXCL CAP            INCL CAP
                                                 (SCH IX,C8)   (SCH IX,C12)    (SCH XIV,C25)   (SCH XV,C25)   (SCH XVII,L37)      (SCH XVIII,L37)
          70 REN DIAL
          71 ORGAN ACQ
          72 AMB
          73
          74
          75
          76
          77
          78 SUBTOTAL ANCI.



               ROUTINE INPATIENT CARE SERVICES
          79 MED/SURG
          80 PED
          81 OB
          82 PSYCH
          83 VENT UNIT
          84 SNFs
          85
          86
          87
          88 SUBTOTAL ACUTE
          89 ICU
          90 CCU




                                                                          Page 11
                                                                        SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                            (2)             (3)            (4)             (5)            (6)                 (7)
                                                   EXPENSE       DIRECT          EXPENSE        EXPENSE           PATIENT SER.            PATIENT SER.
                                                   BEFORE        EXPENSE         AFTER           AFTER                EXPENSE BY          EXPENSE BY
                                                   RECLASS.                      STEPDOWN       STEPDOWN                 DEPT.                DEPT.
                                                                                 EXCL CAP        INCL CAP       EXCL CAP            INCL CAP
                                                  (SCH IX,C8)   (SCH IX,C12)    (SCH XIV,C25)   (SCH XV,C25)   (SCH XVII,L37)      (SCH XVIII,L37)
          91 NEO
          92
          93
          94
          95
          96
          97 SUBTOTAL ICU
          98 NEWB
          99 CHR
         100 SUBTOTAL I/P


               ROUTINE AMBULATORY CARE SERVICES
         101 EMERG
         102 CLINIC
         103 SAT
         104 SURG
         105 A. DIAL.
         106 H. DIAL.
         107 PSY
         108 H. HEALTH
         109 OBS. BEDS
         110 PRI. REFER.
         111 HOSPITAL LICENSED HEALTH CENTER(S)
         112




                                                                           Page 12
                                                                               SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                              (2)                  (3)             (4)                 (5)                   (6)                 (7)
                                                     EXPENSE            DIRECT          EXPENSE              EXPENSE                 PATIENT SER.            PATIENT SER.
                                                     BEFORE             EXPENSE          AFTER               AFTER                       EXPENSE BY          EXPENSE BY
                                                     RECLASS.                           STEPDOWN             STEPDOWN                       DEPT.                DEPT.
                                                                                         EXCL CAP            INCL CAP              EXCL CAP            INCL CAP
                                                    (SCH IX,C8)        (SCH IX,C12)    (SCH XIV,C25)        (SCH XV,C25)          (SCH XVII,L37)      (SCH XVIII,L37)
         113
         114 SUBTOTAL ROUTINE AMBULATORY SERVICES


         115 TOT. PAT.
         116 TOT PAT+OH


               NON PAT. CARE
         117 NON-PAT ANC                            xxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
         118 RESEARCH
         119 OTH.NON-PAT
         120 SUBTOTAL N/P


         121 RECOVERY                               xxxxxxxxxxxxxxxx
         122 TOTAL PAT & N/P
         123 PROV. BAD DEBT
       123.01 GR UCP ASSMT
         124 TOTPAT+NPAT+B/D+UCP ASSMNT




                                                                                  Page 13
                                                                   SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II      SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                    (8)                (9)                 (10)                 (11)               (12)        (13)         (14)
                                                 GROSS        PAT. EXPENSE         PAT. EXPENSE       GROSS
                                                REVENUE       BY                  BY                 REVENUE            NON-PHYS.    PHYS.       NO. OF
                                                BY DEPT.     SERVICE             SERVICE               BY SERVICE        FTE         FTE         UNITS
                                                             EXCL CAP            INC CAP
                                        (SCH VI,L37)       (SCH XVII,C2)       (SCH XVIII,C2)       (SCH VI,C2)                                 (SCH XVI,L37)
                OVERHEAD
              1 DEP                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
              2 LEASE                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
              3 INT-LT                  xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
              4 AMOR.BOND ISSUE COSTS   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
              5 SUB                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
              6 FRINGE                  xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
              7 ADM                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
              8 PURCH                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
              9 GEN.ACCT.               xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          10 PAT.ACCT                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          11 INS-PROF                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          12 INS-HOSP                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          13 INS-OTHER                  xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          14 INT-ST                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          15 SUB                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
          16 PL MAINT                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          17 PL OP                      xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          18 SEC                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          19 PARK                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          20 LIC                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          21 SUB                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
          22 LAUND                      xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          23 HSKP                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx




                                                                     Page 14
                                                                   SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II   SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                    (8)                (9)                 (10)                 (11)               (12)        (13)         (14)
                                                 GROSS        PAT. EXPENSE         PAT. EXPENSE       GROSS
                                                REVENUE       BY                  BY                 REVENUE            NON-PHYS.    PHYS.       NO. OF
                                                BY DEPT.     SERVICE             SERVICE               BY SERVICE        FTE         FTE         UNITS
                                                             EXCL CAP            INC CAP
                                        (SCH VI,L37)       (SCH XVII,C2)       (SCH XVIII,C2)       (SCH VI,C2)                                 (SCH XVI,L37)
          24 CAFE                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          25 DIET                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          26 MAINT PER                  xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          27 NURS ADM                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          28 INSVC ED                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          29 SUB                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
          30 NURS FL                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          31 RN+LPN                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          32 MED-TEACH                  xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          33 MED-ADM                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          34 SUB                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
          35 POST GRAD                  xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          36 CENT SER                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          37 PHARM                      xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          38 MED REC                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          39 MED CARE                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          40 SOC SER                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          41 CENT TRAN                  xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          42 OTHER OH                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx
          43 SUBTOTAL OH                xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                           xxxxxxxxxxxxxxxxxxx


              ANCILLARY CARE SERVICES
          44 SURG                                          xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          45 LABOR                                         xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx




                                                                     Page 15
                                                                 SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II   SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                  (8)                (9)                 (10)                (11)               (12)       (13)     (14)
                                               GROSS       PAT. EXPENSE         PAT. EXPENSE       GROSS
                                              REVENUE      BY                  BY                 REVENUE            NON-PHYS.   PHYS.    NO. OF
                                              BY DEPT.    SERVICE             SERVICE               BY SERVICE        FTE        FTE      UNITS
                                                           EXCL CAP           INC CAP
                                       (SCH VI,L37)      (SCH XVII,C2)       (SCH XVIII,C2)      (SCH VI,C2)                             (SCH XVI,L37)
          46 REC RM                                      xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          47 ANEST                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          48 IV THER                                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          49 MED SUP                                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          50 DRUG                                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          51 LAB                                         xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          52 BLOOD                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          53 BL PROC                                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          54 EKG                                         xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          55 CARD CATH                                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          56 DIAG RAD                                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          57 THER RAD                                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          58 CT SCAN                                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          59 NUC MED                                     xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          60 RESP THER                                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          61 PULM                                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          62 EEG                                         xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          63 ELEC                                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          64 PHY THER                                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          65 OCC THER                                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          66 SPEECH                                      xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          67 REC THER                                    xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          68 AUD                                         xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          69 PSYCH                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx




                                                                   Page 16
                                                                           SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                            (8)                (9)                 (10)                (11)               (12)       (13)     (14)
                                                         GROSS       PAT. EXPENSE         PAT. EXPENSE       GROSS
                                                        REVENUE      BY                  BY                 REVENUE            NON-PHYS.   PHYS.    NO. OF
                                                        BY DEPT.    SERVICE             SERVICE               BY SERVICE        FTE        FTE      UNITS
                                                                     EXCL CAP           INC CAP
                                                 (SCH VI,L37)      (SCH XVII,C2)       (SCH XVIII,C2)      (SCH VI,C2)                             (SCH XVI,L37)
          70 REN DIAL                                              xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          71 ORGAN ACQ                                             xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          72 AMB                                                   xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          73                                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          74                                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          75                                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          76                                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          77                                                       xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
          78 SUBTOTAL ANCI.                                        xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx                       xxxxxxxxxxxxxxxxxxx



               ROUTINE INPATIENT CARE SERVICES
          79 MED/SURG
          80 PED
          81 OB
          82 PSYCH
          83 VENT UNIT
          84 SNFs
          85
          86
          87
          88 SUBTOTAL ACUTE
          89 ICU
          90 CCU




                                                                             Page 17
                                                                            SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                             (8)                (9)                 (10)              (11)          (12)       (13)     (14)
                                                          GROSS       PAT. EXPENSE         PAT. EXPENSE    GROSS
                                                         REVENUE      BY                  BY               REVENUE       NON-PHYS.   PHYS.    NO. OF
                                                         BY DEPT.    SERVICE             SERVICE            BY SERVICE    FTE        FTE      UNITS
                                                                      EXCL CAP           INC CAP
                                                  (SCH VI,L37)      (SCH XVII,C2)       (SCH XVIII,C2)    (SCH VI,C2)                        (SCH XVI,L37)
          91 NEO
          92
          93
          94
          95
          96
          97 SUBTOTAL ICU
          98 NEWB
          99 CHR
         100 SUBTOTAL I/P


               ROUTINE AMBULATORY CARE SERVICES
         101 EMERG
         102 CLINIC
         103 SAT
         104 SURG
         105 A. DIAL.
         106 H. DIAL.
         107 PSY
         108 H. HEALTH
         109 OBS. BEDS
         110 PRI. REFER.
         111 HOSPITAL LICENSED HEALTH CENTER(S)
         112




                                                                              Page 18
                                                                                  SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                                (8)                   (9)                 (10)              (11)            (12)          (13)          (14)
                                                             GROSS          PAT. EXPENSE         PAT. EXPENSE    GROSS
                                                            REVENUE         BY                  BY               REVENUE        NON-PHYS.       PHYS.         NO. OF
                                                            BY DEPT.       SERVICE             SERVICE            BY SERVICE      FTE           FTE           UNITS
                                                                            EXCL CAP           INC CAP
                                                    (SCH VI,L37)          (SCH XVII,C2)       (SCH XVIII,C2)    (SCH VI,C2)                                  (SCH XVI,L37)
         113
         114 SUBTOTAL ROUTINE AMBULATORY SERVICES                                                                                                            xxxxxxxxxxxxxxxxxxx


         115 TOT. PAT.                                                                                                                                       xxxxxxxxxxxxxxxxxxx
         116 TOT PAT+OH                                                                                                                                      xxxxxxxxxxxxxxxxxxx


               NON PAT. CARE
         117 NON-PAT ANC                                                                                                        xxxxxxxxxxxxx xxxxxxxxxxxx
         118 RESEARCH
         119 OTH.NON-PAT
         120 SUBTOTAL N/P


         121 RECOVERY                               xxxxxxxxxxxxxxxxxxx                                         xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
         122 TOTAL PAT & N/P                                                                                                                                 xxxxxxxxxxxxxxxxxxx
         123 PROV. BAD DEBT                         xxxxxxxxxxxxxxxxxxx                                         xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
       123.01 GR UCP ASSMT                          xxxxxxxxxxxxxxxxxxx                                         xxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx
         124 TOTPAT+NPAT+B/D+UCP ASSMNT                                                                                                                      xxxxxxxxxxxxxxxxxxx




                                                                                    Page 19
                                                             SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II      SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                    (15)


                                         UNIT OF
                                         MEASURE



                OVERHEAD
              1 DEP                     xxxxxxxxxxxxx    1
              2 LEASE                   xxxxxxxxxxxxx    2
              3 INT-LT                  xxxxxxxxxxxxx    3
              4 AMOR.BOND ISSUE COSTS   xxxxxxxxxxxxx    4
              5 SUB                     xxxxxxxxxxxxx    5
              6 FRINGE                  xxxxxxxxxxxxx    6
              7 ADM                     xxxxxxxxxxxxx    7
              8 PURCH                   xxxxxxxxxxxxx    8
              9 GEN.ACCT.               xxxxxxxxxxxxx    9
          10 PAT.ACCT                   xxxxxxxxxxxxx   10
          11 INS-PROF                   xxxxxxxxxxxxx   11
          12 INS-HOSP                   xxxxxxxxxxxxx   12
          13 INS-OTHER                  xxxxxxxxxxxxx   13
          14 INT-ST                     xxxxxxxxxxxxx   14
          15 SUB                        xxxxxxxxxxxxx   15
          16 PL MAINT                   xxxxxxxxxxxxx   16
          17 PL OP                      xxxxxxxxxxxxx   17
          18 SEC                        xxxxxxxxxxxxx   18
          19 PARK                       xxxxxxxxxxxxx   19
          20 LIC                        xxxxxxxxxxxxx   20
          21 SUB                        xxxxxxxxxxxxx   21
          22 LAUND                      xxxxxxxxxxxxx   22
          23 HSKP                       xxxxxxxxxxxxx   23




                                                               Page 20
                                                             SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II   SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                    (15)


                                         UNIT OF
                                         MEASURE



          24 CAFE                       xxxxxxxxxxxxx   24
          25 DIET                       xxxxxxxxxxxxx   25
          26 MAINT PER                  xxxxxxxxxxxxx   26
          27 NURS ADM                   xxxxxxxxxxxxx   27
          28 INSVC ED                   xxxxxxxxxxxxx   28
          29 SUB                        xxxxxxxxxxxxx   29
          30 NURS FL                    xxxxxxxxxxxxx   30
          31 RN+LPN                     xxxxxxxxxxxxx   31
          32 MED-TEACH                  xxxxxxxxxxxxx   32
          33 MED-ADM                    xxxxxxxxxxxxx   33
          34 SUB                        xxxxxxxxxxxxx   34
          35 POST GRAD                  xxxxxxxxxxxxx   35
          36 CENT SER                   xxxxxxxxxxxxx   36
          37 PHARM                      xxxxxxxxxxxxx   37
          38 MED REC                    xxxxxxxxxxxxx   38
          39 MED CARE                   xxxxxxxxxxxxx   39
          40 SOC SER                    xxxxxxxxxxxxx   40
          41 CENT TRAN                  xxxxxxxxxxxxx   41
          42 OTHER OH                   xxxxxxxxxxxxx   42
          43 SUBTOTAL OH                xxxxxxxxxxxxx   43


              ANCILLARY CARE SERVICES
          44 SURG                                       44
          45 LABOR                                      45




                                                               Page 21
                                                      SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II   SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                 (15)


                                       UNIT OF
                                       MEASURE



          46 REC RM                              46
          47 ANEST                               47
          48 IV THER                             48
          49 MED SUP                             49
          50 DRUG                                50
          51 LAB                                 51
          52 BLOOD                               52
          53 BL PROC                             53
          54 EKG                                 54
          55 CARD CATH                           55
          56 DIAG RAD                            56
          57 THER RAD                            57
          58 CT SCAN                             58
          59 NUC MED                             59
          60 RESP THER                           60
          61 PULM                                61
          62 EEG                                 62
          63 ELEC                                63
          64 PHY THER                            64
          65 OCC THER                            65
          66 SPEECH                              66
          67 REC THER                            67
          68 AUD                                 68
          69 PSYCH                               69




                                                        Page 22
                                                                      SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                             (15)


                                                  UNIT OF
                                                  MEASURE



          70 REN DIAL                                            70
          71 ORGAN ACQ                                           71
          72 AMB                                                 72
          73                                                     73
          74                                                     74
          75                                                     75
          76                                                     76
          77                                                     77
          78 SUBTOTAL ANCI.                      xxxxxxxxxxxxx   78



               ROUTINE INPATIENT CARE SERVICES
          79 MED/SURG                                            79
          80 PED                                                 80
          81 OB                                                  81
          82 PSYCH                                               82
          83 VENT UNIT                                           83
          84 SNFs                                                84
          85                                                     85
          86                                                     86
          87                                                     87
          88 SUBTOTAL ACUTE                                      88
          89 ICU                                                 89
          90 CCU                                                 90




                                                                        Page 23
                                                                  SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                            (15)


                                                  UNIT OF
                                                  MEASURE



          91 NEO                                             91
          92                                                 92
          93                                                 93
          94                                                 94
          95                                                 95
          96                                                 96
          97 SUBTOTAL ICU                                    97
          98 NEWB                                            98
          99 CHR                                             99
         100 SUBTOTAL I/P                                   100


               ROUTINE AMBULATORY CARE SERVICES
         101 EMERG                                          101
         102 CLINIC                                         102
         103 SAT                                            103
         104 SURG                                           104
         105 A. DIAL.                                       105
         106 H. DIAL.                                       106
         107 PSY                                            107
         108 H. HEALTH                                      108
         109 OBS. BEDS                                      109
         110 PRI. REFER.                                    110
         111 HOSPITAL LICENSED HEALTH CENTER(S)             111
         112                                                112




                                                                    Page 24
                                                                             SCHEDULE-II


HOSPITAL______________________
FOR FISCAL YEAR ENDED ______________


SCHEDULE II    SUMMARY SCHEDULE


DHCFP-403 VERSION 2005                                (15)


                                                     UNIT OF
                                                     MEASURE



         113                                                          113
         114 SUBTOTAL ROUTINE AMBULATORY SERVICES   xxxxxxxxxxxxx     114


         115 TOT. PAT.                              xxxxxxxxxxxxx     115
         116 TOT PAT+OH                             xxxxxxxxxxxxx     116


               NON PAT. CARE
         117 NON-PAT ANC                            xxxxxxxxxxxxx     117
         118 RESEARCH                               xxxxxxxxxxxxx     118
         119 OTH.NON-PAT                            xxxxxxxxxxxxx     119
         120 SUBTOTAL N/P                           xxxxxxxxxxxxx     120


         121 RECOVERY                               xxxxxxxxxxxxx     121
         122 TOTAL PAT & N/P                        xxxxxxxxxxxxx     122
         123 PROV. BAD DEBT                         xxxxxxxxxxxxx     123
       123.01 GR UCP ASSMT                          xxxxxxxxxxxxx   123.01
         124 TOTPAT+NPAT+B/D+UCP ASSMNT             xxxxxxxxxxxxx     124




                                                                               Page 25
                                                            SCHEDULE-III


HOSPITAL______________________
FOR FISCAL YEAR ENDED___________


SCHEDULE III              PATIENT STATISTICS
DHCFP-403 VERSION 2005
                            (2)                  (3)         (4)               (5)           (6)         (7)
                          WGT. AVG.            WGT. AVG.   WGT. AVG.         MAX.LICENSED   INPATIENT   PERCENTAGE
 INPATIENT                AVAILABLE            STAFFED     LICENSED          BED DAYS        DAYS       OF OCCUPANCY
 SERVICE                  BEDS                 BEDS        BEDS              AVAILABLE                  (C6/C5)x100


1 MED/SURG
2 PEDIATRIC
3 OBSTETRIC
4 PSYCHIATRIC
5 VENT UNIT
6 SNFs
7
8
9
10 SUBTOT. ACUTE
11 MED/SURG, ICU
12 CORONARY ICU
13 NEONATAL ICU
14
15
16
17
18
19 SUBTOTAL ICU
20 NEWBORN NURS.
21 CHRONIC+REHAB
22 TOTAL
23 # MED ADMISS:
24 # SUR ADMISS:
25 # DELIVERIES:




                                                                   Page 26
                                                                   SCHEDULE-III


HOSPITAL______________________
FOR FISCAL YEAR ENDED___________


SCHEDULE III              PATIENT STATISTICS
DHCFP-403 VERSION 2005
                            (2)                   (3)               (4)                (5)          (6)         (7)
                          WGT. AVG.            WGT. AVG.          WGT. AVG.         MAX.LICENSED   INPATIENT   PERCENTAGE
INPATIENT                 AVAILABLE            STAFFED            LICENSED          BED DAYS        DAYS       OF OCCUPANCY
SERVICE                   BEDS                 BEDS               BEDS              AVAILABLE                  (C6/C5)x100


26 # NEWB. DAYS:


* 366 IN LEAP YEARS
** IN COMPUTING AVERAGE LENGTH OF STAY, ONLY ICU COST CENTERS INCLUDE TRANSFERS OUT.




                                                                          Page 27
                                                              SCHEDULE-III


HOSPITAL______________________
FOR FISCAL YEAR ENDED___________


SCHEDULE III
DHCFP-403 VERSION 2005
                            (8)            (9)         (10)           (11)      (12)       (13)
                           AVERAGE        ADMISSIONS   TRANSFERS      TRANSFERSDISCHARGES AVG. LENGTH
 INPATIENT                 DAILY CENSUS                IN             OUT      (INCLUDE   OF STAY
 SERVICE                   (C6/365*)                                           DEATHS)    (C6/C12**)


1 MED/SURG                                                                                               1
2 PEDIATRIC                                                                                              2
3 OBSTETRIC                                                                                              3
4 PSYCHIATRIC                                                                                            4
5 VENT UNIT                                                                                              5
6 SNFs                                                                                                   6
7                                                                                                        7
8                                                                                                        8
9                                                                                                        9
10 SUBTOT. ACUTE                                                                                        10
11 MED/SURG, ICU                                                                                        11
12 CORONARY ICU                                                                                         12
13 NEONATAL ICU                                                                                         13
14                                                                                                      14
15                                                                                                      15
16                                                                                                      16
17                                                                                                      17
18                                                                                                      18
19 SUBTOTAL ICU                                                                                         19
20 NEWBORN NURS.                                                                                        20
21 CHRONIC+REHAB                                                                                        21
22 TOTAL                                                                                                22
23 # MED ADMISS:                                                                                        23
24 # SUR ADMISS:                                                                                        24
25 # DELIVERIES:                                                                                        25




                                                                   Page 28
                                                                   SCHEDULE-III


HOSPITAL______________________
FOR FISCAL YEAR ENDED___________


SCHEDULE III
DHCFP-403 VERSION 2005
                            (8)              (9)            (10)           (11)        (12)        (13)
                           AVERAGE         ADMISSIONS      TRANSFERS      TRANSFERSDISCHARGES AVG. LENGTH
INPATIENT                  DAILY CENSUS                    IN             OUT          (INCLUDE   OF STAY
SERVICE                    (C6/365*)                                                   DEATHS)    (C6/C12**)


26 # NEWB. DAYS:                                                                                               26


* 366 IN LEAP YEARS
** IN COMPUTING AVERAGE LENGTH OF STAY, ONLY ICU COST CENTERS INCLUDE TRANSFERS OUT.




                                                                       Page 29
                                                                     SCHEDULE-IIIA


HOSPITAL______________________
FOR FISCAL YEAR ENDED___________


SCHEDULE III-A           RECONCILIATION OF PATIENT DAYS REPORTED ON SCHEDULE III AND SCHEDULES V OR V-A


DHCFP-403 VERSION 2005


 INPATIENT
 SERVICE                 SCH. III        SCH. V-A       DIFFERENCE       EXPLANATION


1 MED/SURG
2 PEDIATRIC
3 OBSTETRIC
4 PSYCHIATRIC
5 VENT UNIT
6 SNFs
7
8
9
10 SUBTOT. ACUTE
11 MED/SURG ICU
12 CORONARY ICU
13 NEONATAL ICU
14
15
16
17
18
19 SUBTOTAL ICU
20 NEWBORN NURS.
21 CHRONIC+REHAB
22 TOTAL




                                                                        Page 30
                                                                  SCHEDULE-IIIB


HOSPITAL______________________
FOR FISCAL YEAR ENDED___________


   SCHEDULE III-B                                                         SUPPLEMENTARY INFORMATION-OBSERVATION BEDS
   DHCFP-403 VERSION 2005



   DOES THE HOSPITAL HAVE A DISTINCT UNIT FOR OBSERVATION BEDS?
   -----YES. IF YES, COMPLETE SECTION A AND SEE INSTRUCTIONS.
   ----- NO. IF NO, COMPLETE SECTION B AND SEE INSTRUCTIONS.


   SECTION A.                                                                            COL 2          COL 3
   ---------
 1 TOTAL OBSERVATION BEDS HOURS:                                                    ____________     XXXXXX



   SECTION B.
   ---------
   COMPUTATION OF EQUIVALENT OBSERVATION BEDS DAYS
 1 TOTAL OBSERVATION BEDS HOURS:                                                    ____________     XXXXXX
 2 DIVIDE BY 24 HOURS:                                                                    24         XXXXXX
 3 EQUIVALENT OBSERVATION BEDS DAYS:                                                ____________     XXXXXX


   APPORTIONMENT OF EQUIVALENT OBSERVATION BEDS DAYS


 4 SCH.III, COL 6, LINE 10                                                          ____________     XXXXXX
 5 LESS: SCH.III, COL 6, LINE 6                                                     ____________     XXXXXX
 6 ACUTE I/P DAYS EXCLUDING SNFs DAYS:                                              ____________     XXXXXX
                                                                                                        RATIO
 7 EQUIVALENT OBSERVATION BEDS DAYS (FROM LINE 3):                                  ____________   COL2 L7 / COL2 L9
 8 ACUTE I/P DAYS EXCLUDING SNFs DAYS (FROM LINE 6):                                ____________   COL2 L8 / COL2 L9
 9 TOTAL (LINE 7 + LINE 8):                                                         ____________    _________




                                                                     Page 31
                                                          SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV   SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



A. TEACHING STATUS               YES     NO


1. ARE YOU A MEMBER OF THE COUNCIL OF
  TEACHING HOSPITALS?             ___ ___


2. DO YOU HAVE AN AFFILIATION WITH A
  MEDICAL SCHOOL?               ___ ___
  IF YES, LIST THE NAME OF THE SCHOOL(S)
  AND AFFILIATION.


3. DO YOU OFFER AN ACCREDITED RESIDENCY
  TRAINING PROGRAM?               ___ ___
  IF YES, LIST THE PROGRAMS THAT YOUR
  HOSPITAL IS ACCREDITED FOR AND THE
  NUMBER OF FULL-TIME EQUIVALENT
  RESIDENTS WHO COMPLETED TRAINING
  DURING THE PAST YEAR.


4. DO YOU OPERATE A SCHOOL OF NURSING?        ___ ___
  IF YES, PLEASE SPECIFY THE TYPE OF
  DEGREE(S) AWARDED, THE LENGTH OF
  THE PROGRAM(S), AND THE NUMBER OF
  STUDENTS.


5. DO YOU HAVE OTHER HEALTH PROFESSIONAL        ___ ___
  EDUCATION PROGRAMS?
  IF YES, LIST THE TYPE OF PROGRAM(S),
  THE TYPE OF DEGREE(S) AWARDED, THE
  LENGTH OF PROGRAM(S), AND THE NUMBER
  OF STUDENTS.




                                                            Page 32
                                                               SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV    SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



B. SERVICE CHANGES       YES    NO


1. WERE ANY BEDS ADDED, DELETED, OR      ___ ___
  CONVERTED TO A NEW USE?
  IF YES, PLEASE SPECIFY THE NUMBER OF
  BEDS, SERVICES AFFECTED, AND DATE
  OF CHANGE.


2. ORGANIZATIONAL CHANGES


 a. PLEASE INDICATE WHETHER THE HOSPITAL HAS MERGED OR TAKEN
   PART IN AN ACQUISITION WITH ANOTHER PROVIDER DURING THE
   FISCAL YEAR.


    ___ MERGER
    ___ ACQUISITION




                                                                 Page 33
                                                               SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV   SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



   FOR EACH PROVIDER WITH WHOM THE HOSPITAL HAS MERGED OR
   FOR EACH PROVIDER THAT THE HOSPITAL HAS ACQUIRED, PLEASE
   PROVIDE THE FOLLOWING INFORMATION:


   PROVIDER NAME __________________________


   PROVIDER TYPE:


      ___ ACUTE CARE HOSPITAL


      ___ NON-ACUTE HOSPITAL (PLEASE SPECIFY TYPE BELOW)
          ___ REHABILITATION
          ___ CHRONIC
          ___ CHRONIC/REHABILITATION
          ___ PSYCHIATRIC
          ___ OTHER (PLEASE INDICATE TYPE) ___________


      ___ PHYSICIAN GROUP


      ___ NURSING HOME


      ___ HOSPICE


      ___ OTHER (PLEASE INDICATE TYPE) _______________



 b. FOR EACH FORMAL, FINANCIAL ARRANGEMENT/RELATIONSHIP THE
   HOSPITAL HAS WITH ANOTHER SIGNIFICANT HEALTHCARE PROVIDER
   ORGANIZATION, PLEASE PROVIDE THE INFORMATION REQUESTED
   BELOW. (NOTE: DO NOT INCLUDE RELATIONSHIPS WITH
   INDIVIDUAL PHYSICIANS OR SUPPLY VENDORS).




                                                                 Page 34
                                                           SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV   SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



   PROVIDER NAME __________________________


   PROVIDER TYPE:


      ___ ACUTE CARE HOSPITAL


      ___ NON-ACUTE HOSPITAL (PLEASE SPECIFY TYPE BELOW)
          ___ REHABILITATION
          ___ CHRONIC
          ___ CHRONIC/REHABILITATION
          ___ PSYCHIATRIC
          ___ OTHER (PLEASE INDICATE TYPE) ___________


      ___ PHYSICIAN GROUP


      ___ NURSING HOME


      ___ HOSPICE


      ___ OTHER (PLEASE INDICATE TYPE) _______________



   NATURE OF ARRANGEMENT:


        ___ AFFILIATION
        ___ REFERRAL



        ___ RISK SHARING
        ___ OTHER (PLEASE INDICATE TYPE) ______________




                                                             Page 35
                                                               SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV   SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



   WAS THIS A NEW ARRANGEMENT IN THIS FISCAL YEAR?
        ___ YES
        ___ NO


 c. DOES THE HOSPITAL HAVE ANY FORMAL, FINANCIAL
   ARRANGEMENTS/AGREEMENTS WITH EMPLOYERS WHEREBY THE
   EMPLOYER DIRECTLY CONTRACTS WITH THE HOSPITAL FOR BOTH
   INPATIENT AND OUTPATIENT SERVICES OR WHEREBY THE EMPLOYER
   AND HOSPITAL ARE INVOLVED IN A RISK SHARING AGREEMENT FOR
   BOTH INPATIENT AND OUTPATIENT SERVICES?


   ___ YES _____(PLEASE INDICATE HOW MANY EMPLOYERS)
   ___ NO


   NUMBER OF ARRANGEMENTS IN QUESTION 2 ABOVE WHICH WERE NEW
   IN THIS FISCAL YEAR?   _____




3. WERE ANY COSTS ASSOCIATED WITH PHYSICIANS ___ ___
  CHANGING FROM HOSPITAL BASED EMPLOYMENT
  OR FEE FOR SERVICES ARRANGEMENTS TRANS-
  FERRED ON OR OFF?


  IF YES, SPECIFY THE DEPARTMENT AFFECTED, ___ ___
  DATE OF THE TRANSFER, AND LIST THE
  ASSOCIATED COSTS AND GROSS REVENUES.


4. WERE ANY DETERMINATION OF NEED APPLI-    ___ ___
  CATIONS APPROVED?


  IF YES, GIVE DATE OF APPROVAL, PROJECT




                                                                 Page 36
                                                     SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV     SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



  NUMBER, BRIEF PROJECT DESCRIPTION, APPROVED
  CAPITAL EXPENDITURES AND ESTIMATED DATE OF
  COMPLETION.


5. WERE ANY DETERMINATION OF NEED PROJECTS ___ ___
  OPERATIONALIZED?


  IF YES, GIVE DATE OF APPROVAL, PROJECT
  NUMBER, BRIEF PROJECT DESCRIPTION, FINAL
  CAPITAL EXPENDITURES, AND THE DATE THAT
  THE OPERATIONS BEGAN.




                                                       Page 37
                                                        SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV       SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



C.    PERSONNEL


      EMPLOYEE CLASSIFICATION                           NO. FTE


1.    .01 MANAGEMENT + SUPERVISION


2.    .02 TEACHING + SPECIALIST


3.    .03 REGISTERED NURSES


4.    .04 LICENSED PRACTICAL NURSES


5.    .05 AIDES, ORDERLIES + ATTENDANTS


6.    .06 PHYSICIANS


7.    .07 INTERNS, RESIDENTS, + FELLOWS


8.    .08 NON -PHYSICIAN MEDICAL PRACTITIONERS


9.    .11 ENVIRONMENT, HOTEL + FOOD SERVICE EMPLOYEES


10. .12 CLERICAL + OTHER ADMINISTRATIVE EMPLOYEES


11.    TOTAL




                                                           Page 38
                                                                                               SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV     SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



D. RN/LPN/CAN WAGE DATA




Section D: Salary and Benefit Data


                                                Salaries and
                                                   Wages
                                                                     Shift       Overtime
                                                 (Excludes                                      Total Salaries
                     Employee Classification                     differential   differential                     Fringe Benefits   Total Hours
                                                  Overtime                                       and Wages
                                                                   wages          wages
                                                  and Shift
                                                Differentials)

                   Registered Nurse
  1                                                                                             xxxxxxxxxxx
                   - Medical/Surgical
                   Registered Nurse -
  2                                                                                             xxxxxxxxxxx
                   Specialist
  3                Licensed Practical Nurse                                                     xxxxxxxxxxx
  4                Certified Nurse Assistants                                                   xxxxxxxxxxx
                   TOTAL                                                                       xxxxxxxxxxxxx




E. MASSHEALTH PROVIDERS




                                                                                                  Page 39
                                                                                      SCHEDULE-IV




FOR FISCAL YEAR ENDING ______



SCHEDULE IV    SUPPLEMENTARY INFORMATION
DHCFP-403 VERSION 2005



List all MassHealth provider numbers for the hospital and related entities for which costs are reported on this DHCFP-403.
List the MassHealth (VPN) number, the name of the organization if different from the hospital, the Medicare Provider Number and the address if different from the hospital.

                                           Name of Organization                                             Address
                    MassHealth Number (VPN)(if different from hospital) Medicare Provider Number (if different from hospital)
1      Provider 1
2                                         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
3                                         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
4      Provider 2
5                                         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
6                                         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
7      Provider 3
8                                         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
9                                         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
10     Provider 4
11                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
12                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
13     Provider 5
14                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
15                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
16     Provider 6
17                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
18                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
19     Provider 7
20                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
21                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
22     Provider 8
23                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
24                                        xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                                                       xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
       etc.




                                                                                          Page 40
                                                         COVER-SCH-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


       SCHEDULE V-A                                                     PAYOR INFORMATION
       DHCFP-403 VERSION 2005


       INPATIENT PAYOR INFORMATION


       INPATIENT
       STATISTICS


       PATIENT DAYS
   1   MEDICAL/SURGICAL
   2   PEDIATRIC
   3   OBSTETRIC
   4   PSYCHIATRIC
   5   VENTILATOR UNIT
   6   SKILLED NURSING FACILITIES
   7
   8
   9
  10 SUBTOTAL ACUTE
  11   MEDICAL/SURGICAL INTENSIVE CARE
  12   CORONARY INTENSIVE CARE
  13   NEONATAL INTENSIVE CARE
  14
  15
  16
  17
  18
  19 SUBTOTAL INTENSIVE CARE
  20 NEWBORN NURSERY
  21 CHRONIC AND REHABILITATION
  22 TOTAL PATIENT DAYS (TOTAL LINES 10+19+20+21)
  23   ADMINISTRATIVELY NECESSARY DAYS (INCLUDE ABOVE)




                                                            Page 41
                                                                      COVER-SCH-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


       SCHEDULE V-A                                                                  PAYOR INFORMATION
       DHCFP-403 VERSION 2005


  24   ADMISSIONS
  25   DISCHARGES




       OUTPATIENT VISITS:


  26 EMERGENCY SERVICES
  27 CLINIC / AMBULATORY SERVICES
  28 SATTELITE CLINIC SERVICES
  29 AMBULATORY SURGERY SERVICES
  30 AMBULATORY RENAL DIALYSIS SERVICES
  31 HOME DIALYSIS SERVICES
  32 PSYCHIATRIC / PSYCHOLOGICAL SERVICES
  33 HOME HEALTH SERVICES
  34 OBSERVATION BEDS
  35 PRIVATE REFERRALS
  36 HOSPITAL LICENSED HEALTH CENTER(S)
  37
  38
  39 TOTAL OUTPATIENT DEPARTMENT VISITS (TOTAL LINES 26 THROUGH 38)



       GROSS PATIENT SERVICE REVENUE
  40 INPATIENT ROUTINE




                                                                         Page 42
                                                               COVER-SCH-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


     SCHEDULE V-A                                                             PAYOR INFORMATION
     DHCFP-403 VERSION 2005


  41 INPATIENT ANCILLARY
  42 OUTPATIENT ROUTINE
  43 OUTPATIENT ANCILLARY
  44 TOTAL GROSS PATIENT SERVICE REVENUE (LINES 40+41+42+43)


      DEDUCTIONS
  45 CONTRACTUAL ADJUSTMENTS
      FREE CARE
  46 GENERAL LEDGER PATIENT
  47 EMPLOYEE
  48 COURTESY
  49 OTHER FREE CARE
  50 TOTAL FREE CARE (LINES 46+47+48+49)
  51 TOTAL DEDUCTIONS (LINES 45+50)
  52 GROSS RECEIPTS FROM UNCOMPENSATED CARE POOL
52.01 TOTAL NET PATIENT SERVICE REVENUE (LINES 44-51+52)
52.02 TOTAL PREMIUM REVENUE (LINES 65.02+ 78.02)
  53 PROVISION FOR BAD DEBTS
  54 BAD DEBTS WRITTEN OFF


      INPATIENT GROSS PATIENT SERVICE REVENUE


  55 INPATIENT ROUTINE
  56 INPATIENT ANCILLARY
  57 TOTAL INPATIENT GROSS PATIENT SERVICE REVENUE


      DEDUCTIONS


  58 CONTRACTUAL ADJUSTMENTS




                                                                  Page 43
                                                       COVER-SCH-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


     SCHEDULE V-A                                                     PAYOR INFORMATION
     DHCFP-403 VERSION 2005


      FREE CARE
  59 GENERAL LEDGER PATIENT
  60 EMPLOYEE
  61 COURTESY
  62 OTHER FREE CARE
  63 TOTAL FREE CARE (LINES 59+60+61+62)
  64 TOTAL DEDUCTIONS (LINES 58+63)
  65 GROSS RECEIPTS FROM UNCOMPENSATED CARE POOL
65.01 NET INPATIENT SERVICE REVENUE (LINES 57-64+65)
65.02 I/P PREMIUM REVENUE
  66 PROVISION FOR BAD DEBTS
  67 BAD DEBTS WRITTEN OFF


      OUTPATIENT GROSS PATIENT SERVICE REVENUE
  68 OUTPATIENT ROUTINE
  69 OUTPATIENT ANCILLARY
  70 TOTAL OUTPATIENT GROSS PATIENT SERVICE REVENUE


      DEDUCTIONS
  71 CONTRACTUAL ADJUSTMENTS


      FREE CARE
  72 GENERAL LEDGER PATIENT
  73 EMPLOYEE
  74 COURTESY
  75 OTHER FREE CARE
  76 TOTAL FREE CARE (LINES 72+73+74+75)
  77 TOTAL DEDUCTIONS (LINES 71+76)
  78 GROSS RECEIPTS FROM UNCOMPENSATED CARE POOL




                                                          Page 44
                                                        COVER-SCH-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


     SCHEDULE V-A                                                      PAYOR INFORMATION
     DHCFP-403 VERSION 2005


78.01 NET OUTPATIENT SERVICE REVENUE (LINES 70-77+78)
78.02 O/P PREMIUM REVENUE
  79 PROVISION FOR BAD DEBTS
  80 BAD DEBTS WRITTEN OFF




                                                           Page 45
                                                             SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


          SCHEDULE V-A                                           PAYOR INFORMATION
          DHCFP-403 VERSION 2005


                                          (2)          (3)              (4)          (5)              (6)      (7)         (8)
                                        TOTAL                MEDICARE                      MEDICAID         WORKERS      SELF PAY
                                   (C.3 THRU C.12)   MANAGED     NON-MANAGED   MANAGED        NON-MANAGED COMPENSATION
          INPATIENT
          STATISTICS


          PATIENT DAYS
      1   MED/SURG
      2   PEDI
      3   OB
      4   PSYCH
      5   VENT UNIT
      6   SNFs
      7
      8
      9
     10 SUBTOTAL ACUTE
     11   ICU
     12   CCU
     13   NEO
     14
     15
     16
     17
     18
     19 SUBTOTAL ICU
     20 NEWB
     21 CHR + REHAB
     22 TOTAL PATIENT DAYS




                                                                Page 46
                                                             SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


          SCHEDULE V-A                                           PAYOR INFORMATION
          DHCFP-403 VERSION 2005


                                          (2)          (3)              (4)          (5)              (6)      (7)         (8)
                                        TOTAL                MEDICARE                      MEDICAID         WORKERS      SELF PAY
                                   (C.3 THRU C.12)   MANAGED     NON-MANAGED   MANAGED        NON-MANAGED COMPENSATION
     23   ANDS
     24   ADM
     25   DIS



          OUTPATIENT
          STATISTICS


     26 EMERG SVCS
     27 CLINIC/AMB
     28 SAT. CLIN
     29 AMB SURGERY
     30 AMB RENAL DIAL
     31 HOME DIAL SVC
     32 PSYCHIATRY
     33 HOME HEALTH
     34 OBSERVATION BEDS
     35 PRIVATE REFER
     36 HOSPITAL LIC HEALTH CENT
     37
     38
     39 TOTAL OPD STATS



           GPSR
     40 I/P ROUTINE




                                                                Page 47
                                                            SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


        SCHEDULE V-A                                            PAYOR INFORMATION
        DHCFP-403 VERSION 2005


                                         (2)          (3)              (4)          (5)              (6)      (7)         (8)
                                       TOTAL                MEDICARE                      MEDICAID         WORKERS      SELF PAY
                                  (C.3 THRU C.12)   MANAGED     NON-MANAGED   MANAGED        NON-MANAGED COMPENSATION
     41 I/P ANCILLARY
     42 O/P ROUTINE
     43 O/P ANCILLARY
     44 TOTAL


          DEDUCT
     45 CONT-ADJ
         FREE CARE:
     46 GENERAL LEDGER PATIENT
     47 EMPLOYEE
     48 COURTESY
     49 OTHER FREE CARE
     50 TOTAL FREE CARE
     51 TOTAL DED
     52 GR REC FR UCP
   52.01 NET REVENUE
   52.02 TOTAL PREMIUM REVENUE
     53 PROV FOR BAD DEBTS


     54 B/D WRITTEN OFF


          INPATIENT GPSR
     55 INPATIENT ROUTINE
     56 INPATIENT ANCILLARY
     57 TOTAL I/P GPSR




                                                               Page 48
                                                            SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


        SCHEDULE V-A                                            PAYOR INFORMATION
        DHCFP-403 VERSION 2005


                                         (2)          (3)              (4)          (5)              (6)        (7)       (8)
                                       TOTAL                MEDICARE                      MEDICAID           WORKERS    SELF PAY
                                  (C.3 THRU C.12)   MANAGED     NON-MANAGED   MANAGED        NON-MANAGED COMPENSATION
          DEDUCT
     58 CONT-ADJ                                                                                           XXXXXXXXXXXXXXXXXXXXX
         FREE CARE:                                                                                        XXXXXXXXXXXXXXXXXXXXX
     59 GENERAL LEDGER PATIENT                                                                             XXXXXXXXXXXXXXXXXXXXX
     60 EMPLOYEE                                                                                           XXXXXXXXXXXXXXXXXXXXX
     61 COURTESY                                                                                           XXXXXXXXXXXXXXXXXXXXX
     62 OTHER FREE CARE                                                                                    XXXXXXXXXXXXXXXXXXXXX
     63 TOTAL FREE CARE                                                                                    XXXXXXXXXXXXXXXXXXXXX
     64 TOTAL DED                                                                                          XXXXXXXXXXXXXXXXXXXXX
     65 GR REC FR UCP                                                                                      XXXXXXXXXXXXXXXXXXXXX
   65.01 NET I/P REVENUE                                                                                   XXXXXXXXXXXXXXXXXXXXX
   65.02 I/P PREMIUM REVENUE
     66 PROV FOR BAD DEBTS                                                                                 XXXXXXXXXXXXXXXXXXXXX


     67 B/D WRITTEN OFF


          OUTPATIENT GPSR
     68 OUTPATIENT ROUTINE
     69 OUTPATIENT ANCILLARY
     70 TOTAL O/P GPSR



          DEDUCT
     71 CONT-ADJ                                                                                           XXXXXXXXXXXXXXXXXXXXX
         FREE CARE:                                                                                        XXXXXXXXXXXXXXXXXXXXX
     72 GENERAL LEDGER PATIENT                                                                             XXXXXXXXXXXXXXXXXXXXX




                                                               Page 49
                                                            SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


        SCHEDULE V-A                                            PAYOR INFORMATION
        DHCFP-403 VERSION 2005


                                         (2)          (3)              (4)          (5)              (6)        (7)       (8)
                                       TOTAL                MEDICARE                      MEDICAID           WORKERS    SELF PAY
                                  (C.3 THRU C.12)   MANAGED     NON-MANAGED   MANAGED        NON-MANAGED COMPENSATION
     73 EMPLOYEE                                                                                           XXXXXXXXXXXXXXXXXXXXX
     74 COURTESY                                                                                           XXXXXXXXXXXXXXXXXXXXX
     75 OTHER FREE CARE                                                                                    XXXXXXXXXXXXXXXXXXXXX
     76 TOTAL FREE CARE                                                                                    XXXXXXXXXXXXXXXXXXXXX
     77 TOTAL DED                                                                                          XXXXXXXXXXXXXXXXXXXXX
     78 GR REC FR UCP                                                                                      XXXXXXXXXXXXXXXXXXXXX
   78.01 NET O/P REVENUE                                                                                   XXXXXXXXXXXXXXXXXXXXX
   78.02 O/P PREMIUM REVENUE
     79 PROV FOR BAD DEBTS                                                                                 XXXXXXXXXXXXXXXXXXXXX


     80 B/D WRITTEN OFF




                                                               Page 50
                                                              SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


          SCHEDULE V-A
          DHCFP-403 VERSION 2005


                                       (9)        (10)        (11)         (12)       (13)
                                     OTHER      MANAGED   NON-MANAGED     OTHER   NON-PATIENT
                                   GOVERNMENT    CARE        CARE
          INPATIENT
          STATISTICS


          PATIENT DAYS
      1   MED/SURG                                                                               1
      2   PEDI                                                                                   2
      3   OB                                                                                     3
      4   PSYCH                                                                                  4
      5   VENT UNIT                                                                              5
      6   SNFs                                                                                   6
      7                                                                                          7
      8                                                                                          8
      9                                                                                          9
     10 SUBTOTAL ACUTE                                                                          10
     11   ICU                                                                                   11
     12   CCU                                                                                   12
     13   NEO                                                                                   13
     14                                                                                         14
     15                                                                                         15
     16                                                                                         16
     17                                                                                         17
     18                                                                                         18
     19 SUBTOTAL ICU                                                                            19
     20 NEWB                                                                                    20
     21 CHR + REHAB                                                                             21
     22 TOTAL PATIENT DAYS                                                                      22




                                                                     Page 51
                                                              SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


          SCHEDULE V-A
          DHCFP-403 VERSION 2005


                                       (9)        (10)        (11)         (12)       (13)
                                     OTHER      MANAGED   NON-MANAGED     OTHER   NON-PATIENT
                                   GOVERNMENT    CARE        CARE
     23   ANDS                                                                                  23
     24   ADM                                                                                   24
     25   DIS                                                                                   25



          OUTPATIENT
          STATISTICS


     26 EMERG SVCS                                                                              26
     27 CLINIC/AMB                                                                              27
     28 SAT. CLIN                                                                               28
     29 AMB SURGERY                                                                             29
     30 AMB RENAL DIAL                                                                          30
     31 HOME DIAL SVC                                                                           31
     32 PSYCHIATRY                                                                              32
     33 HOME HEALTH                                                                             33
     34 OBSERVATION BEDS                                                                        34
     35 PRIVATE REFER                                                                           35
     36 HOSPITAL LIC HEALTH CENT                                                                36
     37                                                                                         37
     38                                                                                         38
     39 TOTAL OPD STATS                                                                         39



           GPSR
     40 I/P ROUTINE                                                                             40




                                                                     Page 52
                                                             SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


        SCHEDULE V-A
        DHCFP-403 VERSION 2005


                                      (9)        (10)        (11)         (12)       (13)
                                    OTHER      MANAGED   NON-MANAGED     OTHER   NON-PATIENT
                                  GOVERNMENT    CARE        CARE
     41 I/P ANCILLARY                                                                            41
     42 O/P ROUTINE                                                                              42
     43 O/P ANCILLARY                                                                            43
     44 TOTAL                                                                                    44


          DEDUCT
     45 CONT-ADJ                                                                                 45
         FREE CARE:
     46 GENERAL LEDGER PATIENT                                                                   46
     47 EMPLOYEE                                                                                 47
     48 COURTESY                                                                                 48
     49 OTHER FREE CARE                                                                          49
     50 TOTAL FREE CARE                                                                          50
     51 TOTAL DED                                                                                51
     52 GR REC FR UCP                                                                            52
   52.01 NET REVENUE                                                                           52.01
   52.02 TOTAL PREMIUM REVENUE                                                                 52.02
     53 PROV FOR BAD DEBTS                                                                       53


     54 B/D WRITTEN OFF                                                                          54


          INPATIENT GPSR
     55 INPATIENT ROUTINE                                                                        55
     56 INPATIENT ANCILLARY                                                                      56
     57 TOTAL I/P GPSR                                                                           57




                                                                    Page 53
                                                             SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


        SCHEDULE V-A
        DHCFP-403 VERSION 2005


                                      (9)        (10)        (11)         (12)       (13)
                                     OTHER     MANAGED   NON-MANAGED     OTHER   NON-PATIENT
                                  GOVERNMENT    CARE        CARE
          DEDUCT
     58 CONT-ADJ                  XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           58
         FREE CARE:               XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXX
     59 GENERAL LEDGER PATIENT    XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           59
     60 EMPLOYEE                  XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           60
     61 COURTESY                  XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           61
     62 OTHER FREE CARE           XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           62
     63 TOTAL FREE CARE           XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           63
     64 TOTAL DED                 XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           64
     65 GR REC FR UCP             XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           65
   65.01 NET I/P REVENUE          XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX         65.01
   65.02 I/P PREMIUM REVENUE                                                                   65.02
     66 PROV FOR BAD DEBTS        XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           66


     67 B/D WRITTEN OFF                                                                          67


          OUTPATIENT GPSR
     68 OUTPATIENT ROUTINE                                                                       68
     69 OUTPATIENT ANCILLARY                                                                     69
     70 TOTAL O/P GPSR                                                                           70



          DEDUCT
     71 CONT-ADJ                  XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           71
         FREE CARE:               XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX
     72 GENERAL LEDGER PATIENT    XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           72




                                                                    Page 54
                                                             SCHEDULE-VA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


        SCHEDULE V-A
        DHCFP-403 VERSION 2005


                                      (9)        (10)        (11)         (12)       (13)
                                     OTHER     MANAGED   NON-MANAGED     OTHER   NON-PATIENT
                                  GOVERNMENT    CARE        CARE
     73 EMPLOYEE                  XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           73
     74 COURTESY                  XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           74
     75 OTHER FREE CARE           XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           75
     76 TOTAL FREE CARE           XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           76
     77 TOTAL DED                 XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           77
     78 GR REC FR UCP             XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           78
   78.01 NET O/P REVENUE          XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX         78.01
   78.02 O/P PREMIUM REVENUE                                                                   78.02
     79 PROV FOR BAD DEBTS        XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX           79


     80 B/D WRITTEN OFF                                                                          80




                                                                    Page 55
          HOSPITAL______________________
          FOR FISCAL YEAR ENDED _________


          SCHEDULE V-B
          DHCFP-403 VERSION 2005
                                                     (1)                                    (2)      (3)      (4)       (5)        (6)      (7)
                                                                                                  MEDICAID MEDICAID MEDICAID   MEDICAID SELF-PAY
                                                                                                  MANAGED MANAGED NON-MANAGED  NON-MANAGED
                                                                                         TOTAL                       INPATIENT OUTPATIENTINPATIENT
                                                                                                  INPATIENT OUTPATIENT

Line 1    Gross Patient Service Revenue (From Schedule V-A)


Line 2    Base Rate payments
Line 3    High Public Payer disproportionate share
Line 4    Federally Mandated disproportionate share
Line 5    Safety Net payment
Line 6    Supplemental payment, Public Service/Municipal Hospitals
Line 7    Supplemental payment, Commonwealth-Owned Medical School Affiliated Hospitals
Line 8    Supplemental payment, Essential MassHealth Hospitals
Line 9    Other payment (Specify)
Line 10   Other payment (Specify)
Line 11   Other payment (Specify)
Line 12   SUBTOTAL: REVENUE


Line 13   Contractual Adjustment (line 1 less line 12)
   (8)
SELF-PAY

OUTPATIENT




             12
             13
             14
             15
             16
             17
             18
             19
                                                 COVER-SCH-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________



SCHEDULE VI
DHCFP-403 VERSION 2005                                  GROSS PATIENT SERVICE REVENUE




             ROUTINE INPATIENT CARE SERVICES
         1 MEDICAL & SURGICAL ACUTE
         2 PEDIATRIC ACUTE
         3 OBSTETRIC ACUTE
         4 PSYCHIATRIC ACUTE
         5 VENTILATOR UNIT
         6 SKILLED NURSING FACILITIES
         7
         8
         9
        10 SUBTOTAL ACUTE
        11 MEDICAL AND SURGICAL INTENSIVE CARE
        12 CORONARY INTENSIVE CARE
        13 NEONATAL INTENSIVE CARE
        14
        15
        16
        17
        18
        19 SUBTOTAL INTENSIVE CARE
        20 NEWBORN NURSERY
        21 CHRONIC & REHABILITATION
        22 SUBTOTAL INPATIENT




                                                   Page 58
                                                                     COVER-SCH-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________



SCHEDULE VI
DHCFP-403 VERSION 2005                                                      GROSS PATIENT SERVICE REVENUE




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERGENCY SERVICES
        24 CLINIC OR AMBULATORY SERVICES
        25 SATELLITE CLINIC SERVICES
        26 AMBULATORY SURGERY SERVICES
        27 AMBULATORY RENAL DIALYSIS SERVICES
        28 HOME DIALYSIS SERVICES
        29 PSYCHIATRY
        30 HOME HEALTH SERVICES
        31 OBSERVATION BEDS
        32 PRIVATE REFERRALS
        33 HOSPITAL LICENSED HEALTH CENTER(S)
        34
        35
        36 SUBTOTAL AMBULATORY SERVICES


        37 TOTAL INPATIENT AND AMBULATORY CARE (LINE 22 & LINE 36)




                                                                       Page 59
                                                               COVER-SCH-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________



SCHEDULE VI
DHCFP-403 VERSION 2005                                                GROSS PATIENT SERVICE REVENUE




           NON-PATIENT CARE
        38 NON-PATIENT ANCILLARY
        39 RESEARCH
        40 OTHER NON-PATIENT
        41 SUBTOTAL NON-PATIENT


        42 TOTAL PATIENT AND NON-PATIENT (LINE 37 & LINE 41)




                                                                 Page 60
                                                             SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                           (2)       (3)           (4)          (5)       (6)        (7)       (8)     (9)
                                        TOTAL      ROUTINE   ANCILLARY       SURGERY    LABOR     RECOVERY   ANEST      IV
                                         GPSR       GPSR         GPSR                    AND        ROOM             THERAPY
                                       (C.3+C.4)             (C.5 to C.38)             DELIVERY


     ROUTINE INPATIENT CARE SERVICES
 1 MED/SURG
 2 PEDI
 3 OB
 4 PSYCH
 5 VENT UNIT
 6 SNFs
 7
 8
 9
10 SUBTOTAL ACUTE
11 ICU
12 CCU
13 NEO
14
15
16
17
18
19 SUBTOTAL ICU
20 NEWB
21 CHR & REH
22 SUBTOTAL I/P




                                                                  Page 61
                                                            SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


   SCHEDULE VI
   DHCFP-403 VERSION 2005


   GROSS PATIENT SERVICE REVENUE
                                          (2)       (3)           (4)          (5)       (6)        (7)       (8)     (9)
                                       TOTAL      ROUTINE   ANCILLARY       SURGERY    LABOR     RECOVERY   ANEST      IV
                                        GPSR       GPSR         GPSR                    AND        ROOM             THERAPY
                                      (C.3+C.4)             (C.5 to C.38)             DELIVERY




   ROUTINE AMBULATORY CARE SERVICES
23 EMERG
24 CLINIC
25 SAT
26 SURG
27 A. DIAL.
28 H. DIAL.
29 PSY
30 H. HEALTH
31 OBS. BEDS




                                                                 Page 62
                                                           SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                         (2)       (3)           (4)          (5)       (6)        (7)       (8)     (9)
                                      TOTAL      ROUTINE   ANCILLARY       SURGERY    LABOR     RECOVERY   ANEST      IV
                                       GPSR       GPSR         GPSR                    AND        ROOM             THERAPY
                                     (C.3+C.4)             (C.5 to C.38)             DELIVERY


32 PRI. REFER
33 HOSP LIC HEALTH CENTER(S)
34
35
36 SUBTOTAL AMB


37 TOT INP+AMB


     NON-PATIENT CARE
38 NON-PAT ANC
39 RESEARCH
40 OTH. NON-PAT
41 SUBTOTAL N/P


42 TOTPAT+NPAT




                                                                Page 63
                                                            SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                          (10)     (11)       (12)         (13)       (14)      (15)       (16)      (17)
                                       MEDICAL    DRUGS   LABORATORY      BLOOD     BLOOD      EKG     CARD CATH DIAGNOSTIC
                                       SUPPLIES                                   PROCESSING                     RADIOLOGY


     ROUTINE INPATIENT CARE SERVICES
 1 MED/SURG
 2 PEDI
 3 OB
 4 PSYCH
 5 VENT UNIT
 6 SNFs
 7
 8
 9
10 SUBTOTAL ACUTE
11 ICU
12 CCU
13 NEO
14
15
16
17
18
19 SUBTOTAL ICU
20 NEWB
21 CHR & REH
22 SUBTOTAL I/P




                                                              Page 64
                                                           SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


   SCHEDULE VI
   DHCFP-403 VERSION 2005


   GROSS PATIENT SERVICE REVENUE
                                         (10)     (11)       (12)         (13)       (14)      (15)       (16)      (17)
                                      MEDICAL    DRUGS   LABORATORY      BLOOD     BLOOD      EKG     CARD CATH DIAGNOSTIC
                                      SUPPLIES                                   PROCESSING                     RADIOLOGY




   ROUTINE AMBULATORY CARE SERVICES
23 EMERG
24 CLINIC
25 SAT
26 SURG
27 A. DIAL.
28 H. DIAL.
29 PSY
30 H. HEALTH
31 OBS. BEDS




                                                             Page 65
                                                          SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                        (10)     (11)       (12)         (13)       (14)      (15)       (16)      (17)
                                     MEDICAL    DRUGS   LABORATORY      BLOOD     BLOOD      EKG     CARD CATH DIAGNOSTIC
                                     SUPPLIES                                   PROCESSING                     RADIOLOGY


32 PRI. REFER
33 HOSP LIC HEALTH CENTER(S)
34
35
36 SUBTOTAL AMB


37 TOT INP+AMB


     NON-PATIENT CARE
38 NON-PAT ANC
39 RESEARCH
40 OTH. NON-PAT
41 SUBTOTAL N/P


42 TOTPAT+NPAT




                                                            Page 66
                                                               SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                            (18)       (19)        (20)      (21)      (22)     (23)    (24)      (25)
                                       THERAPEUTIC      CT      NUCLEAR RESPIRATORY PULMONARY   EEG    ELEC    PHYSICAL
                                        RADIOLOGY    SCANNER    MEDICINE  THERAPY                              THERAPY


     ROUTINE INPATIENT CARE SERVICES
 1 MED/SURG
 2 PEDI
 3 OB
 4 PSYCH
 5 VENT UNIT
 6 SNFs
 7
 8
 9
10 SUBTOTAL ACUTE
11 ICU
12 CCU
13 NEO
14
15
16
17
18
19 SUBTOTAL ICU
20 NEWB
21 CHR & REH
22 SUBTOTAL I/P




                                                                 Page 67
                                                            SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


   SCHEDULE VI
   DHCFP-403 VERSION 2005


   GROSS PATIENT SERVICE REVENUE
                                         (18)       (19)        (20)      (21)      (22)     (23)    (24)      (25)
                                    THERAPEUTIC      CT      NUCLEAR RESPIRATORY PULMONARY   EEG    ELEC    PHYSICAL
                                     RADIOLOGY    SCANNER    MEDICINE  THERAPY                              THERAPY




   ROUTINE AMBULATORY CARE SERVICES
23 EMERG
24 CLINIC
25 SAT
26 SURG
27 A. DIAL.
28 H. DIAL.
29 PSY
30 H. HEALTH
31 OBS. BEDS




                                                              Page 68
                                                             SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                          (18)       (19)        (20)      (21)      (22)     (23)    (24)      (25)
                                     THERAPEUTIC      CT      NUCLEAR RESPIRATORY PULMONARY   EEG    ELEC    PHYSICAL
                                      RADIOLOGY    SCANNER    MEDICINE  THERAPY                              THERAPY


32 PRI. REFER
33 HOSP LIC HEALTH CENTER(S)
34
35
36 SUBTOTAL AMB


37 TOT INP+AMB


     NON-PATIENT CARE
38 NON-PAT ANC
39 RESEARCH
40 OTH. NON-PAT
41 SUBTOTAL N/P


42 TOTPAT+NPAT




                                                               Page 69
                                                             SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                            (26)      (27)        (28)      (29)       (30)      (31)        (32)
                                       OCCUPATIONAL SPEECH- RECREATIONAL AUDIOLOGY   PSYCH     RENAL       ORGAN
                                          THERAPY  THERAPY     THERAPY                        DIALYSIS   ACQUISITION


     ROUTINE INPATIENT CARE SERVICES
 1 MED/SURG
 2 PEDI
 3 OB
 4 PSYCH
 5 VENT UNIT
 6 SNFs
 7
 8
 9
10 SUBTOTAL ACUTE
11 ICU
12 CCU
13 NEO
14
15
16
17
18
19 SUBTOTAL ICU
20 NEWB
21 CHR & REH
22 SUBTOTAL I/P




                                                               Page 70
                                                          SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


   SCHEDULE VI
   DHCFP-403 VERSION 2005


   GROSS PATIENT SERVICE REVENUE
                                         (26)      (27)        (28)      (29)       (30)      (31)        (32)
                                    OCCUPATIONAL SPEECH- RECREATIONAL AUDIOLOGY   PSYCH     RENAL       ORGAN
                                       THERAPY  THERAPY     THERAPY                        DIALYSIS   ACQUISITION




   ROUTINE AMBULATORY CARE SERVICES
23 EMERG
24 CLINIC
25 SAT
26 SURG
27 A. DIAL.
28 H. DIAL.
29 PSY
30 H. HEALTH
31 OBS. BEDS




                                                            Page 71
                                                           SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                          (26)      (27)        (28)      (29)       (30)      (31)        (32)
                                     OCCUPATIONAL SPEECH- RECREATIONAL AUDIOLOGY   PSYCH     RENAL       ORGAN
                                        THERAPY  THERAPY     THERAPY                        DIALYSIS   ACQUISITION


32 PRI. REFER
33 HOSP LIC HEALTH CENTER(S)
34
35
36 SUBTOTAL AMB


37 TOT INP+AMB


     NON-PATIENT CARE
38 NON-PAT ANC
39 RESEARCH
40 OTH. NON-PAT
41 SUBTOTAL N/P


42 TOTPAT+NPAT




                                                             Page 72
                                                          SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                          (33)     (34)   (35)         (36)   (37)   (38)
                                       AMBULANCE




     ROUTINE INPATIENT CARE SERVICES
 1 MED/SURG                                                                                  1
 2 PEDI                                                                                      2
 3 OB                                                                                        3
 4 PSYCH                                                                                     4
 5 VENT UNIT                                                                                 5
 6 SNFs                                                                                      6
 7                                                                                           7
 8                                                                                           8
 9                                                                                           9
10 SUBTOTAL ACUTE                                                                           10
11 ICU                                                                                      11
12 CCU                                                                                      12
13 NEO                                                                                      13
14                                                                                          14
15                                                                                          15
16                                                                                          16
17                                                                                          17
18                                                                                          18
19 SUBTOTAL ICU                                                                             19
20 NEWB                                                                                     20
21 CHR & REH                                                                                21
22 SUBTOTAL I/P                                                                             22



                                                                 Page 73
                                                         SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


   SCHEDULE VI
   DHCFP-403 VERSION 2005


   GROSS PATIENT SERVICE REVENUE
                                         (33)     (34)   (35)         (36)   (37)   (38)
                                      AMBULANCE




   ROUTINE AMBULATORY CARE SERVICES
23 EMERG                                                                                   23
24 CLINIC                                                                                  24
25 SAT                                                                                     25
26 SURG                                                                                    26
27 A. DIAL.                                                                                27
28 H. DIAL.                                                                                28
29 PSY                                                                                     29
30 H. HEALTH                                                                               30
31 OBS. BEDS                                                                               31



                                                                Page 74
                                                        SCHEDULE-VI


HOSPITAL______________________
FOR FISCAL YEAR ENDED____________


     SCHEDULE VI
     DHCFP-403 VERSION 2005


     GROSS PATIENT SERVICE REVENUE
                                        (33)     (34)   (35)         (36)   (37)   (38)
                                     AMBULANCE




32 PRI. REFER                                                                             32
33 HOSP LIC HEALTH CENTER(S)                                                              33
34                                                                                        34
35                                                                                        35
36 SUBTOTAL AMB                                                                           36

37 TOT INP+AMB                                                                            37

     NON-PATIENT CARE
38 NON-PAT ANC                                                                            38
39 RESEARCH                                                                               39
40 OTH. NON-PAT                                                                           40
41 SUBTOTAL N/P                                                                           41

42 TOTPAT+NPAT                                                                            42




                                                               Page 75
                                                                         SCHEDULE-VIA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _____________________


SCHEDULE VI-A - RECONCILIATION OF PATIENT SERVICE REVENUE
DHCFP-403 VERSION 2005
               RECONCILIATION OF GROSS PATIENT SERVICE REVENUE


                                                                   VARIANCE       EXPLANATION OF VARIANCE
               SCHEDULE VI, COL 2, LINE 37         $---------
               AUDITED FINANCIAL STATEMENT         $---------    $---------       ___________________________



               SCHEDULE VI, COL 2, LINE 37         $---------
               SCHEDULE V-A, COL 2, LINE 44        $---------    $---------       ___________________________


               RECONCILIATION OF NET PATIENT SERVICE REVENUE




               SCHEDULE V-A,COL 2,LINE 52.01       $---------
               NPSR, AUDITED F/S                   $---------    $---------       ___________________________



**             SCHEDULE V-A,COL 2,LINE 52.01       $---------
               SCHEDULE XXIII, COL B, LINE 55      $---------    $---------       ___________________________




** Required for non-acute hospitals only




                                                                              Page 76
                                                               SCHEDULE-VII


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


SCHEDULE VII        OTHER INCOME & RECOVERY OF EXPENSES
DHCFP-403 VERSION 2005


                                                                             (2)      (3)          (4)             (5)
                                                                        AMOUNT      AMOUNT          KEY
                                                                        RECEIVED   RECOVERED   (SCH.IX c.11,   EXPLANATION
                                                                                        *         LINE # )
OTHER INCOME AND RECOVERY OF EXPENSES



1 TRANSFERS FROM RESTRICTED FUNDS FOR RESEARCH EXPENSES
2 TRANSFERS FROM RESTRICTED FUNDS FOR RN/LPN EDUCATION
3 TRANSFERS FROM RESTRICTED FUNDS FOR POSTGRADUATE MEDICAL EDUCATION
4 TRANSFERS FROM RESTRICTED FUNDS FOR OTHER EDUCATION
5 RN/LPN EDUCATION
6 POSTGRADUATE MEDICAL EDUCATION
7 OTHER EDUCATION
8 CAFETERIA SALES
9 LAUNDRY AND LINEN SERVICES
10 EMPLOYEE AND STUDENT HOUSING
11 PURCHASING SERVICES
12 PARKING
13 HOUSEKEEPING SERVICES
14 DATA PROCESSING SERVICES
15 TELEPHONE AND TELEGRAPH
16 SALE OF ABSTRACTS/MED RECORDS
17 DONATED COMMODITIES
18 CASH DISCOUNTS ON PURCHASES
19 SALE OF SCRAP AND WASTE
20 REBATES AND REFUNDS
21 GIFT SHOP AND COFFEE SHOP
22 BAD DEBT RECOVERIES




                                                                   Page 77
                                                                  SCHEDULE-VII


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


SCHEDULE VII        OTHER INCOME & RECOVERY OF EXPENSES
DHCFP-403 VERSION 2005


                                                                                (2)      (3)          (4)             (5)
                                                                           AMOUNT      AMOUNT          KEY
                                                                           RECEIVED   RECOVERED   (SCH.IX c.11,   EXPLANATION
                                                                                           *         LINE # )
OTHER INCOME AND RECOVERY OF EXPENSES



23 VENDING MACHINE COMMISSIONS, INCLUDING TELEPHONES
24 OTHER COMMISSIONS
25 TELEVISION/RADIO RENTALS
26 MANAGEMENT SERVICES
27 SALE OF RADIOLOGY FILM
28 INSURED LOSS
29 TRANSERS FROM RESTRICTED FUNDS FOR OTHER OPERATING EXPENSES(SPECIFY)
30 GAIN OR LOSS ON SALE OF HOSPITAL PROPERTY & EQUIPMENT
31 DONATED SERVICES
32 GROSS PHYSICIAN PRIVATE OFFICE INCOME
33 GROSS OTHER RENTAL INCOME
34 UNRESTRICTED CONTRIBUTIONS
35 INCOME,GAINS & LOSSES FROM UNRESTRICTED INVESTMENTS
36 UNRESTRICTED INCOME FROM ENDOWMENT FUNDS
37 UNRESTRICTED INCOME FROM OTHER FUNDS
38 TERM ENDOWMENT FUNDS BECOMING UNRESTRICTED
39 FUND RAISING
40 FEDERAL GRANTS
41 STATE GRANTS
42 LOCAL GRANTS
43 OTHER GRANTS
44 INCOME RESTRICTED TO PATIENT CARE OPERATIONS




                                                                      Page 78
                                                                SCHEDULE-VII


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


SCHEDULE VII       OTHER INCOME & RECOVERY OF EXPENSES
DHCFP-403 VERSION 2005


                                                                              (2)      (3)          (4)             (5)
                                                                          AMOUNT     AMOUNT          KEY
                                                                         RECEIVED   RECOVERED   (SCH.IX c.11,   EXPLANATION
                                                                                         *         LINE # )
OTHER INCOME AND RECOVERY OF EXPENSES



45 BOARD RESTRICTED INCOME
46 OTHER RESTRICTED INCOME
47 OTHER
48 SUBTOTAL (LINES 1 THRU 47)
49 GAIN/LOSS ON ADVANCE REFUNDING
50 TOTAL


* ANY RECOVERY OF LESS THAN 100% MUST BE ACCOMPANIED BY AN EXPLANATORY NOTE




                                                                    Page 79
                                                                                             SCHEDULE-VIIA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


     SCHEDULE VII-A                                           AMORTIZATION OF GAINS AND LOSSES
     DHCFP-403 VERSION 2005




                         (1)                           (2)               (3)           (4)           (5)                (6)             (7)             (8)             (9)            (10)            (11)


                                                    Year             Year        Amount to be   Years to be
                     Description                    Started        Completed      Amortized     Amortized            2003            2004            2005            2006            2007            2008
                      -----------                   -------         ----------     ---------     ---------            ----            ----            ----            ----            ----            ----
 1
 2
 3
 4
 5
 6
 7
 8
 9
10
11
12
13
14
15


     TOTAL (to be carried forward to SCHEDULE VII for each year)                                              ----            ----            ----            ----            ----            ----




                                                                                                Page 80
                                                                                             SCHEDULE-VIIA


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


     SCHEDULE VII-A
     DHCFP-403 VERSION 2005




                         (1)                           (12)            (13)            (14)             (15)            (16)            (17)            (18)   (19)



                     Description                    2009             2010            2011             2012            2013            2014            2015     2016
                      -----------                     ----            ----            ----             ----            ----            ----            ----     ----
 1
 2
 3
 4
 5
 6
 7
 8
 9
10
11
12
13
14
15


                                              ----            ----
     TOTAL (to be carried forward to SCHEDULE VII for each year)              ----             ----            ----            ----            ----




                                                                                                Page 81
                                                                    SCHEDULE-VIIB


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


         SCHEDULE VII-B   SUPPLEMENTARY SCHEDULE- OTHER INCOME & RECOVERY OF EXPENSES
         DHCFP-403 VERSION 2005
                                                              (2)          (3)               (4)                 (5)


                                                        AMOUNT        AMOUNT                 KEY
         OTHER INCOME AND RECOVERY OF EXPENSES          RECEIVED      RECOVERED     SCH IX COL 11 LINE NO.   EXPLANATION



     1
     2
     3
     4
     5
     6
     7
     8
     9
    10
    11
    12
    13
    14
    15
    16
    17
    18
    19
    20


         * ANY RECOVERY OF LESS THAN 100% MUST BE ACCOMPANIED BY AN EXPLANATORY NOTE




                                                                       Page 82
                                                                                    SCHEDULE-VIIC


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________


SCHEDULE VII-C                         RECONCILIATION OF OTHER INCOME
DHCFP-403 VERSION 2005
                                                                                         EXPLANATION OF
                                                      SUBTOTAL        VARIANCE                VARIANCE
1 SCHEDULE VII, COL 2, LINE 48         $-----------
2 LESS: SCHEDULE VII, COL 2, LINE 22   $-----------   $-----------


AUDITED FINANCIAL STATEMENTS:
3 OTHER REVENUE                        $-----------
4 ADD: NET NONOPERATING GAIN/LOSS $-----------        $-----------   $-----------     --------------------------------




                                                                                       Page 83
                                                                   SCHEDULE-VIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



SCHEDULE VIII                                 SPECIFIC FREE CARE INCOME
DHCFP-403 VERSION 2005


                                     (2)             (3)             (4)
                                  PRINCIPAL   TOTAL EARNED     PRINC AMOUNT
                                  BALANCE        INCOME          USED FOR
                                  YEAR END       FOR YEAR        FREE CARE
                                                               DURING YEAR


AGGREGATE FUNDS:
____________________________________________________________________________________




                                                                          Page 84
                                                                  COVER-SCH-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX                DIRECT EXPENSES
        DHCFP-403 VERSION 2005



        OVERHEAD
     1 BUILDING AND FIXED EQUIPMENT DEPRECIATION
     2 CAPITAL LEASES - AMORTIZATION ON BUILDING AND FIXED EQUIPMENT
     3 INTEREST - LONG TERM
     4 AMORTIZATION OF BOND ISSUE COSTS
     5 SUBTOTAL LINES 1+2+3+4, COLUMN 12
     6 FRINGE BENEFITS
     7 ADMINISTRATION
     8 PURCHASING
     9 GENERAL ACCOUNTING
     10 PATIENT ACCOUNTS & INPATIENT ADMITTING
     11 INSURANCE - PROFESSIONAL MALPRACTICE
     12 INSURANCE - HOSPITAL MALPRACTICE
     13 INSURANCE - OTHER
     14 INTEREST - SHORT TERM
     15 SUBTOTAL LINES 7 THROUGH 14, COLUMN 12
     16 PLANT MAINTENANCE AND REPAIRS
     17 PLANT OPERATIONS
     18 SECURITY
     19 PARKING
     20 LICENSES AND TAXES (OTHER THAN INCOME)
     21 SUBTOTAL LINES 17 THROUGH 20, COLUMN 12
     22 LAUNDRY AND LINEN
     23 HOUSEKEEPING
     24 CAFETERIA
     25 DIETARY SERVICES
     26 MAINTENANCE OF PERSONNEL




                                                                       Page 85
                                                       COVER-SCH-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX                  DIRECT EXPENSES
        DHCFP-403 VERSION 2005



     27 NURSING ADMINISTRATION
     28 INSERVICE EDUCATION (NURSING)
     29 SUBTOTAL LINES 27+28, COLUMN 12
     30 NURSING FLOAT
     31 RN & LPN EDUCATION
     32 MEDICAL STAFF - TEACHING
     33 MEDICAL STAFF - ADMINISTRATION
     34 SUBTOTAL LINES 32+33, COLUMN 12
     35 POST GRADUATE MEDICAL EDUCATION
     36 CENTRAL SERVICE AND SUPPLIES
     37 PHARMACY
     38 MEDICAL RECORDS
     39 MEDICAL CARE REVIEW
     40 SOCIAL SERVICES
     41 CENTRAL PATIENT TRANSPORTATION
     42 OTHER OVERHEAD
     43 SUBTOTAL OVERHEAD


        ANCILLARY CARE SERVICES
     44 SURGERY
     45 LABOR AND DELIVERY
     46 RECOVERY ROOM
     47 ANESTHESIOLOGY
     48 INTRAVENOUS THERAPY
     49 MEDICAL SUPPLIES - SPECIAL
     50 DRUGS - SPECIAL
     51 LABORATORY




                                                         Page 86
                                                      COVER-SCH-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



          SCHEDULE IX               DIRECT EXPENSES
          DHCFP-403 VERSION 2005



     52 BLOOD
     53 BLOOD PROCESSING AND STORAGING
     54 ELECTROCARDIOLOGY (EKG)
     55 CARDIAC CATHERIZATION LABORATORY
     56 DIAGNOSTIC RADIOLOGY
     57 THERAPEUTIC RADIOLOGY
     58 COMPUTERIZED TOMOGRAPHY
     59 NUCLEAR MEDICINE
     60 RESPIRATORY THERAPY
     61 PULMONARY FUNCTION TESTING
     62 ELECTROENCEPHALOGRAPHY (EEG)
     63 ELECTROMYOGRAPHY
     64 PHYSICAL THERAPY
     65 OCCUPATIONAL THERAPY
     66 SPEECH - LANGUAGE THERAPY
     67 RECREATIONAL THERAPY
     68 AUDIOLOGY
     69 PSYCHOLOGY/PSYCHIATRY
     70 RENAL DIALYSIS
     71 ORGAN ACQUISITION
     72 AMBULANCE
     73
     74
     75
     76
     77
     78 SUBTOTAL ANCILLARY




                                                        Page 87
                                                       COVER-SCH-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



          SCHEDULE IX                DIRECT EXPENSES
          DHCFP-403 VERSION 2005




          ROUTINE INPATIENT CARE SERVICES
     79 MEDICAL & SURGICAL ACUTE
     80 PEDIATRIC ACUTE
     81 OBSTETRIC ACUTE
     82 PSYCHIATRIC ACUTE
     83 VENTILATOR UNIT
     84 SKILLED NURSING FACILITIES
     85
     86
     87
     88 SUBTOTAL ACUTE
     89 MEDICAL & SURGICAL INTENSIVE CARE
     90 CORONARY INTENSIVE CARE
     91 NEONATAL INTENSIVE CARE
     92
     93
     94
     95
     96
     97 SUBTOTAL INTENSIVE CARE
     98 NEWBORN NURSERY
     99 CHRONIC AND REHABILITATION
    100 SUBTOTAL ROUTINE INPATIENT CARE


          ROUTINE AMBULATORY CARE SERVICES
    101 EMERGENCY SERVICES




                                                         Page 88
                                                                 COVER-SCH-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



          SCHEDULE IX               DIRECT EXPENSES
          DHCFP-403 VERSION 2005



    102 CLINIC OR AMBULATORY SERVICES
    103 SATELLITE CLINIC SERVICES
    104 AMBULATORY SURGERY SERVICES
    105 AMBULATORY RENAL DIALYSIS SERVICES
    106 HOME DIALYSIS SERVICES
    107 PSYCHIATRY
    108 HOME HEALTH SERVICES
    109 OBSERVATION BEDS
    110 PRIVATE REFERRALS
    111 HOSPITAL LICENSED HEALTH CENTER(S)
    112
    113
    114 SUBTOTAL ROUTINE AMBULATORY SERVICES


    115 TOTAL PATIENT CARE (LINES 78+100+114)
    116 TOTAL PATIENT CARE AND OVERHEAD (LINES 43+115)


          NON-PATIENT CARE
    117 NON-PATIENT ANCILLARY
    118 RESEARCH
    119 OTHER NON-PATIENT
    120 SUBTOTAL NON-PATIENT


    121 RECOVERY OF EXPENSES (SCHEDULE VII, COLUMN 3, LINE 50)
    122 TOTAL PATIENT AND NON-PATIENT (LINES 116+120+121)
    123 PROVISION FOR BAD DEBT
 123.01 GROSS UNCOMPENSATED CARE POOL ASSESSMENT




                                                                   Page 89
                                                                   COVER-SCH-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX               DIRECT EXPENSES
        DHCFP-403 VERSION 2005



    124 TOTAL PATIENT, NON-PATIENT, PROVISION FOR BAD DEBTS AND GROSS UNCOMPENSATED CARE POOL ASSESSMENT (LINES 122+123+123.01)
    125 GENERAL FUND
    126 GRAND TOTAL




                                                                       Page 90
                                                                SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



      SCHEDULE IX                            DIRECT EXPENSES
      DHCFP-403 VERSION 2005


                                    (2)             (3)            (4)        (5)         (6)         (7)          (8)        (9)       (10)
                                  SALARIES      PHYSICIAN      PURCHASED SUPPLIES SUBTOTAL M. MOVABLE          SUBTOTAL    RECLASS.   RECLASS.
                                    AND      COMPENSATION       SERVICES     AND      (C 2+3+4+5) EQUIPEMENT    (C. 6+7)     DR.        (CR)
                                   WAGES       SCH XXV,C2                  EXPENSES             DEPRECIATION


      OVERHEAD
    1 DEP
    2 LEASE
    3 INT-LT
    4 AMOR.BOND ISSUE COSTS
    5 SUB                            x             x              x           x           x          x            x          x          x
    6 FRINGE
    7 ADM
    8 PURCH
    9 GEN.ACCT.
   10 PAT.ACCT
   11 INS-PROF
   12 INS-HOSP
   13 INS-OTHER
   14 INT-ST
   15 SUB                            x             x              x           x           x          x            x          x          x
   16 PL MAINT
   17 PL OP
   18 SEC
   19 PARK
   20 LIC
   21 SUB                            x             x              x           x           x          x            x          x          x
   22 LAUND




                                                                   Page 91
                                                                SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



      SCHEDULE IX                            DIRECT EXPENSES
      DHCFP-403 VERSION 2005


                                    (2)             (3)            (4)        (5)         (6)         (7)          (8)        (9)       (10)
                                  SALARIES      PHYSICIAN      PURCHASED SUPPLIES SUBTOTAL M. MOVABLE          SUBTOTAL    RECLASS.   RECLASS.
                                    AND      COMPENSATION       SERVICES     AND      (C 2+3+4+5) EQUIPEMENT    (C. 6+7)     DR.        (CR)
                                   WAGES       SCH XXV,C2                  EXPENSES             DEPRECIATION


   23 HSKP
   24 CAFE
   25 DIET
   26 MAINT PER
   27 NURS ADM
   28 INSVC ED
   29 SUB                            x             x              x           x           x          x            x          x          x
   30 NURS FL
   31 RN+LPN
   32 MED-TEACH
   33 MED-ADM
   34 SUB                            x             x              x           x           x          x            x          x          x
   35 POST GRAD
   36 CENT SER
   37 PHARM
   38 MED REC
   39 MED CARE
   40 SOC SER
   41 CENT TRAN
   42 OTHER OH
   43 SUBTOTAL OH


      ANCILLARY CARE SERVICES




                                                                   Page 92
                                                                SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



      SCHEDULE IX                            DIRECT EXPENSES
      DHCFP-403 VERSION 2005


                                    (2)             (3)            (4)        (5)         (6)         (7)          (8)        (9)       (10)
                                  SALARIES      PHYSICIAN      PURCHASED SUPPLIES SUBTOTAL M. MOVABLE          SUBTOTAL    RECLASS.   RECLASS.
                                    AND      COMPENSATION       SERVICES     AND      (C 2+3+4+5) EQUIPEMENT    (C. 6+7)     DR.        (CR)
                                   WAGES       SCH XXV,C2                  EXPENSES             DEPRECIATION


   44 SURG
   45 LABOR
   46 REC RM
   47 ANEST
   48 IV THER
   49 MED SUP
   50 DRUG
   51 LAB
   52 BLOOD
   53 BL PROC
   54 EKG
   55 CARD CATH
   56 DIAG RAD
   57 THER RAD
   58 CT SCAN
   59 NUC MED
   60 RESP THER
   61 PULM
   62 EEG
   63 ELEC
   64 PHY THER
   65 OCC THER
   66 SPEECH




                                                                   Page 93
                                                                        SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX                                  DIRECT EXPENSES
        DHCFP-403 VERSION 2005


                                            (2)             (3)            (4)        (5)         (6)         (7)          (8)        (9)       (10)
                                          SALARIES      PHYSICIAN      PURCHASED SUPPLIES SUBTOTAL M. MOVABLE          SUBTOTAL    RECLASS.   RECLASS.
                                            AND      COMPENSATION       SERVICES     AND      (C 2+3+4+5) EQUIPEMENT    (C. 6+7)     DR.        (CR)
                                           WAGES       SCH XXV,C2                  EXPENSES             DEPRECIATION


   67 REC THER
   68 AUD
   69 PSYCH
   70 REN DIAL
   71 ORGAN ACQ
   72 AMB
   73
   74
   75
   76
   77
   78 SUBTOTAL ANCI.


        ROUTINE INPATIENT CARE SERVICES
   79 MED/SURG
   80 PED
   81 OB
   82 PSY
   83 VENT UNIT
   84 SNFs
   85
   86
   87




                                                                           Page 94
                                                                         SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX                                   DIRECT EXPENSES
        DHCFP-403 VERSION 2005


                                             (2)             (3)            (4)        (5)         (6)         (7)          (8)        (9)       (10)
                                           SALARIES      PHYSICIAN      PURCHASED SUPPLIES SUBTOTAL M. MOVABLE          SUBTOTAL    RECLASS.   RECLASS.
                                             AND      COMPENSATION       SERVICES     AND      (C 2+3+4+5) EQUIPEMENT    (C. 6+7)     DR.        (CR)
                                            WAGES       SCH XXV,C2                  EXPENSES             DEPRECIATION


   88 SUBTOTAL ACUTE
   89 ICU
   90 CCU
   91 NEO
   92
   93
   94
   95
   96
   97 SUBTOTAL ICU
   98 NEWB
   99 CHR
  100 SUBTOTAL I/P


        ROUTINE AMBULATORY CARE SERVICES
  101 EMERG
  102 CLINIC
  103 SAT
  104 SURG
  105 A. DIAL.
  106 H. DIAL.
  107 PSY
  108 H. HEALTH




                                                                            Page 95
                                                                         SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX                                   DIRECT EXPENSES
        DHCFP-403 VERSION 2005


                                             (2)             (3)            (4)        (5)         (6)         (7)          (8)        (9)       (10)
                                           SALARIES      PHYSICIAN      PURCHASED SUPPLIES SUBTOTAL M. MOVABLE          SUBTOTAL    RECLASS.   RECLASS.
                                             AND      COMPENSATION       SERVICES     AND      (C 2+3+4+5) EQUIPEMENT    (C. 6+7)     DR.        (CR)
                                            WAGES       SCH XXV,C2                  EXPENSES             DEPRECIATION


  109 OBS. BEDS
  110 PRI. REFER.
  111 HOSPITAL LICENSED HEALTH CENTER(S)
  112
  113
  114 SUBTOTAL AMB.


  115 TOT. PAT.
  116 TOT PAT+OH


        NON-PATIENT CARE
  117 NON-PAT ANC                             x             x              x           x           x          x            x          x          x
  118 RESEARCH
  119 OTH.NON-PAT
  120 SUBTOTAL N/P




 121 RECOVERY                                 x             x              x           x           x          x            x
 122 TOTAL PAT + N/P
 123 PROV. BAD DEBT                           x             x              x                                  x                       x          x



                                                                            Page 96
                                                                SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



       SCHEDULE IX                           DIRECT EXPENSES
       DHCFP-403 VERSION 2005


                                    (2)             (3)            (4)        (5)         (6)         (7)          (8)        (9)       (10)
                                  SALARIES      PHYSICIAN      PURCHASED SUPPLIES SUBTOTAL M. MOVABLE          SUBTOTAL    RECLASS.   RECLASS.
                                    AND      COMPENSATION       SERVICES     AND      (C 2+3+4+5) EQUIPEMENT    (C. 6+7)     DR.        (CR)
                                   WAGES       SCH XXV,C2                  EXPENSES             DEPRECIATION


 123   GR UCP ASSMT                 x              x              x                                  x                       x          x
 124   TOTPAT+NPAT+B/D+GR UCP ASSMT
 125   GENRL FUND                   x              x              x           x           x          x            x
 126   GRAND TOTAL                  x              x              x           x           x          x            x




                                                                   Page 97
                                                                 SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



      SCHEDULE IX
      DHCFP-403 VERSION 2005


                                      (11)         (12)           (13)
                                  RECOVERIES     TOTAL       EXPENSES TO
                                     (CR)       DIRECT       BE STEPPED
                                               EXPENSES         DOWN
                                             (C.8+9+10+11)      (C.12)
      OVERHEAD
    1 DEP                                                         x            1
    2 LEASE                                                       x            2
    3 INT-LT                                                      x            3
    4 AMOR.BOND ISSUE COSTS                                       x            4
    5 SUB                             x           x                            5
    6 FRINGE                                                                   6
    7 ADM                                                         x            7
    8 PURCH                                                       x            8
    9 GEN.ACCT.                                                   x            9
   10 PAT.ACCT                                                    x           10
   11 INS-PROF                                                    x           11
   12 INS-HOSP                                                    x           12
   13 INS-OTHER                                                   x           13
   14 INT-ST                                                      x           14
   15 SUB                             x           x                           15
   16 PL MAINT                                                                16
   17 PL OP                                                       x           17
   18 SEC                                                         x           18
   19 PARK                                                        x           19
   20 LIC                                                         x           20
   21 SUB                             x           x                           21
   22 LAUND                                                                   22




                                                                         Page 98
                                                                 SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



      SCHEDULE IX
      DHCFP-403 VERSION 2005


                                      (11)         (12)           (13)
                                  RECOVERIES     TOTAL       EXPENSES TO
                                     (CR)       DIRECT       BE STEPPED
                                               EXPENSES         DOWN
                                             (C.8+9+10+11)      (C.12)
   23 HSKP                                                                    23
   24 CAFE                                                                    24
   25 DIET                                                                    25
   26 MAINT PER                                                               26
   27 NURS ADM                                                    x           27
   28 INSVC ED                                                    x           28
   29 SUB                             x           x                           29
   30 NURS FL                                                     x           30
   31 RN+LPN                                                                  31
   32 MED-TEACH                                                   x           32
   33 MED-ADM                                                     x           33
   34 SUB                             x           x                           34
   35 POST GRAD                                                               35
   36 CENT SER                                                                36
   37 PHARM                                                                   37
   38 MED REC                                                                 38
   39 MED CARE                                                                39
   40 SOC SER                                                                 40
   41 CENT TRAN                                   x               x           41
   42 OTHER OH                                                                42
   43 SUBTOTAL OH                                                             43


      ANCILLARY CARE SERVICES




                                                                         Page 99
                                                                 SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



      SCHEDULE IX
      DHCFP-403 VERSION 2005


                                      (11)         (12)           (13)
                                  RECOVERIES     TOTAL       EXPENSES TO
                                     (CR)       DIRECT       BE STEPPED
                                               EXPENSES         DOWN
                                             (C.8+9+10+11)      (C.12)
   44 SURG                                                        x         44
   45 LABOR                                                       x         45
   46 REC RM                                                      x         46
   47 ANEST                                                       x         47
   48 IV THER                                                     x         48
   49 MED SUP                                                     x         49
   50 DRUG                                                        x         50
   51 LAB                                                         x         51
   52 BLOOD                                                       x         52
   53 BL PROC                                                     x         53
   54 EKG                                                         x         54
   55 CARD CATH                                                   x         55
   56 DIAG RAD                                                    x         56
   57 THER RAD                                                    x         57
   58 CT SCAN                                                     x         58
   59 NUC MED                                                     x         59
   60 RESP THER                                                   x         60
   61 PULM                                                        x         61
   62 EEG                                                         x         62
   63 ELEC                                                        x         63
   64 PHY THER                                                    x         64
   65 OCC THER                                                    x         65
   66 SPEECH                                                      x         66




                                                                      Page 100
                                                                         SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX
        DHCFP-403 VERSION 2005


                                              (11)         (12)           (13)
                                          RECOVERIES     TOTAL       EXPENSES TO
                                             (CR)       DIRECT       BE STEPPED
                                                       EXPENSES         DOWN
                                                     (C.8+9+10+11)      (C.12)
   67 REC THER                                                            x         67
   68 AUD                                                                 x         68
   69 PSYCH                                                               x         69
   70 REN DIAL                                                            x         70
   71 ORGAN ACQ                                                           x         71
   72 AMB                                                                 x         72
   73                                                                     x         73
   74                                                                     x         74
   75                                                                     x         75
   76                                                                     x         76
   77                                                                     x         77
   78 SUBTOTAL ANCI.                                                      x         78


        ROUTINE INPATIENT CARE SERVICES
   79 MED/SURG                                                            x         79
   80 PED                                                                 x         80
   81 OB                                                                  x         81
   82 PSY                                                                 x         82
   83 VENT UNIT                                                           x         83
   84 SNFs                                                                x         84
   85                                                                     x         85
   86                                                                     x         86
   87                                                                     x         87




                                                                              Page 101
                                                                      SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX
        DHCFP-403 VERSION 2005


                                           (11)         (12)           (13)
                                       RECOVERIES     TOTAL       EXPENSES TO
                                           (CR)      DIRECT       BE STEPPED
                                                    EXPENSES         DOWN
                                                  (C.8+9+10+11)      (C.12)
   88 SUBTOTAL ACUTE                                                   x         88
   89 ICU                                                              x         89
   90 CCU                                                              x         90
   91 NEO                                                              x         91
   92                                                                  x         92
   93                                                                  x         93
   94                                                                  x         94
   95                                                                  x         95
   96                                                                  x         96
   97 SUBTOTAL ICU                                                     x         97
   98 NEWB                                                             x         98
   99 CHR                                                              x         99
  100 SUBTOTAL I/P                                                     x        100


        ROUTINE AMBULATORY CARE SERVICES
  101 EMERG                                                            x        101
  102 CLINIC                                                           x        102
  103 SAT                                                              x        103
  104 SURG                                                             x        104
  105 A. DIAL.                                                         x        105
  106 H. DIAL.                                                         x        106
  107 PSY                                                              x        107
  108 H. HEALTH                                                        x        108




                                                                           Page 102
                                                                          SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



        SCHEDULE IX
        DHCFP-403 VERSION 2005


                                               (11)         (12)           (13)
                                           RECOVERIES     TOTAL       EXPENSES TO
                                              (CR)       DIRECT       BE STEPPED
                                                        EXPENSES         DOWN
                                                      (C.8+9+10+11)      (C.12)
  109 OBS. BEDS                                                            x        109
  110 PRI. REFER.                                                          x        110
  111 HOSPITAL LICENSED HEALTH CENTER(S)                                   x        111
  112                                                                      x        112
  113                                                                      x        113
  114 SUBTOTAL AMB.                                                        x        114


  115 TOT. PAT.                                                            x        115
  116 TOT PAT+OH                                                           x        116


        NON-PATIENT CARE
  117 NON-PAT ANC                              x           x               x        117
  118 RESEARCH                                                             x        118
  119 OTH.NON-PAT                                                          x        119
  120 SUBTOTAL N/P                                                         x        120




 121 RECOVERY                                                              x        121
 122 TOTAL PAT + N/P                                                       x        122
 123 PROV. BAD DEBT                            x                           x        123



                                                                               Page 103
                                                                 SCHEDULE-IX


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



       SCHEDULE IX
       DHCFP-403 VERSION 2005


                                      (11)         (12)           (13)
                                  RECOVERIES     TOTAL       EXPENSES TO
                                     (CR)       DIRECT       BE STEPPED
                                               EXPENSES         DOWN
                                             (C.8+9+10+11)      (C.12)
 123   GR UCP ASSMT                 x                             x        123
 124   TOTPAT+NPAT+B/D+GR UCP ASSMT                               x        124
 125   GENRL FUND                   x             x               x        125
 126   GRAND TOTAL                  x             x               x        126




                                                                      Page 104
                                                                   SCHEDULE-IXA


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE IX-A - RECONCILIATION OF EXPENSES
DHCFP-403 VERSION 2005


                                                       AUDITED
                                             SCH. IX     F/S     DIFFERENCE EXPLANATION



TOTAL EXPENSES


TOTAL DEPRECIATION EXPENSE


TOTAL INTEREST EXPENSE




                                                                      Page 105
                                                                SCHEDULE-X


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



           SCHEDULE X                                            SUMMARY OF NON-PATIENT EXPENSES
           DHCFP-403 VERSION 2005


                                                                    (2)        (3)       (4)
                                                                   SALARY     OTHER     TOTAL
                                                                  + WAGES


         1 RESEARCH - ON SITE
         2 RESEARCH - OFF SITE
         3 FUND RAISING EXPENSE
         4 TELEVISION EXPENSE
         5 GIFT SHOP
         6 COFFEE SHOP
         7 EXPENSE INCURRED IN PRODUCING NON-OPERATING INCOME
         8 MEDICAL EDUCATION EXPENSE
         9 PRIVATE DUTY NURSES AND OTHER AGENCY EXPENSE
        10 REAL ESTATE TAXES AND OTHER EXPENSE
             ON NON-PATIENT HOSPITAL PROPERTY
        11 MEDICAL OFFICE BUILDING
        12 PENALTIES AND FINES
        13 NON-QUALIFYING PHYSICIAN FEES + SALARIES
        14 OTHER (SPECIFY)
        15 OTHER (SPECIFY)
        16 OTHER (SPECIFY)
        17 OTHER (SPECIFY)
        18 OTHER (SPECIFY)
        19 OTHER (SPECIFY)
        20 TOTAL*




                                                                 Page 106
                                                                SCHEDULE-X




* TOTAL (LINE 20, COL.4) MUST TIE TO SCHEDULE IX, COL.8, LINE 120.




                                                                     Page 107
                                                                      SCHEDULE-XI


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



SCHEDULE XI                                       PRELIMINARY ADJUSTING ENTRIES
DHCFP-403 VERSION 2005


                                          (1)         (2)       (3)          (4)
                                       SCH IX         DR.        CR.     PRELIMINARY
                                       LINE REF                           ENTRY NO.
 EXPLANATION
                                   1
                                   2
                                   3
                                   4
                                   5
                                   6
                                   7
                                   8
                                   9
                                  10
                                  11
                                  12
                                  13
                                  14
                                  15
                                  16
                                  17
                                  18
                                  19
                                  20
                                  21
                                  22
                                  23
                                  24




                                                                        Page 108
                                                                      SCHEDULE-XI


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



SCHEDULE XI                                       PRELIMINARY ADJUSTING ENTRIES
DHCFP-403 VERSION 2005


                                          (1)         (2)       (3)          (4)
                                       SCH IX         DR.        CR.     PRELIMINARY
                                       LINE REF                           ENTRY NO.
 EXPLANATION
                                  25
                                  26
                                  27
                                  28
                                  29
                                  30
                                  31
                                  32
                                  33
                                  34
                                  35
                                  36
                                  37
                                  38
                                  39
                                  40
                                  41
                                  42
                                  43
                                  44
                                  45
                                  46
                                  47
                                  48




                                                                        Page 109
                                                                      SCHEDULE-XI


HOSPITAL______________________
FOR FISCAL YEAR ENDED _________



SCHEDULE XI                                       PRELIMINARY ADJUSTING ENTRIES
DHCFP-403 VERSION 2005


                                          (1)         (2)       (3)          (4)
                                       SCH IX         DR.        CR.     PRELIMINARY
                                       LINE REF                           ENTRY NO.
 EXPLANATION
                                  49
                                  50




                                                                        Page 110
                                                                     SCHEDULE-XII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________________


SCHEDULE XII - SUMMARY OF
DHCFP-403 VERSION 2005
                                 PRELIMINARY ADJUSTING ENTRIES


        (1)          (2)                 (3)      (4)        (5)        (6)         (7)       (8)        (9)        (10)       (11)       (12)
     REF. SCH IX DEPT. NAME          TOTAL      TOTAL     PE NO. 1   PE NO. 2   PE NO. 3   PE NO. 4   PE NO. 5   PE NO. 6   PE NO. 7   PE NO. 8
       LINE NO.                    RECLASS.    RECLASS.     DR.        DR.         DR.       DR.        DR.        DR.        DR.        DR.
                                         DR.     (CR.)     (CR.)      (CR.)        (CR.)    (CR.)      (CR.)      (CR.)      (CR.)      (CR.)




              GENERAL FUND
                  TOTAL



        (1)          (2)                 (3)      (4)        (5)        (6)         (7)       (8)        (9)        (10)       (11)       (12)
     REF. SCH IX DEPT. NAME          TOTAL      TOTAL     PE NO. 1   PE NO. 2   PE NO. 3   PE NO. 4   PE NO. 5   PE NO. 6   PE NO. 7   PE NO. 8
              LINE NO.            RECOVERIES RECOVERIES     DR.        DR.         DR.       DR.        DR.        DR.        DR.        DR.
                                         DR.     (CR.)     (CR.)      (CR.)        (CR.)    (CR.)      (CR.)      (CR.)      (CR.)      (CR.)




              GENERAL FUND
                  TOTAL




                                                                        Page 111
                                                                         SCHEDULE-XII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________________


SCHEDULE XII - SUMMARY OF
DHCFP-403 VERSION 2005



        (1)          (2)                  (13)      (14)        (15)
     REF. SCH IX DEPT. NAME         PE NO. 9     PE NO. 10   PE NO. 11
       LINE NO.                          DR.        DR.         DR.
                                         (CR.)     (CR.)       (CR.)




              GENERAL FUND
                  TOTAL



        (1)          (2)                  (13)      (14)        (15)
     REF. SCH IX DEPT. NAME         PE NO. 9     PE NO. 10   PE NO. 11
              LINE NO.                   DR.        DR.         DR.
                                         (CR.)     (CR.)       (CR.)




              GENERAL FUND
                  TOTAL




                                                                           Page 112
                                                                 COVER-SCH-XIII


       ___________________
HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


        SCHEDULE XIII
        DHCFP-403 VERSION 2005


                   STEPDOWN STATISTICS


          OVERHEAD
     1 DEPRECIATION THROUGH AMORTIZATION OF BOND ISSUE COSTS
     2 FRINGE BENEFITS
     3 ADMINISTRATION THROUGH INTEREST-SHORT TERM
     4 PLANT MAINTENANCE AND REPAIRS
     5 PLANT OPERATIONS THRU LICENSES + TAXES (OTHER THAN INCOME TAXES)
     6 LAUNDRY AND LINEN
     7 HOUSEKEEPING
     8 CAFETERIA
     9 DIETARY
     10 MAINTENANCE OF PERSONNEL
     11 NURSING ADMINISTRATION AND INSERVICE EDUCATION-NURSING
     12 RN + LPN EDUCATION
     13 MEDICAL STAFF-TEACHING AND ADMINISTRATION
     14 POST GRADUATE MEDICAL EDUCATION
     15 CENTRAL SERVICE AND SUPPLIES
     16 PHARMACY
     17 MEDICAL RECORDS
     18 MEDICAL CARE REVIEW
     19 SOCIAL SERVICES
     20 OTHER OVERHEAD
     21 SUBTOTAL OVERHEAD


        ANCILLARY CARE SERVICES
     22 SURGERY
     23 LABOR + DELIVERY
     24 RECOVERY ROOM




                                                                    Page 113
                                             COVER-SCH-XIII


       ___________________
HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


          SCHEDULE XIII
          DHCFP-403 VERSION 2005


                     STEPDOWN STATISTICS


     25 ANESTHESIOLOGY
     26 IV THERAPY
     27 MEDICAL SUPPLIES-SPECIAL
     28 DRUGS-SPECIAL
     29 LABORATORY
     30 BLOOD
     31 BLOOD PROCESSING + STORAGE
     32 ELECTROCARDIOLOGY (EKG)
     33 CARDIAC CATHERERIZATION LABORATORY
     34 DIAGNOSTIC RADIOLOGY
     35 THERAPEUTIC RADIOLOGY
     36 COMPUTERIZED TOMOGRAPHY
     37 NUCLEAR MEDICINE
     38 RESPIRATORY THERAPY
     39 PULMONARY THERAPY
     40 ELECTROENCEPHALOGRAPHY (EEG)
     41 ELECTROMYOGRAPHY
     42 PHYSICAL THERAPY
     43 OCCUPATIONAL THERAPY
     44 SPEECH-LANGUAGE THERAPY
     45 RECREATIONAL THERAPY
     46 AUDIOLOGY
     47 PSYCHOLOGY/PSYCHIATRY
     48 RENAL DIALYSIS
     49 ORGAN ACQUISITION
     50 AMBULANCE
     51




                                                Page 114
                                              COVER-SCH-XIII


       ___________________
HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


          SCHEDULE XIII
          DHCFP-403 VERSION 2005


                     STEPDOWN STATISTICS


     52
     53
     54
     55
     56 SUBTOTAL ANCILLARY


          ROUTINE INPATIENT CARE SERVICES
     57 MEDICAL + SURGICAL ACUTE
     58 PEDIATRIC ACUTE
     59 OBSTETRIC ACUTE
     60 PSYCHIATRIC ACUTE
     61 VENTILATOR UNIT
     62 SKILLED NURSING FACILITIES
     63
     64
     65
     66 SUBTOTAL ACUTE


     67 MEDICAL AND SURGICAL INTENSIVE CARE
     68 CORONARY INTENSIVE CARE
     69 NEONATAL INTENSIVE CARE
     70
     71
     72
     73
     74
     75 SUBTOTAL INTENSIVE CARE




                                                 Page 115
                                                         COVER-SCH-XIII


       ___________________
HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


          SCHEDULE XIII
          DHCFP-403 VERSION 2005


                     STEPDOWN STATISTICS


     76 NEWBORN NURSERY
     77 CHRONIC AND REHABILITATION
     78 SUBTOTAL ROUTINE INPATIENT CARE


          ROUTINE AMBULATORY CARE SERVICES
     79 EMERGENCY SERVICES
     80 CLINIC OR AMBULATORY
     81 SATELLITE CLINIC SERVICES
     82 AMBULATORY SURGERY SERVICES
     83 AMBULATORY RENAL DIALYSIS SERVICES
     84 HOME DIALYSIS SERVICES
     85 PSYCHIATRY
     86 HOME HEALTH SERVICES
     87 OBSERVATION BEDS
     88 PRIVATE REFERRALS
     89 HOSPITAL LICENSED HEALTH CENTER(S)
     90
     91
     92 SUBTOTAL ROUTINE AMBULATORY SERVICES


     93 TOTAL PATIENT CARE (LINES 56 + 78 + 92)
     94 TOTAL PATIENT CARE AND OVERHEAD (LINES 21 +93)


          NON-PATIENT CARE
     95 NON-PATIENT ANCILLARY
     96 RESEARCH
     97 OTHER NON-PATIENT




                                                            Page 116
                                                                           COVER-SCH-XIII


       ___________________
HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


        SCHEDULE XIII
        DHCFP-403 VERSION 2005


                    STEPDOWN STATISTICS


     98 SUBTOTAL NON-PATIENT


     99 XXXXXXXXXXXXXXXXXXX
    100 TOTAL PATIENT AND NON-PATIENT (LINES 94 +98)


    101 TOTAL STATISTIC FOR STEPDOWN ( TOTAL STATISTIC BELOW THE DARK LINE)
    102 UNIT COST MULTIPLIER EXCLUDING CAPITAL (SCH. XIV, COL. 4 / SCH. XIII, L. 101)
    103 UNIT COST MULTIPLIER INCLUDING CAPITAL (SCH. XV, COL. 4 / SCH. XIII, L. 101)




                                                                               Page 117
                                                                        SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005


                                   STEPDOWN STATISTICS
                                        (2)          (3)          (4)          (5)        (6)        (7)            (8)         (9)         (10)
                                                                           DEP THRU     FRINGE    ADM THRU     PLANT MAIN PLANT OP THRU LNDRY+LINEN
                                                                          AMTZ B I CST BENEFITS IN-SHRT TERM    +REPAIRS   LIC+TAXES
                                                                                                                                        NO. DRY LBS
                                                                             SQ.FT.     PAYRL $    PAYRL $        SQ.FT.      SQ.FT.    PROCESSED


    OVERHEAD
 1 DEPR THRU AMTZ B I CST          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 2 FRINGE                          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 3 ADM                             xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 4 PL MAINT                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 5 PL OP                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 6 LAUND                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 7 HSKPG                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 8 CAFE                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
 9 DIET                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
10 MAIN PER                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
11 NURS ADM                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
12 RN +LPN                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
13 MED ST                          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
14 POST GRAD                       xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
15 CENT SER                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
16 PHARM                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
17 MED REC                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
18 MED CARE                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
19 SOC SER                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
20 OTHER                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
21 SUBTOTAL OVERHEAD               xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx




                                                                          Page 118
                                                                        SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005


                                   STEPDOWN STATISTICS
                                        (2)          (3)          (4)          (5)        (6)        (7)            (8)         (9)         (10)
                                                                           DEP THRU     FRINGE    ADM THRU     PLANT MAIN PLANT OP THRU LNDRY+LINEN
                                                                          AMTZ B I CST BENEFITS IN-SHRT TERM    +REPAIRS   LIC+TAXES
                                                                                                                                        NO. DRY LBS
                                                                             SQ.FT.     PAYRL $    PAYRL $        SQ.FT.      SQ.FT.    PROCESSED


    ANCILLARY CARE SERVICES
22 SURGERY                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
23 LABOR                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
24 REC RM                          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
25 ANEST                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
26 IV THER                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
27 MED SUP                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
28 DRUGS                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
29 LAB                             xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
30 BLOOD                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
31 BL PROC                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
32 EKG                             xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
33 CARD CATH                       xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
34 DIAG RAD                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
35 THER RAD                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
36 CT SCAN                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
37 NUC MED                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
38 RESP THER                       xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
39 PULM                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
40 EEG                             xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
41 ELEC                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
42 PHY THER                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx




                                                                          Page 119
                                                                            SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005


                                       STEPDOWN STATISTICS
                                            (2)          (3)          (4)          (5)        (6)        (7)            (8)         (9)         (10)
                                                                               DEP THRU     FRINGE    ADM THRU     PLANT MAIN PLANT OP THRU LNDRY+LINEN
                                                                              AMTZ B I CST BENEFITS IN-SHRT TERM    +REPAIRS   LIC+TAXES
                                                                                                                                            NO. DRY LBS
                                                                                 SQ.FT.     PAYRL $    PAYRL $        SQ.FT.      SQ.FT.    PROCESSED
43 OCC THER                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
44 SPEECH                              xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
45 REC THER                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
46 AUD                                 xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
47 PSYCH                               xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
48 RENAL DIAL                          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
49 ORGAN ACQ                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
50 AMB                                 xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
51                                     xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
52                                     xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
53                                     xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
54                                     xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
55                                     xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
56 SUBTOTAL ANCILLARY                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx



     ROUTINE INPATIENT CARE SERVICES
57 MED/SURG                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
58 PED                                 xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
59 OB                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
60 PSY                                 xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
61 VENT UNIT                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
62 SNFs                                xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx




                                                                              Page 120
                                                                         SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005


                                   STEPDOWN STATISTICS
                                         (2)          (3)          (4)          (5)        (6)        (7)            (8)         (9)         (10)
                                                                            DEP THRU     FRINGE    ADM THRU     PLANT MAIN PLANT OP THRU LNDRY+LINEN
                                                                           AMTZ B I CST BENEFITS IN-SHRT TERM    +REPAIRS   LIC+TAXES
                                                                                                                                         NO. DRY LBS
                                                                              SQ.FT.     PAYRL $    PAYRL $        SQ.FT.      SQ.FT.    PROCESSED
63                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
64                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
65                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
66 SUBTOTAL ACUTE                   xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
67 ICU                              xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
68 CCU                              xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
69 NEO                              xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
70                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
71                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
72                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
73                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
74                                  xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
75 SUBTOTAL ICU                     xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
76 NEWBORN                          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
77 CHR & REHAB                      xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
78 SUBTOTAL I/P                     xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx


     ROUTINE AMBULATORY CARE SERVICES
79 EMERG                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
80 CLINIC                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
81 SAT                              xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
82 SURG                             xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
83 A. DIAL                          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx




                                                                           Page 121
                                                                          SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005


                                    STEPDOWN STATISTICS
                                          (2)          (3)          (4)           (5)        (6)          (7)          (8)           (9)          (10)
                                                                             DEP THRU     FRINGE     ADM THRU    PLANT MAIN PLANT OP THRU LNDRY+LINEN
                                                                            AMTZ B I CST BENEFITS IN-SHRT TERM    +REPAIRS      LIC+TAXES
                                                                                                                                            NO. DRY LBS
                                                                               SQ.FT.     PAYRL $      PAYRL $      SQ.FT.         SQ.FT.    PROCESSED
84 H. DIAL                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
85 PSY                               xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
86 H. HEALTH                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
87 OBS. BEDS                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
88 PRI. REFER                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
                                    xxxxxxxxxx
89 HOSPITAL LICENSED HEALTH CENTER(S)             xxxxxxxxxx   xxxxxxxxxx
90                                   xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
91                                   xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
92 SUBTOTAL AMB                      xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx


93 TOT PAT                           xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
94 TOT PAT+OTH                       xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx


     NON-PATIENT CARE
95 NON-PAT ANC                       xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx    xxxxxxxxxx
96 RESEARCH                          xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
97 OTH NON-PAT                       xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
98 SUBTOTAL NON-PATIENT              xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx


99 XXXXXX                            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx    xxxxxxxxxx
### TOT PAT +NON-PAT                 xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx


### TOT STAT                         xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx




                                                                            Page 122
                                                                        SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005


                                   STEPDOWN STATISTICS
                                        (2)          (3)          (4)          (5)        (6)        (7)            (8)         (9)         (10)
                                                                           DEP THRU     FRINGE    ADM THRU     PLANT MAIN PLANT OP THRU LNDRY+LINEN
                                                                          AMTZ B I CST BENEFITS IN-SHRT TERM    +REPAIRS   LIC+TAXES
                                                                                                                                        NO. DRY LBS
                                                                             SQ.FT.     PAYRL $    PAYRL $        SQ.FT.      SQ.FT.    PROCESSED
### UCM EXC                        xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
### UCM INC.                       xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx




                                                                          Page 123
                                                               SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005


                                                                                              STEPDOWN STATISTICS
                                      (11)       (12)        (13)         (14)       (15)              (16)             (17)       (18)        (19)
                                   HOUSEKEEP CAFETERIA    DIETARY     MAINT OF    NURS. ADM         RN+LPN          MED STAFF   POST GRAD CNT SERVICE
                                                                      PERSONNEL +INSERV.ED            EDUC          TEACH+ADM   MED EDUC   +SUPPLIES
                                     HRS OF   FULL TIME NO.OF MEALS AVG NO. OF
                                    SERVICE   EQUIVAL.    SERVED      LIVING IN   NURS. HRS        ASSD. TIME          HRS         HRS     COSTED REQ


    OVERHEAD
 1 DEPR THRU AMTZ B I CST
 2 FRINGE
 3 ADM
 4 PL MAINT
 5 PL OP
 6 LAUND
 7 HSKPG
 8 CAFE
 9 DIET
10 MAIN PER
11 NURS ADM
12 RN +LPN
13 MED ST
14 POST GRAD
15 CENT SER
16 PHARM
17 MED REC
18 MED CARE
19 SOC SER
20 OTHER
21 SUBTOTAL OVERHEAD




                                                                    Page 124
                                                               SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005


                                                                                              STEPDOWN STATISTICS
                                      (11)       (12)        (13)         (14)       (15)              (16)             (17)       (18)        (19)
                                   HOUSEKEEP CAFETERIA    DIETARY     MAINT OF    NURS. ADM         RN+LPN          MED STAFF   POST GRAD CNT SERVICE
                                                                      PERSONNEL +INSERV.ED            EDUC          TEACH+ADM   MED EDUC   +SUPPLIES
                                     HRS OF   FULL TIME NO.OF MEALS AVG NO. OF
                                    SERVICE   EQUIVAL.    SERVED      LIVING IN   NURS. HRS        ASSD. TIME          HRS         HRS     COSTED REQ


    ANCILLARY CARE SERVICES
22 SURGERY
23 LABOR
24 REC RM
25 ANEST
26 IV THER
27 MED SUP
28 DRUGS
29 LAB
30 BLOOD
31 BL PROC
32 EKG
33 CARD CATH
34 DIAG RAD
35 THER RAD
36 CT SCAN
37 NUC MED
38 RESP THER
39 PULM
40 EEG
41 ELEC
42 PHY THER




                                                                    Page 125
                                                                   SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005


                                                                                                  STEPDOWN STATISTICS
                                          (11)       (12)        (13)         (14)       (15)              (16)             (17)       (18)        (19)
                                       HOUSEKEEP CAFETERIA    DIETARY     MAINT OF    NURS. ADM         RN+LPN          MED STAFF   POST GRAD CNT SERVICE
                                                                          PERSONNEL +INSERV.ED            EDUC          TEACH+ADM   MED EDUC   +SUPPLIES
                                         HRS OF   FULL TIME NO.OF MEALS AVG NO. OF
                                        SERVICE   EQUIVAL.    SERVED      LIVING IN   NURS. HRS        ASSD. TIME          HRS         HRS     COSTED REQ
43 OCC THER
44 SPEECH
45 REC THER
46 AUD
47 PSYCH
48 RENAL DIAL
49 ORGAN ACQ
50 AMB
51
52
53
54
55
56 SUBTOTAL ANCILLARY



     ROUTINE INPATIENT CARE SERVICES
57 MED/SURG
58 PED
59 OB
60 PSY
61 VENT UNIT
62 SNFs




                                                                        Page 126
                                                                   SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005


                                                                                                  STEPDOWN STATISTICS
                                          (11)       (12)        (13)         (14)       (15)              (16)             (17)       (18)        (19)
                                    HOUSEKEEP CAFETERIA       DIETARY     MAINT OF    NURS. ADM         RN+LPN          MED STAFF   POST GRAD CNT SERVICE
                                                                          PERSONNEL +INSERV.ED            EDUC          TEACH+ADM   MED EDUC   +SUPPLIES
                                        HRS OF    FULL TIME NO.OF MEALS AVG NO. OF
                                        SERVICE   EQUIVAL.    SERVED      LIVING IN   NURS. HRS        ASSD. TIME          HRS         HRS     COSTED REQ
63
64
65
66 SUBTOTAL ACUTE
67 ICU
68 CCU
69 NEO
70
71
72
73
74
75 SUBTOTAL ICU
76 NEWBORN
77 CHR & REHAB
78 SUBTOTAL I/P


     ROUTINE AMBULATORY CARE SERVICES
79 EMERG
80 CLINIC
81 SAT
82 SURG
83 A. DIAL




                                                                        Page 127
                                                                       SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005


                                                                                                       STEPDOWN STATISTICS
                                          (11)         (12)          (13)         (14)         (15)                 (16)          (17)         (18)         (19)
                                    HOUSEKEEP CAFETERIA          DIETARY      MAINT OF    NURS. ADM           RN+LPN         MED STAFF    POST GRAD CNT SERVICE
                                                                              PERSONNEL +INSERV.ED              EDUC         TEACH+ADM    MED EDUC      +SUPPLIES
                                        HRS OF    FULL TIME NO.OF MEALS AVG NO. OF
                                        SERVICE    EQUIVAL.       SERVED      LIVING IN   NURS. HRS         ASSD. TIME            HRS         HRS      COSTED REQ
84 H. DIAL
85 PSY
86 H. HEALTH
87 OBS. BEDS
88 PRI. REFER
89 HOSPITAL LICENSED HEALTH CENTER(S)
90
91
92 SUBTOTAL AMB


93 TOT PAT
94 TOT PAT+OTH


     NON-PATIENT CARE
95 NON-PAT ANC                      xxxxxxxxxx    xxxxxxxxxx   xxxxxxxxxx    xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
96 RESEARCH
97 OTH NON-PAT
98 SUBTOTAL NON-PATIENT


99 XXXXXX                           xxxxxxxxxx    xxxxxxxxxx   xxxxxxxxxx    xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx            xxxxxxxxxx   xxxxxxxxxx   xxxxxxxxxx
### TOT PAT +NON-PAT


### TOT STAT




                                                                            Page 128
                                                               SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005


                                                                                              STEPDOWN STATISTICS
                                      (11)       (12)        (13)         (14)       (15)              (16)             (17)       (18)        (19)
                                   HOUSEKEEP CAFETERIA    DIETARY     MAINT OF    NURS. ADM         RN+LPN          MED STAFF   POST GRAD CNT SERVICE
                                                                      PERSONNEL +INSERV.ED            EDUC          TEACH+ADM   MED EDUC   +SUPPLIES
                                     HRS OF   FULL TIME NO.OF MEALS AVG NO. OF
                                    SERVICE   EQUIVAL.    SERVED      LIVING IN   NURS. HRS        ASSD. TIME          HRS         HRS     COSTED REQ
### UCM EXC
### UCM INC.




                                                                    Page 129
                                                                            SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005



                                       (20)          (21)            (22)           (23)     (24)      (25)
                                   PHARMACY MED REC MED CARE                      SOCIAL    OTHER XXXXX
                                                                  REVIEW         SERVICES           XXXXX


                                   COSTED REQ       % TIME       NO. OF PAT NO. CASES (SPECIFY)


    OVERHEAD
 1 DEPR THRU AMTZ B I CST                       x            x               x                      xxxxxxxxxx 1
 2 FRINGE                                       x            x               x                      xxxxxxxxxx 2
 3 ADM                                          x            x               x                      xxxxxxxxxx 3
 4 PL MAINT                                     x            x               x                      xxxxxxxxxx 4
 5 PL OP                                        x            x               x                      xxxxxxxxxx 5
 6 LAUND                                        x            x               x                      xxxxxxxxxx 6
 7 HSKPG                                        x            x               x                      xxxxxxxxxx 7
 8 CAFE                                         x            x               x                      xxxxxxxxxx 8
 9 DIET                                         x            x               x                      xxxxxxxxxx 9
10 MAIN PER                                     x            x               x                      xxxxxxxxxx10
11 NURS ADM                                     x            x               x                      xxxxxxxxxx11
12 RN +LPN                                      x            x               x                      xxxxxxxxxx12
13 MED ST                                       x            x               x                      xxxxxxxxxx13
14 POST GRAD                                    x            x               x                      xxxxxxxxxx14
15 CENT SER                                     x            x               x                      xxxxxxxxxx15
16 PHARM                                        x            x               x                      xxxxxxxxxx16
17 MED REC                                      x            x               x                      xxxxxxxxxx17
18 MED CARE                                     x            x               x                      xxxxxxxxxx18
19 SOC SER                                      x            x               x                      xxxxxxxxxx19
20 OTHER                                        x            x               x                      xxxxxxxxxx20
21 SUBTOTAL OVERHEAD                            x            x               x                      xxxxxxxxxx21




                                                                                 Page 130
                                                                            SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005



                                       (20)          (21)            (22)           (23)     (24)      (25)
                                   PHARMACY MED REC MED CARE                      SOCIAL    OTHER XXXXX
                                                                  REVIEW         SERVICES           XXXXX


                                   COSTED REQ       % TIME       NO. OF PAT NO. CASES (SPECIFY)


    ANCILLARY CARE SERVICES
22 SURGERY                                      x            x               x                      xxxxxxxxxx22
23 LABOR                                        x            x               x                      xxxxxxxxxx23
24 REC RM                                       x            x               x                      xxxxxxxxxx24
25 ANEST                                        x            x               x                      xxxxxxxxxx25
26 IV THER                                      x            x               x                      xxxxxxxxxx26
27 MED SUP                                      x            x               x                      xxxxxxxxxx27
28 DRUGS                                        x            x               x                      xxxxxxxxxx28
29 LAB                                          x            x               x                      xxxxxxxxxx29
30 BLOOD                                        x            x               x                      xxxxxxxxxx30
31 BL PROC                                      x            x               x                      xxxxxxxxxx31
32 EKG                                          x            x               x                      xxxxxxxxxx32
33 CARD CATH                                    x            x               x                      xxxxxxxxxx33
34 DIAG RAD                                     x            x               x                      xxxxxxxxxx34
35 THER RAD                                     x            x               x                      xxxxxxxxxx35
36 CT SCAN                                      x            x               x                      xxxxxxxxxx36
37 NUC MED                                      x            x               x                      xxxxxxxxxx37
38 RESP THER                                    x            x               x                      xxxxxxxxxx38
39 PULM                                         x            x               x                      xxxxxxxxxx39
40 EEG                                          x            x               x                      xxxxxxxxxx40
41 ELEC                                         x            x               x                      xxxxxxxxxx41
42 PHY THER                                     x            x               x                      xxxxxxxxxx42




                                                                                 Page 131
                                                                                SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005



                                           (20)          (21)            (22)           (23)     (24)      (25)
                                       PHARMACY MED REC MED CARE                      SOCIAL    OTHER XXXXX
                                                                      REVIEW         SERVICES           XXXXX


                                       COSTED REQ       % TIME       NO. OF PAT NO. CASES (SPECIFY)
43 OCC THER                                         x            x               x                      xxxxxxxxxx43
44 SPEECH                                           x            x               x                      xxxxxxxxxx44
45 REC THER                                         x            x               x                      xxxxxxxxxx45
46 AUD                                              x            x               x                      xxxxxxxxxx46
47 PSYCH                                            x            x               x                      xxxxxxxxxx47
48 RENAL DIAL                                       x            x               x                      xxxxxxxxxx48
49 ORGAN ACQ                                        x            x               x                      xxxxxxxxxx49
50 AMB                                              x            x               x                      xxxxxxxxxx50
51                                                  x            x               x                      xxxxxxxxxx51
52                                                  x            x               x                      xxxxxxxxxx52
53                                                  x            x               x                      xxxxxxxxxx53
54                                                  x            x               x                      xxxxxxxxxx54
55                                                  x            x               x                      xxxxxxxxxx55
56 SUBTOTAL ANCILLARY                               x            x               x                      xxxxxxxxxx56



     ROUTINE INPATIENT CARE SERVICES
57 MED/SURG                                                                                             xxxxxxxxxx57
58 PED                                                                                                  xxxxxxxxxx58
59 OB                                                                                                   xxxxxxxxxx59
60 PSY                                                                                                  xxxxxxxxxx60
61 VENT UNIT                                                                                            xxxxxxxxxx61
62 SNFs                                                                                                 xxxxxxxxxx62




                                                                                     Page 132
                                                                     SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005



                                        (20)      (21)        (22)        (23)       (24)      (25)
                                    PHARMACY MED REC MED CARE           SOCIAL    OTHER XXXXX
                                                           REVIEW      SERVICES             XXXXX


                                    COSTED REQ   % TIME   NO. OF PAT NO. CASES (SPECIFY)
63                                                                                          xxxxxxxxxx63
64                                                                                          xxxxxxxxxx64
65                                                                                          xxxxxxxxxx65
66 SUBTOTAL ACUTE                                                                           xxxxxxxxxx66
67 ICU                                                                                      xxxxxxxxxx67
68 CCU                                                                                      xxxxxxxxxx68
69 NEO                                                                                      xxxxxxxxxx69
70                                                                                          xxxxxxxxxx70
71                                                                                          xxxxxxxxxx71
72                                                                                          xxxxxxxxxx72
73                                                                                          xxxxxxxxxx73
74                                                                                          xxxxxxxxxx74
75 SUBTOTAL ICU                                                                             xxxxxxxxxx75
76 NEWBORN                                                                                  xxxxxxxxxx76
77 CHR & REHAB                                                                              xxxxxxxxxx77
78 SUBTOTAL I/P                                                                             xxxxxxxxxx78


     ROUTINE AMBULATORY CARE SERVICES
79 EMERG                                                                                    xxxxxxxxxx79
80 CLINIC                                                                                   xxxxxxxxxx80
81 SAT                                                                                      xxxxxxxxxx81
82 SURG                                                                                     xxxxxxxxxx82
83 A. DIAL                                                                                  xxxxxxxxxx83




                                                                       Page 133
                                                                        SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


     SCHEDULE XIII
     DHCFP-403 VERSION 2005



                                           (20)       (21)       (22)         (23)       (24)      (25)
                                        PHARMACY MED REC MED CARE           SOCIAL     OTHER XXXXX
                                                              REVIEW      SERVICES              XXXXX


                                    COSTED REQ     % TIME    NO. OF PAT NO. CASES (SPECIFY)
84 H. DIAL                                                                                      xxxxxxxxxx84
85 PSY                                                                                          xxxxxxxxxx85
86 H. HEALTH                                                                                    xxxxxxxxxx86
87 OBS. BEDS                                                                                    xxxxxxxxxx87
88 PRI. REFER                                                                                   xxxxxxxxxx88
89 HOSPITAL LICENSED HEALTH CENTER(S)                                                           xxxxxxxxxx89
90                                                                                              xxxxxxxxxx90
91                                                                                              xxxxxxxxxx91
92 SUBTOTAL AMB                                                                                 xxxxxxxxxx92


93 TOT PAT                                                                                      xxxxxxxxxx93
94 TOT PAT+OTH                                                                                  xxxxxxxxxx94


     NON-PATIENT CARE
95 NON-PAT ANC                      xxxxxxxxxx    xxxxxxxxxx xxxxxxxxxx   xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx95
96 RESEARCH                                                                                     xxxxxxxxxx96
97 OTH NON-PAT                                                                                  xxxxxxxxxx97
98 SUBTOTAL NON-PATIENT                                                                         xxxxxxxxxx98


99 XXXXXX                           xxxxxxxxxx    xxxxxxxxxx xxxxxxxxxx   xxxxxxxxxx xxxxxxxxxx xxxxxxxxxx99
### TOT PAT +NON-PAT                                                                                     #
                                                                                                xxxxxxxxxx ##


### TOT STAT                                                                                             #
                                                                                                xxxxxxxxxx ##




                                                                           Page 134
                                                                    SCHEDULE-XIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED __________


    SCHEDULE XIII
    DHCFP-403 VERSION 2005



                                       (20)      (21)        (22)        (23)       (24)      (25)
                                   PHARMACY MED REC MED CARE           SOCIAL    OTHER XXXXX
                                                          REVIEW      SERVICES             XXXXX


                                   COSTED REQ   % TIME   NO. OF PAT NO. CASES (SPECIFY)
### UCM EXC                                                                                         #
                                                                                           xxxxxxxxxx ##
### UCM INC.                                                                                        #
                                                                                           xxxxxxxxxx ##




                                                                      Page 135
                                                                 COVER-SCH-XIV


HOSPITAL______________________
FISCAL YEAR ENDED__________


        SCHEDULE XIV
        DHCFP-403 VERSION 2005


             STEPDOWN EXPENSES-EXCLUDING CAPITAL


        OVERHEAD
     1 DEPRECIATION THRU AMORTIZATION OF BOND ISSUE COSTS
     2 FRINGE BENEFITS
     3 ADMINISTRATION THRU INTEREST-SHORT TERM
     4 PLANT MAINTENANCE AND REPAIRS
     5 PLANT OPERATIONS THRU LICENSES + TAXES
     6 LAUNDRY AND LINEN
     7 HOUSEKEEPING
     8 CAFETERIA
     9 DIETARY SERVICES
     10 MAINTENANCE OF PERSONNEL
     11 NURSING ADMINISTRATION AND INSERVICE EDUCATION-NURSING
     12 RN + LPN EDUCATION
     13 MEDICAL STAFF-TEACHING AND ADMINISTRATION
     14 POST GRADUATE MEDICAL EDUATION
     15 CENTRAL SERVICE AND SUPPLIES
     16 PHARMACY
     17 MEDICAL RECORDS
     18 MEDICAL CARE REVIEW
     19 SOCIAL SERVICES
     20 OTHER OVERHEAD
     21 SUBTOTAL OVERHEAD


        ANCILLARY CARE SERVICES
     22 SURGERY
     23 LABOR + DELIVERY
     24 RECOVERY ROOM




                                                                    Page 136
                                                     COVER-SCH-XIV


HOSPITAL______________________
FISCAL YEAR ENDED__________


          SCHEDULE XIV
          DHCFP-403 VERSION 2005


               STEPDOWN EXPENSES-EXCLUDING CAPITAL


     25 ANESTHESIOLOGY
     26 IV THERAPY
     27 MEDICAL SUPPLIES-SPECIAL
     28 DRUG-SPECIAL
     29 LABORATORY
     30 BLOOD
     31 BLOOD PROCESSING + STORAGING
     32 ELECTROCARDIOLOGY (EKG)
     33 CARDIAC CATHETERIZATION LABORATORY
     34 DIAGNOSTIC RADIOLOGY
     35 THERAPEUTIC RADIOLOGY
     36 COMPUTERIZED TOMOGRAPHY
     37 NUCLEAR MEDICINE
     38 RESPIRATORY THERAPY
     39 PULMONARY FUNCTION TESTING
     40 ELECTROENCEPHALOGRAPHY (EEG)
     41 ELECTROMOGRAPHY
     42 PHYSICAL THERAPY
     43 OCCUPATIONAL THERAPY
     44 SPEECH-LANGUAGE THERAPY
     45 RECREATIONAL THERAPY
     46 AUDIOLOGY
     47 PSYCHOLOGY/PSYCHIATRY
     48 RENAL DIALYSIS
     49 ORGAN ACQUISITION
     50 AMBULANCE
     51




                                                        Page 137
                                                     COVER-SCH-XIV


HOSPITAL______________________
FISCAL YEAR ENDED__________


          SCHEDULE XIV
          DHCFP-403 VERSION 2005


               STEPDOWN EXPENSES-EXCLUDING CAPITAL


     52
     53
     54
     55
     56 SUBTOTAL ANCILLARY


          ROUTINE INPATIENT CARE SERVICES
     57 MEDICAL + SURGICAL ACUTE
     58 PEDIATRIC ACUTE
     59 OBSTETRIC ACUTE
     60 PSYCHIATRIC ACUTE
     61 VENTILATOR UNIT
     62 SKILLED NURSING FACILITIES
     63
     64
     65
     66 SUBTOTAL ACUTE


     67 MEDICAL + SURGICAL INTENSIVE CARE
     68 CORONARY INTENSIVE CARE
     69 NEONATAL INTENSIVE CARE
     70
     71
     72
     73
     74
     75 SUBTOTAL INTENSIVE CARE




                                                        Page 138
                                                          COVER-SCH-XIV


HOSPITAL______________________
FISCAL YEAR ENDED__________


          SCHEDULE XIV
          DHCFP-403 VERSION 2005


               STEPDOWN EXPENSES-EXCLUDING CAPITAL


     76 NEWBORN NURSERY
     77 CHRONIC AND REHABILIATION
     78 SUBTOTAL ROUTINE INPATIENT CARE


          ROUTINE AMBULATORY CARE
     79 EMERGENCY SERVICES
     81 CLINIC OR AMBULATORY SERVICES
     82 SATELLITE CLINIC SERVICES
     82 AMBULATORY SURGERY SERVICES
     83 AMBULATORY RENAL DIALYSIS SERVICES
     84 HOME DIALYSIS SERVICES
     85 PSYCHIATRY
     86 HOME HEALTH SERVICES
     87 OBSERVATION BEDS
     88 PRIVATE REFERRALS
     89 HOSPITAL LICENSED HEALTH CENTER(S)
     90
     91
     92 SUBTOTAL ROUTINE AMBULATORY SERVICES
     93 TOTAL PATIENT CARE (LINES 56 + 78 + 92)
     94 TOTAL PATIENT CARE AND OVERHEAD (LINES 21 + 93)


          NON-PATIENT CARE
     95 NON-PATIENT ANCILLARY
     96 RESEARCH
     97 OTHER NON-PATIENT
     98 SUBTOTAL NON-PATIENT




                                                             Page 139
                                                                   COVER-SCH-XIV


HOSPITAL______________________
FISCAL YEAR ENDED__________


        SCHEDULE XIV
        DHCFP-403 VERSION 2005


              STEPDOWN EXPENSES-EXCLUDING CAPITAL



     99 RECOVERY OF EXPENSES (SCH VII, C.3, L.50)
    100 TOTAL PATIENT + NON-PATIENT (LINES 94 + 98 + 99)
    101 PROVISION FOR BAD DEBT
 101.01 GROSS UNCOMPENSATED CARE POOL ASSESSMENT
    102 TOTAL PATIENT AND NON-PATIENT, PROVISION FOR BAD DEBTS AND GROSS UNCOMPENSATED CARE POOL ASSESSMENT (LINES 100 + 101 + 101.01)




                                                                       Page 140
                                                                           SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV               STEPDOWN EXPENSES-EXCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                       (2)            (3)            (4)         (5)        (6)         (7)       (8)        (9)         (10)        (11)
                                 DIRECT EXP. ALLOCATED TOTAL EXP.               X         FRINGE                      PLANT OP THRU
                                                                                                    ADM THRU PLANT MAIN           LNDRY+LINENHOUSEKEEP
                                 (SC IX,C.13)       EXPENSE FOR STEPDWN                 BENEFITS IN-SHRT TERM +REPAIRS   LIC+TAXES
                                                                (Cols.2+3)                                                           NO. DRY LBS   HRS OF
                                                                                          PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
      OVERHEAD


    1 DEP                             X               X             X           X           X          X         X          X            X           X
    2 FRINGE                                          X                         X           X          X         X          X            X           X
    3 ADM                                                                       X                      X         X          X            X           X
    4 PL MAINT                                                                  X                                X          X            X           X
    5 PL OP                                                                     X                                           X            X           X
    6 LAUND                                                                     X                                                        X           X
    7 HSKP                                                                      X                                                                    X
    8 CAFE                                                                      X
    9 DIET                                                                      X
   10 MAINT PER                                                                 X
   11 NURS ADM                                                                  X
   12 RN+LPN                                                                    X
   13 MED STAFF                                                                 X
   14 POST GRAD                                                                 X
   15 CENT SER                                                                  X
   16 PHARM                                                                     X
   17 MED REC                                                                   X
   18 MED CARE                                                                  X
   19 SOC SER                                                                   X
   20 OTHER                                                                     X
   21 SUBTOTAL                                  X           X                   X


      ANCILLARY CARE SERVICES




                                                                             Page 141
                                                                           SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV               STEPDOWN EXPENSES-EXCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                       (2)            (3)            (4)         (5)        (6)         (7)       (8)        (9)         (10)        (11)
                                 DIRECT EXP. ALLOCATED TOTAL EXP.               X         FRINGE                      PLANT OP THRU
                                                                                                    ADM THRU PLANT MAIN           LNDRY+LINENHOUSEKEEP
                                 (SC IX,C.13)       EXPENSE FOR STEPDWN                 BENEFITS IN-SHRT TERM +REPAIRS   LIC+TAXES
                                                                (Cols.2+3)                                                           NO. DRY LBS   HRS OF
                                                                                          PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
   22 SURGERY                                   X           X                   X
   23 LABOR                                     X           X                   X
   24 REC RM                                    X           X                   X
   25 ANEST                                     X           X                   X
   26 IV THER                                   X           X                   X
   27 MED SUP                                   X           X                   X
   28 DRUG                                      X           X                   X
   29 LAB                                       X           X                   X
   30 BLOOD                                     X           X                   X
   31 BL PROC                                   X           X                   X
   32 EKG                                       X           X                   X
   33 CARD CATH                                 X           X                   X
   34 DIAG RAD                                  X           X                   X
   35 THER RAD                                  X           X                   X
   36 CT SCAN                                   X           X                   X
   37 NUC MED                                   X           X                   X
   38 RESP THER                                 X           X                   X
   39 PULM                                      X           X                   X
   40 EEG                                       X           X                   X
   41 ELEC                                      X           X                   X
   42 PHY THER                                  X           X                   X
   43 OCC THER                                  X           X                   X
   44 SPEECH                                    X           X                   X
   45 REC THER                                  X           X                   X
   46 AUD                                       X           X                   X




                                                                             Page 142
                                                                                SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XIV                 STEPDOWN EXPENSES-EXCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                            (2)            (3)            (4)         (5)        (6)         (7)       (8)        (9)         (10)        (11)
                                     DIRECT EXP. ALLOCATED TOTAL EXP.                X         FRINGE                      PLANT OP THRU
                                                                                                         ADM THRU PLANT MAIN           LNDRY+LINENHOUSEKEEP
                                      (SC IX,C.13)       EXPENSE FOR STEPDWN                 BENEFITS IN-SHRT TERM +REPAIRS   LIC+TAXES
                                                                     (Cols.2+3)                                                           NO. DRY LBS   HRS OF
                                                                                               PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
   47 PSYCH                                          X           X                   X
   48 REN DIAL                                       X           X                   X
   49 ORGAN ACQ                                      X           X                   X
   50 AMB                                            X           X                   X
   51                                                X           X                   X
   52                                                X           X                   X
   53                                                X           X                   X
   54                                                X           X                   X
   55                                                X           X                   X
   56 SUBTOTAL ANC                                   X           X                   X


        ROUTINE INPATIENT CARE SERVICES
   57 MED/SURG                                       X           X                   X
   58 PED                                            X           X                   X
   59 OB                                             X           X                   X
   60 PSY                                            X           X                   X
   61 VENT UNIT                                      X           X                   X
   62 SNFs                                           X           X                   X
   63                                                X           X                   X
   64                                                X           X                   X
   65                                                X           X                   X
   66 SUBTOTAL ACUTE                                 X           X                   X
   67 ICU                                            X           X                   X
   68 CCU                                            X           X                   X
   69 NEO                                            X           X                   X




                                                                                  Page 143
                                                                              SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XIV               STEPDOWN EXPENSES-EXCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                           (2)           (3)            (4)         (5)        (6)         (7)       (8)        (9)         (10)        (11)
                                   DIRECT EXP. ALLOCATED TOTAL EXP.                X         FRINGE                      PLANT OP THRU
                                                                                                       ADM THRU PLANT MAIN           LNDRY+LINENHOUSEKEEP
                                    (SC IX,C.13)       EXPENSE FOR STEPDWN                 BENEFITS IN-SHRT TERM +REPAIRS   LIC+TAXES
                                                                   (Cols.2+3)                                                           NO. DRY LBS   HRS OF
                                                                                             PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
   70                                              X           X                   X
   71                                              X           X                   X
   72                                              X           X                   X
   73                                              X           X                   X
   74                                              X           X                   X
   75 SUBTOTAL ICU                                 X           X                   X
   76 NEWBORN                                      X           X                   X
   77 CHRONIC                                      X           X                   X
   78 SUBTOTAL I/P                                 X           X                   X


        ROUTINE AMBULATORY CARE SERVICES
   79 EMERG                                        X           X                   X
   80 CLINIC                                       X           X                   X
   81 SAT                                          X           X                   X
   82 SURG                                         X           X                   X
   83 A. DIAL                                      X           X                   X
   84 H.DIAL                                       X           X                   X
   85 PSY                                          X           X                   X
   86 H.HEALTH                                     X           X                   X
   87 OBS. BEDS                                    X           X                   X
   88 PRI. REFER.                                  X           X                   X
   89 HOSPITAL LICENSED HEALTH CENTER(S)           X           X                   X
   90                                              X           X                   X
   91                                              X           X                   X
   92 SUBTOTAL AMB                                 X           X                   X




                                                                                Page 144
                                                                           SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV               STEPDOWN EXPENSES-EXCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                       (2)            (3)            (4)         (5)        (6)         (7)       (8)        (9)         (10)        (11)
                                 DIRECT EXP. ALLOCATED TOTAL EXP.               X         FRINGE                      PLANT OP THRU
                                                                                                    ADM THRU PLANT MAIN           LNDRY+LINENHOUSEKEEP
                                 (SC IX,C.13)       EXPENSE FOR STEPDWN                 BENEFITS IN-SHRT TERM +REPAIRS   LIC+TAXES
                                                                (Cols.2+3)                                                           NO. DRY LBS   HRS OF
                                                                                          PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
   93 TOT PAT                                   X           X                   X
   94 TOT PAT+OH                                X           X                   X


      NON-PATIENT CARE
   95 NON-PAT ANC                                     X             X           X           X          X         X          X            X           X
   96 RESEARCH                                        X             X           X
   97 OTHER NON-PAT                                   X             X           X
   98 SUBTOTAL N/P                                    X             X           X


   99 RECOVERY                                        X             X           X           X          X         X          X            X           X
  100 TOT PAT + NON-PAT                               X             X           X
  101 PROV FOR BAD DEBTS                              X             X           X           X          X         X          X            X           X
  101 GR UCP ASSMT                                    X             X           X           X          X         X          X            X           X
  102 TOT PAT+NON-PAT+B/D                             X             X           X           X          X         X          X            X           X
       +GR UCP ASSMT




                                                                             Page 145
                                                                  SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV                                                              STEPDOWN EXPENSES-EXCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                    (12)       (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                 CAFETERIA   DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                       PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                 FULL TIME NO.OF MEALS AVG NO. OF
                                 EQUIVAL.    SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
      OVERHEAD


    1 DEP                           X          X          X            X            X           X         X           X         X           X
    2 FRINGE                        X          X          X            X            X           X         X           X         X           X
    3 ADM                           X          X          X            X            X           X         X           X         X           X
    4 PL MAINT                      X          X          X            X            X           X         X           X         X           X
    5 PL OP                         X          X          X            X            X           X         X           X         X           X
    6 LAUND                         X          X          X            X            X           X         X           X         X           X
    7 HSKP                          X          X          X            X            X           X         X           X         X           X
    8 CAFE                          X          X          X            X            X           X         X           X         X           X
    9 DIET                                     X          X            X            X           X         X           X         X           X
   10 MAINT PER                                           X            X            X           X         X           X         X           X
   11 NURS ADM                                                         X            X           X         X           X         X           X
   12 RN+LPN                                                                        X           X         X           X         X           X
   13 MED STAFF                                                                                 X         X           X         X           X
   14 POST GRAD                                                                                           X           X         X           X
   15 CENT SER                                                                                                        X         X           X
   16 PHARM                                                                                                                     X           X
   17 MED REC                                                                                                                               X
   18 MED CARE                                                                                                                              X
   19 SOC SER                                                                                                                               X
   20 OTHER                                                                                                                                 X
   21 SUBTOTAL                                                                                                                              X


      ANCILLARY CARE SERVICES




                                                                    Page 146
                                                                  SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV                                                              STEPDOWN EXPENSES-EXCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                    (12)       (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                 CAFETERIA   DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                       PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                 FULL TIME NO.OF MEALS AVG NO. OF
                                 EQUIVAL.    SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
   22 SURGERY                                                                                                                               X
   23 LABOR                                                                                                                                 X
   24 REC RM                                                                                                                                X
   25 ANEST                                                                                                                                 X
   26 IV THER                                                                                                                               X
   27 MED SUP                                                                                                                               X
   28 DRUG                                                                                                                                  X
   29 LAB                                                                                                                                   X
   30 BLOOD                                                                                                                                 X
   31 BL PROC                                                                                                                               X
   32 EKG                                                                                                                                   X
   33 CARD CATH                                                                                                                             X
   34 DIAG RAD                                                                                                                              X
   35 THER RAD                                                                                                                              X
   36 CT SCAN                                                                                                                               X
   37 NUC MED                                                                                                                               X
   38 RESP THER                                                                                                                             X
   39 PULM                                                                                                                                  X
   40 EEG                                                                                                                                   X
   41 ELEC                                                                                                                                  X
   42 PHY THER                                                                                                                              X
   43 OCC THER                                                                                                                              X
   44 SPEECH                                                                                                                                X
   45 REC THER                                                                                                                              X
   46 AUD                                                                                                                                   X




                                                                    Page 147
                                                                           SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XIV                                                                     STEPDOWN EXPENSES-EXCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                             (12)       (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                      CAFETERIA       DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                                PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                          FULL TIME NO.OF MEALS AVG NO. OF
                                          EQUIVAL.    SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
   47 PSYCH                                                                                                                                          X
   48 REN DIAL                                                                                                                                       X
   49 ORGAN ACQ                                                                                                                                      X
   50 AMB                                                                                                                                            X
   51                                                                                                                                                X
   52                                                                                                                                                X
   53                                                                                                                                                X
   54                                                                                                                                                X
   55                                                                                                                                                X
   56 SUBTOTAL ANC                                                                                                                                   X


        ROUTINE INPATIENT CARE SERVICES
   57 MED/SURG
   58 PED
   59 OB
   60 PSY
   61 VENT UNIT
   62 SNFs
   63
   64
   65
   66 SUBTOTAL ACUTE
   67 ICU
   68 CCU
   69 NEO




                                                                             Page 148
                                                                       SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XIV                                                                 STEPDOWN EXPENSES-EXCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                           (12)     (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                    CAFETERIA     DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                            PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                     FULL TIME NO.OF MEALS AVG NO. OF
                                     EQUIVAL.     SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
   70
   71
   72
   73
   74
   75 SUBTOTAL ICU
   76 NEWBORN
   77 CHRONIC
   78 SUBTOTAL I/P


        ROUTINE AMBULATORY CARE SERVICES
   79 EMERG
   80 CLINIC
   81 SAT
   82 SURG
   83 A. DIAL
   84 H.DIAL
   85 PSY
   86 H.HEALTH
   87 OBS. BEDS
   88 PRI. REFER.
   89 HOSPITAL LICENSED HEALTH CENTER(S)
   90
   91
   92 SUBTOTAL AMB




                                                                         Page 149
                                                                  SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV                                                              STEPDOWN EXPENSES-EXCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                    (12)       (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                 CAFETERIA   DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                       PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                 FULL TIME NO.OF MEALS AVG NO. OF
                                 EQUIVAL.    SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
   93 TOT PAT
   94 TOT PAT+OH


      NON-PATIENT CARE
   95 NON-PAT ANC                   X          X          X            X            X           X         X           X         X           X
   96 RESEARCH
   97 OTHER NON-PAT
   98 SUBTOTAL N/P


   99 RECOVERY                      X          X          X            X            X           X         X           X         X           X
  100 TOT PAT + NON-PAT
  101 PROV FOR BAD DEBTS            X          X          X            X            X           X         X           X         X           X
  101 GR UCP ASSMT                  X          X          X            X            X           X         X           X         X           X
  102 TOT PAT+NON-PAT+B/D           X          X          X            X            X           X         X           X         X           X
       +GR UCP ASSMT




                                                                    Page 150
                                                                    SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV
      DHCFP-403 VERSION 2005
                                     (22)        (23)        (24)         (25)
                                 MED CARE      SOCIAL      OTHER      TOTAL EXP.
                                  REVIEW      SERVICES                AFTER STPDW


                                 NO. OF PAT   NO. CASES   (SPECIFY)
      OVERHEAD


    1 DEP                           X            X           X            X         1
    2 FRINGE                        X            X           X            X         2
    3 ADM                           X            X           X            X         3
    4 PL MAINT                      X            X           X            X         4
    5 PL OP                         X            X           X            X         5
    6 LAUND                         X            X           X            X         6
    7 HSKP                          X            X           X            X         7
    8 CAFE                          X            X           X            X         8
    9 DIET                          X            X           X            X         9
   10 MAINT PER                     X            X           X            X         10
   11 NURS ADM                      X            X           X            X         11
   12 RN+LPN                        X            X           X            X         12
   13 MED STAFF                     X            X           X            X         13
   14 POST GRAD                     X            X           X            X         14
   15 CENT SER                      X            X           X            X         15
   16 PHARM                         X            X           X            X         16
   17 MED REC                       X            X           X            X         17
   18 MED CARE                      X            X           X            X         18
   19 SOC SER                       X            X           X            X         19
   20 OTHER                         X            X           X            X         20
   21 SUBTOTAL                      X            X           X            X         21


      ANCILLARY CARE SERVICES




                                                                       Page 151
                                                                    SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV
      DHCFP-403 VERSION 2005
                                     (22)        (23)        (24)         (25)
                                 MED CARE      SOCIAL      OTHER      TOTAL EXP.
                                  REVIEW      SERVICES                AFTER STPDW


                                 NO. OF PAT   NO. CASES   (SPECIFY)
   22 SURGERY                       X            X                                  22
   23 LABOR                         X            X                                  23
   24 REC RM                        X            X                                  24
   25 ANEST                         X            X                                  25
   26 IV THER                       X            X                                  26
   27 MED SUP                       X            X                                  27
   28 DRUG                          X            X                                  28
   29 LAB                           X            X                                  29
   30 BLOOD                         X            X                                  30
   31 BL PROC                       X            X                                  31
   32 EKG                           X            X                                  32
   33 CARD CATH                     X            X                                  33
   34 DIAG RAD                      X            X                                  34
   35 THER RAD                      X            X                                  35
   36 CT SCAN                       X            X                                  36
   37 NUC MED                       X            X                                  37
   38 RESP THER                     X            X                                  38
   39 PULM                          X            X                                  39
   40 EEG                           X            X                                  40
   41 ELEC                          X            X                                  41
   42 PHY THER                      X            X                                  42
   43 OCC THER                      X            X                                  43
   44 SPEECH                        X            X                                  44
   45 REC THER                      X            X                                  45
   46 AUD                           X            X                                  46




                                                                       Page 152
                                                                           SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XIV
        DHCFP-403 VERSION 2005
                                             (22)       (23)        (24)         (25)
                                          MED CARE    SOCIAL      OTHER      TOTAL EXP.
                                           REVIEW    SERVICES                AFTER STPDW


                                      NO. OF PAT     NO. CASES   (SPECIFY)
   47 PSYCH                                  X          X                                  47
   48 REN DIAL                               X          X                                  48
   49 ORGAN ACQ                              X          X                                  49
   50 AMB                                    X          X                                  50
   51                                        X          X                                  51
   52                                        X          X                                  52
   53                                        X          X                                  53
   54                                        X          X                                  54
   55                                        X          X                                  55
   56 SUBTOTAL ANC                           X          X                                  56


        ROUTINE INPATIENT CARE SERVICES
   57 MED/SURG                                                                             57
   58 PED                                                                                  58
   59 OB                                                                                   59
   60 PSY                                                                                  60
   61 VENT UNIT                                                                            61
   62 SNFs                                                                                 62
   63                                                                                      63
   64                                                                                      64
   65                                                                                      65
   66 SUBTOTAL ACUTE                                                                       66
   67 ICU                                                                                  67
   68 CCU                                                                                  68
   69 NEO                                                                                  69




                                                                              Page 153
                                                                        SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XIV
        DHCFP-403 VERSION 2005
                                           (22)      (23)        (24)         (25)
                                     MED CARE      SOCIAL      OTHER      TOTAL EXP.
                                      REVIEW      SERVICES                AFTER STPDW


                                    NO. OF PAT    NO. CASES   (SPECIFY)
   70                                                                                   70
   71                                                                                   71
   72                                                                                   72
   73                                                                                   73
   74                                                                                   74
   75 SUBTOTAL ICU                                                                      75
   76 NEWBORN                                                                           76
   77 CHRONIC                                                                           77
   78 SUBTOTAL I/P                                                                      78


        ROUTINE AMBULATORY CARE SERVICES
   79 EMERG                                                                             79
   80 CLINIC                                                                            80
   81 SAT                                                                               81
   82 SURG                                                                              82
   83 A. DIAL                                                                           83
   84 H.DIAL                                                                            84
   85 PSY                                                                               85
   86 H.HEALTH                                                                          86
   87 OBS. BEDS                                                                         87
   88 PRI. REFER.                                                                       88
   89 HOSPITAL LICENSED HEALTH CENTER(S)                                                89
   90                                                                                   90
   91                                                                                   91
   92 SUBTOTAL AMB                                                                      92




                                                                           Page 154
                                                                    SCHEDULE-XIV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XIV
      DHCFP-403 VERSION 2005
                                     (22)        (23)        (24)         (25)
                                 MED CARE      SOCIAL      OTHER      TOTAL EXP.
                                  REVIEW      SERVICES                AFTER STPDW


                                 NO. OF PAT   NO. CASES   (SPECIFY)
   93 TOT PAT                                                                       93
   94 TOT PAT+OH                                                                    94


      NON-PATIENT CARE
   95 NON-PAT ANC                   X            X           X            X         95
   96 RESEARCH                                                                      96
   97 OTHER NON-PAT                                                                 97
   98 SUBTOTAL N/P                                                                  98


   99 RECOVERY                      X            X           X            X         99
  100 TOT PAT + NON-PAT                                                             100
  101 PROV FOR BAD DEBTS            X            X           X            X         101
  101 GR UCP ASSMT                  X            X           X            X         101
  102 TOT PAT+NON-PAT+B/D           X            X           X                      102
       +GR UCP ASSMT




                                                                       Page 155
                                                                  COVER-SCH-XV


HOSPITAL______________________
FISCAL YEAR ENDED_______________


         SCHEDULE XV
         DHCFP-403 VERSION 2005
                                          STEPDOWN EXPENSES-INCLUDING CAPITAL



         OVERHEAD
      1 DEPRECIATION THRU AMORTIZATION OF BOND ISSUE COSTS
      2 FRINGE BENEFITS
      3 ADMINISTRATION THRU INTEREST-SHORT TERM
      4 PLANT MAINTENANCE AND REPAIRS
      5 PLANT OPERATIONS THRU LICENSES + TAXES
      6 LAUNDRY AND LINEN
      7 HOUSEKEEPING
      8 CAFETERIA
      9 DIETARY SERVICES
      10 MAINTENANCE OF PERSONNEL
      11 NURSING ADMINISTRATION AND INSERVICE EDUCATION-NURSING
      12 RN + LPN EDUCATION
      13 MEDICAL STAFF-TEACHING AND ADMINISTRATION
      14 POST GRADUATE MEDICAL EDUATION
      15 CENTRAL SERVICE AND SUPPLIES
      16 PHARMACY
      17 MEDICAL RECORDS
      18 MEDICAL CARE REVIEW
      19 SOCIAL SERVICES
      20 OTHER OVERHEAD
      21 SUBTOTAL OVERHEAD
‚::
         ANCILLARY CARE SERVICES
      22 SURGERY
      23 LABOR + DELIVERY
      24 RECOVERY ROOM




                                                                    Page 156
                                                             COVER-SCH-XV


HOSPITAL______________________
FISCAL YEAR ENDED_______________


         SCHEDULE XV
         DHCFP-403 VERSION 2005
                                      STEPDOWN EXPENSES-INCLUDING CAPITAL



    25 ANESTHESIOLOGY
    26 IV THERAPY
    27 MEDICAL SUPPLIES-SPECIAL
    28 DRUG-SPECIAL
    29 LABORATORY
    30 BLOOD
    31 BLOOD PROCESSING + STORAGING
    32 ELECTROCARDIOLOGY (EKG)
    33 CARDIAC CATHETERIZATION LABORATORY
    34 DIAGNOSTIC RADIOLOGY
    35 THERAPEUTIC RADIOLOGY
    36 COMPUTERIZED TOMOGRAPHY
    37 NUCLEAR MEDICINE
    38 RESPIRATORY THERAPY
    39 PULMONARY FUNCTION TESTING
    40 ELECTROENCEPHALOGRAPHY (EEG)
    41 ELECTROMOGRAPHY
    42 PHYSICAL THERAPY
    43 OCCUPATIONAL THERAPY
    44 SPEECH-LANGUAGE THERAPY
    45 RECREATIONAL THERAPY
    46 AUDIOLOGY
    47 PSYCHOLOGY/PSYCHIATRY
    48 RENAL DIALYSIS
    49 ORGAN ACQUISITION
    50 AMBULANCE
    51




                                                                Page 157
                                                                  COVER-SCH-XV


HOSPITAL______________________
FISCAL YEAR ENDED_______________


         SCHEDULE XV
         DHCFP-403 VERSION 2005
                                           STEPDOWN EXPENSES-INCLUDING CAPITAL



    52
    53
    54
    55
    56 SUBTOTAL ANCILLARY


         ROUTINE INPATIENT CARE SERVICES
    57 MEDICAL + SURGICAL ACUTE
    58 PEDIATRIC ACUTE
    59 OBSTETRIC ACUTE
    60 PSYCHIATRIC ACUTE
    61 VENTILATOR UNIT
    62 SKILLED NURSING FACILITIES
    63
    64
    65
    66 SUBTOTAL ACUTE


    67 MEDICAL + SURGICAL INTENSIVE CARE
    68 CORONARY INTENSIVE CARE
    69 NEONATAL INTENSIVE CARE
    70
    71
    72
    73
    74
    75 SUBTOTAL INTENSIVE CARE




                                                                     Page 158
                                                                    COVER-SCH-XV


HOSPITAL______________________
FISCAL YEAR ENDED_______________


         SCHEDULE XV
         DHCFP-403 VERSION 2005
                                             STEPDOWN EXPENSES-INCLUDING CAPITAL



    76 NEWBORN NURSERY
    77 CHRONIC AND REHABILIATION
    78 SUBTOTAL ROUTINE INPATIENT CARE


         ROUTINE AMBULATORY CARE
    79 EMERGENCY SERVICES
    80 CLINIC OR AMBULATORY SERVICES
    81 SATELLITE CLINIC SERVICES
    82 AMBULATORY SURGERY SERVICES
    83 AMBULATORY RENAL DIALYSIS SERVICES
    84 HOME DIALYSIS SERVICES
    85 PSYCHIATRY
    86 HOME HEALTH SERVICES
    87 OBSERVATION BEDS
    88 PRIVATE REFERRALS
    89 HOSPITAL LICENSED HEALTH CENTER(S)
    90
    91
    92 SUBTOTAL ROUTINE AMBULATORY SERVICES
    93 TOTAL PATIENT CARE (LINES 56 + 78 + 92)
    94 TOTAL PATIENT CARE AND OVERHEAD (LINES 21 + 93)


         NON-PATIENT CARE
    95 NON-PATIENT ANCILLARY
    96 RESEARCH
    97 OTHER NON-PATIENT
    98 SUBTOTAL NON-PATIENT




                                                                       Page 159
                                                                    COVER-SCH-XV


HOSPITAL______________________
FISCAL YEAR ENDED_______________


       SCHEDULE XV
       DHCFP-403 VERSION 2005
                                             STEPDOWN EXPENSES-INCLUDING CAPITAL




    99 RECOVERY OF EXPENSES (SCH VII, C.3, L.50)
   100 TOTAL PATIENT + NON-PATIENT (LINES 94 + 98 + 99)
   101 PROVISION FOR BAD DEBT
 101.01 GROSS UNCOMPENSATED CARE POOL ASSESSMENT
   102 TOTAL PATIENT AND NON-PATIENT + PROVISION FOR BAD DEBTS + GROSS UNCOMPENSATED CARE POOL ASSESSMENT (LINES 100 + 101 + 101.01)




                                                                       Page 160
                                                                      SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XV                STEPDOWN EXPENSES-INCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                        (2)          (3)        (4)           (5)        (6)        (7)        (8)        (9)         (10)        (11)
                                 DIRECT EXP.     ALLOCATED TOTAL EXP. DEP THRU         FRINGE    ADM THRU PLANT MAIN            LNDRY+LINENHOUSEKEEP
                                                                                                                    PLANT OP THRU
                                  (SC IX,C.13)                      AMORT BOND BENEFITS
                                                  EXPENSE FOR STEPDWN                 IN-SHRT TERM +REPAIRS           LIC+TAXES
                                                            (Cols.2+3)   ISSUE COSTS                                              NO. DRY LBS   HRS OF
                                                                            SQ FT      PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
      OVERHEAD


    1 DEPREC                                        X                        X           X          X         X          X            X           X
    2 FRINGE                                                                             X          X         X          X            X           X
    3 ADM                                                                                           X         X          X            X           X
    4 PL MAINT                                                                                                X          X            X           X
    5 PL OP                                                                                                              X            X           X
    6 LAUND                                                                                                                           X           X
    7 HSKP                                                                                                                                        X
    8 CAFE
    9 DIET
   10 MAINT PER
   11 NURS ADM
   12 RN+LPN
   13 MED STAFF
   14 POST GRAD
   15 CENT SER
   16 PHARM
   17 MED REC
   18 MED CARE
   19 SOC SER
   20 OTHER
   21 SUBTOTAL OH                                   X          X


      ANCILLARY CARE SERVICES




                                                                          Page 161
                                                                      SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XV                STEPDOWN EXPENSES-INCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                        (2)          (3)        (4)           (5)        (6)        (7)        (8)        (9)         (10)        (11)
                                 DIRECT EXP.     ALLOCATED TOTAL EXP. DEP THRU         FRINGE    ADM THRU PLANT MAIN            LNDRY+LINENHOUSEKEEP
                                                                                                                    PLANT OP THRU
                                  (SC IX,C.13)                      AMORT BOND BENEFITS
                                                  EXPENSE FOR STEPDWN                 IN-SHRT TERM +REPAIRS           LIC+TAXES
                                                            (Cols.2+3)   ISSUE COSTS                                              NO. DRY LBS   HRS OF
                                                                            SQ FT      PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
      OVERHEAD
   22 SURGERY                                       X          X
   23 LABOR                                         X          X
   24 REC RM                                        X          X
   25 ANEST                                         X          X
   26 IV THER                                       X          X
   27 MED SUP                                       X          X
   28 DRUG                                          X          X
   29 LAB                                           X          X
   30 BLOOD                                         X          X
   31 BL PROC                                       X          X
   32 EKG                                           X          X
   33 CARD CATH                                     X          X
   34 DIAG RAD                                      X          X
   35 THER RAD                                      X          X
   36 CT SCAN                                       X          X
   37 NUC MED                                       X          X
   38 RESP THER                                     X          X
   39 PULM                                          X          X
   40 EEG                                           X          X
   41 ELEC                                          X          X
   42 PHY THER                                      X          X
   43 OCC THER                                      X          X
   44 SPEECH                                        X          X
   45 REC THER                                      X          X




                                                                          Page 162
                                                                         SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV                STEPDOWN EXPENSES-INCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                           (2)          (3)        (4)           (5)        (6)        (7)        (8)        (9)         (10)        (11)
                                    DIRECT EXP.     ALLOCATED TOTAL EXP. DEP THRU         FRINGE    ADM THRU PLANT MAIN            LNDRY+LINENHOUSEKEEP
                                                                                                                       PLANT OP THRU
                                     (SC IX,C.13)                      AMORT BOND BENEFITS
                                                     EXPENSE FOR STEPDWN                 IN-SHRT TERM +REPAIRS           LIC+TAXES
                                                               (Cols.2+3)   ISSUE COSTS                                              NO. DRY LBS   HRS OF
                                                                               SQ FT      PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
        OVERHEAD
   46 AUD                                              X          X
   47 PSYCH                                            X          X
   48 RENAL DIAL                                       X          X
   49 ORGAN ACQ                                        X          X
   50 AMB                                              X          X
   51                                                  X          X
   52                                                  X          X
   53                                                  X          X
   54                                                  X          X
   55                                                  X          X
   56 SUBTOTAL ANC                                     X          X


        ROUTINE INPATIENT CARE SERVICES
   57 MED/SURG                                         X          X
   58 PED                                              X          X
   59 OB                                               X          X
   60 PSY                                              X          X
   61 VENT UNIT                                        X          X
   62 SNFs                                             X          X
   63                                                  X          X
   64                                                  X          X
   65                                                  X          X
   66 SUBTOTAL ACUTE                                   X          X
   67 ICU                                              X          X




                                                                             Page 163
                                                                       SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV               STEPDOWN EXPENSES-INCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                         (2)          (3)        (4)           (5)        (6)        (7)        (8)        (9)         (10)        (11)
                                  DIRECT EXP.     ALLOCATED TOTAL EXP. DEP THRU         FRINGE    ADM THRU PLANT MAIN            LNDRY+LINENHOUSEKEEP
                                                                                                                     PLANT OP THRU
                                   (SC IX,C.13)                      AMORT BOND BENEFITS
                                                   EXPENSE FOR STEPDWN                 IN-SHRT TERM +REPAIRS           LIC+TAXES
                                                             (Cols.2+3)   ISSUE COSTS                                              NO. DRY LBS   HRS OF
                                                                             SQ FT      PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
        OVERHEAD
   68 CCU                                            X          X
   69 NEO                                            X          X
   70                                                X          X
   71                                                X          X
   72                                                X          X
   73                                                X          X
   74                                                X          X
   75 SUBTOTAL ICU                                   X          X
   76 NEWBORN                                        X          X
   77 CHRONIC                                        X          X
   78 SUBTOTAL I/P                                   X          X


        ROUTINE AMBULATORY CARE
   79 EMERG                                          X          X
   80 CLINIC                                         X          X
   81 SAT                                            X          X
   82 SURG                                           X          X
   83 A. DIAL                                        X          X
   84 H.DIAL                                         X          X
   85 PSY                                            X          X
   86 H.HEALTH                                       X          X
   87 OBS. BEDS                                      X          X
   88 PRI. REFER.                                    X          X
   89 HOSPITAL LICENSED HEALTH CENTER(S)             X          X




                                                                           Page 164
                                                                      SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV              STEPDOWN EXPENSES-INCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                        (2)          (3)        (4)           (5)        (6)        (7)        (8)        (9)         (10)        (11)
                                 DIRECT EXP.     ALLOCATED TOTAL EXP. DEP THRU         FRINGE    ADM THRU PLANT MAIN            LNDRY+LINENHOUSEKEEP
                                                                                                                    PLANT OP THRU
                                  (SC IX,C.13)                      AMORT BOND BENEFITS
                                                  EXPENSE FOR STEPDWN                 IN-SHRT TERM +REPAIRS           LIC+TAXES
                                                            (Cols.2+3)   ISSUE COSTS                                              NO. DRY LBS   HRS OF
                                                                            SQ FT      PAYRL $    PAYRL $    SQ.FT.     SQ.FT.    PROCESSED     SERVICE
        OVERHEAD
   90                                               X          X
   91                                               X          X
   92 SUBTOTAL AMB                                  X          X
   93 TOT PAT                                       X          X
   94 TOT PAT+OTH                                   X          X


        NON-PATIENT CARE
   95 NON-PAT CARE ANC                 X            X          X             X           X          X         X          X            X           X
   96 RESEARCH                                      X          X
   97 OTHER NON-PAT                                 X          X
   98 SUBTOTAL N/P                                  X          X


   99 RECOVERY OF EXP                               X          X             X           X          X         X          X            X           X
  100 TOT PAT + N0N-PAT                             X          X
  101 PROV. FOR BAD DEBT                            X          X             X           X          X         X          X            X           X
101.01 GR UCP ASSMT                                 X          X             X           X          X         X          X            X           X
  102 TOTPAT+N/PAT+B/D                              X          X             X           X          X         X          X            X           X
         + GR UCP ASSMT




                                                                          Page 165
                                                                    SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XV                                                               STEPDOWN EXPENSES-INCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                    (12)       (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                 CAFETERIA   DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                       PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                 FULL TIME NO.OF MEALS AVG NO. OF
                                 EQUIVAL.    SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
      OVERHEAD


    1 DEPREC                        X          X          X            X            X           X         X           X         X           X
    2 FRINGE                        X          X          X            X            X           X         X           X         X           X
    3 ADM                           X          X          X            X            X           X         X           X         X           X
    4 PL MAINT                      X          X          X            X            X           X         X           X         X           X
    5 PL OP                         X          X          X            X            X           X         X           X         X           X
    6 LAUND                         X          X          X            X            X           X         X           X         X           X
    7 HSKP                          X          X          X            X            X           X         X           X         X           X
    8 CAFE                          X          X          X            X            X           X         X           X         X           X
    9 DIET                                     X          X            X            X           X         X           X         X           X
   10 MAINT PER                                           X            X            X           X         X           X         X           X
   11 NURS ADM                                                         X            X           X         X           X         X           X
   12 RN+LPN                                                                        X           X         X           X         X           X
   13 MED STAFF                                                                                 X         X           X         X           X
   14 POST GRAD                                                                                           X           X         X           X
   15 CENT SER                                                                                                        X         X           X
   16 PHARM                                                                                                                     X           X
   17 MED REC                                                                                                                               X
   18 MED CARE                                                                                                                              X
   19 SOC SER                                                                                                                               X
   20 OTHER                                                                                                                                 X
   21 SUBTOTAL OH                                                                                                                           X


      ANCILLARY CARE SERVICES




                                                                      Page 166
                                                                    SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XV                                                               STEPDOWN EXPENSES-INCLUDING CAPITAL
      DHCFP-403 VERSION 2005
                                    (12)       (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                 CAFETERIA   DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                       PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                 FULL TIME NO.OF MEALS AVG NO. OF
                                 EQUIVAL.    SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
      OVERHEAD
   22 SURGERY                                                                                                                               X
   23 LABOR                                                                                                                                 X
   24 REC RM                                                                                                                                X
   25 ANEST                                                                                                                                 X
   26 IV THER                                                                                                                               X
   27 MED SUP                                                                                                                               X
   28 DRUG                                                                                                                                  X
   29 LAB                                                                                                                                   X
   30 BLOOD                                                                                                                                 X
   31 BL PROC                                                                                                                               X
   32 EKG                                                                                                                                   X
   33 CARD CATH                                                                                                                             X
   34 DIAG RAD                                                                                                                              X
   35 THER RAD                                                                                                                              X
   36 CT SCAN                                                                                                                               X
   37 NUC MED                                                                                                                               X
   38 RESP THER                                                                                                                             X
   39 PULM                                                                                                                                  X
   40 EEG                                                                                                                                   X
   41 ELEC                                                                                                                                  X
   42 PHY THER                                                                                                                              X
   43 OCC THER                                                                                                                              X
   44 SPEECH                                                                                                                                X
   45 REC THER                                                                                                                              X




                                                                      Page 167
                                                                       SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV                                                                STEPDOWN EXPENSES-INCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                          (12)     (13)        (14)       (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                    CAFETERIA    DIETARY   MAINT. OF   NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                           PERSONNEL +INSERV.ED       EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                    FULL TIME NO.OF MEALS AVG NO. OF
                                     EQUIVAL.    SERVED    LIVING IN   NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
        OVERHEAD
   46 AUD                                                                                                                                      X
   47 PSYCH                                                                                                                                    X
   48 RENAL DIAL                                                                                                                               X
   49 ORGAN ACQ                                                                                                                                X
   50 AMB                                                                                                                                      X
   51                                                                                                                                          X
   52                                                                                                                                          X
   53                                                                                                                                          X
   54                                                                                                                                          X
   55                                                                                                                                          X
   56 SUBTOTAL ANC                                                                                                                             X


        ROUTINE INPATIENT CARE SERVICES
   57 MED/SURG
   58 PED
   59 OB
   60 PSY
   61 VENT UNIT
   62 SNFs
   63
   64
   65
   66 SUBTOTAL ACUTE
   67 ICU




                                                                         Page 168
                                                                     SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV                                                              STEPDOWN EXPENSES-INCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                      (12)      (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                  CAFETERIA   DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                        PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                  FULL TIME NO.OF MEALS AVG NO. OF
                                   EQUIVAL.   SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
        OVERHEAD
   68 CCU
   69 NEO
   70
   71
   72
   73
   74
   75 SUBTOTAL ICU
   76 NEWBORN
   77 CHRONIC
   78 SUBTOTAL I/P


        ROUTINE AMBULATORY CARE
   79 EMERG
   80 CLINIC
   81 SAT
   82 SURG
   83 A. DIAL
   84 H.DIAL
   85 PSY
   86 H.HEALTH
   87 OBS. BEDS
   88 PRI. REFER.
   89 HOSPITAL LICENSED HEALTH CENTER(S)




                                                                       Page 169
                                                                    SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV                                                             STEPDOWN EXPENSES-INCLUDING CAPITAL
        DHCFP-403 VERSION 2005
                                    (12)       (13)        (14)        (15)         (16)         (17)      (18)       (19)      (20)        (21)
                                 CAFETERIA   DIETARY   MAINT. OF    NURS. ADM     RN+LPN     MED STAFF POST GRAD CNT SERVICE PHARMACY     MED REC
                                                       PERSONNEL +INSERV.ED        EDUC      TEACH+ADM MED EDUC   +SUPPLIES
                                 FULL TIME NO.OF MEALS AVG NO. OF
                                 EQUIVAL.    SERVED    LIVING IN    NURS. HRS    ASSG.TIME      HRS       HRS     COSTED REQ COSTED REQ   % TIME
        OVERHEAD
   90
   91
   92 SUBTOTAL AMB
   93 TOT PAT
   94 TOT PAT+OTH


        NON-PATIENT CARE
   95 NON-PAT CARE ANC              X          X          X            X            X           X         X           X         X           X
   96 RESEARCH
   97 OTHER NON-PAT
   98 SUBTOTAL N/P


   99 RECOVERY OF EXP               X          X          X            X            X           X         X           X         X           X
  100 TOT PAT + N0N-PAT
  101 PROV. FOR BAD DEBT            X          X          X            X            X           X         X           X         X           X
101.01 GR UCP ASSMT                 X          X          X            X            X           X         X           X         X           X
  102 TOTPAT+N/PAT+B/D              X          X          X            X            X           X         X           X         X           X
         + GR UCP ASSMT




                                                                      Page 170
                                                                       SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XV
      DHCFP-403 VERSION 2005                  STEPDOWN EXPENSES-INCLUDING CAPITAL
                                     (22)         (23)        (24)         (25)
                                 MED CARE       SOCIAL      OTHER      TOTAL EXP.
                                  REVIEW       SERVICES                AFTER STPDW


                                 NO. OF PAT    NO. CASES   (SPECIFY)
      OVERHEAD


    1 DEPREC                        X             X           X            X          1
    2 FRINGE                        X             X           X            X          2
    3 ADM                           X             X           X            X          3
    4 PL MAINT                      X             X           X            X          4
    5 PL OP                         X             X           X            X          5
    6 LAUND                         X             X           X            X          6
    7 HSKP                          X             X           X            X          7
    8 CAFE                          X             X           X            X          8
    9 DIET                          X             X           X            X          9
   10 MAINT PER                     X             X           X            X         10
   11 NURS ADM                      X             X           X            X         11
   12 RN+LPN                        X             X           X            X         12
   13 MED STAFF                     X             X           X            X         13
   14 POST GRAD                     X             X           X            X         14
   15 CENT SER                      X             X           X            X         15
   16 PHARM                         X             X           X            X         16
   17 MED REC                       X             X           X            X         17
   18 MED CARE                      X             X           X            X         18
   19 SOC SER                       X             X           X            X         19
   20 OTHER                         X             X           X            X         20
   21 SUBTOTAL OH                   X             X           X            X         21


      ANCILLARY CARE SERVICES




                                                                          Page 171
                                                                       SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


      SCHEDULE XV
      DHCFP-403 VERSION 2005                  STEPDOWN EXPENSES-INCLUDING CAPITAL
                                     (22)         (23)        (24)         (25)
                                 MED CARE       SOCIAL      OTHER      TOTAL EXP.
                                  REVIEW       SERVICES                AFTER STPDW


                                 NO. OF PAT    NO. CASES   (SPECIFY)
      OVERHEAD
   22 SURGERY                       X             X                                  22
   23 LABOR                         X             X                                  23
   24 REC RM                        X             X                                  24
   25 ANEST                         X             X                                  25
   26 IV THER                       X             X                                  26
   27 MED SUP                       X             X                                  27
   28 DRUG                          X             X                                  28
   29 LAB                           X             X                                  29
   30 BLOOD                         X             X                                  30
   31 BL PROC                       X             X                                  31
   32 EKG                           X             X                                  32
   33 CARD CATH                     X             X                                  33
   34 DIAG RAD                      X             X                                  34
   35 THER RAD                      X             X                                  35
   36 CT SCAN                       X             X                                  36
   37 NUC MED                       X             X                                  37
   38 RESP THER                     X             X                                  38
   39 PULM                          X             X                                  39
   40 EEG                           X             X                                  40
   41 ELEC                          X             X                                  41
   42 PHY THER                      X             X                                  42
   43 OCC THER                      X             X                                  43
   44 SPEECH                        X             X                                  44
   45 REC THER                      X             X                                  45




                                                                          Page 172
                                                                          SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV
        DHCFP-403 VERSION 2005                   STEPDOWN EXPENSES-INCLUDING CAPITAL
                                          (22)       (23)        (24)         (25)
                                    MED CARE       SOCIAL      OTHER      TOTAL EXP.
                                      REVIEW      SERVICES                AFTER STPDW


                                    NO. OF PAT    NO. CASES   (SPECIFY)
        OVERHEAD
   46 AUD                                 X          X                                  46
   47 PSYCH                               X          X                                  47
   48 RENAL DIAL                          X          X                                  48
   49 ORGAN ACQ                           X          X                                  49
   50 AMB                                 X          X                                  50
   51                                     X          X                                  51
   52                                     X          X                                  52
   53                                     X          X                                  53
   54                                     X          X                                  54
   55                                     X          X                                  55
   56 SUBTOTAL ANC                        X          X                                  56


        ROUTINE INPATIENT CARE SERVICES
   57 MED/SURG                                                                          57
   58 PED                                                                               58
   59 OB                                                                                59
   60 PSY                                                                               60
   61 VENT UNIT                                                                         61
   62 SNFs                                                                              62
   63                                                                                   63
   64                                                                                   64
   65                                                                                   65
   66 SUBTOTAL ACUTE                                                                    66
   67 ICU                                                                               67




                                                                             Page 173
                                                                        SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV
        DHCFP-403 VERSION 2005                 STEPDOWN EXPENSES-INCLUDING CAPITAL
                                      (22)         (23)        (24)         (25)
                                  MED CARE       SOCIAL      OTHER      TOTAL EXP.
                                    REVIEW      SERVICES                AFTER STPDW


                                  NO. OF PAT    NO. CASES   (SPECIFY)
        OVERHEAD
   68 CCU                                                                             68
   69 NEO                                                                             69
   70                                                                                 70
   71                                                                                 71
   72                                                                                 72
   73                                                                                 73
   74                                                                                 74
   75 SUBTOTAL ICU                                                                    75
   76 NEWBORN                                                                         76
   77 CHRONIC                                                                         77
   78 SUBTOTAL I/P                                                                    78


        ROUTINE AMBULATORY CARE
   79 EMERG                                                                           79
   80 CLINIC                                                                          80
   81 SAT                                                                             81
   82 SURG                                                                            82
   83 A. DIAL                                                                         83
   84 H.DIAL                                                                          84
   85 PSY                                                                             85
   86 H.HEALTH                                                                        86
   87 OBS. BEDS                                                                       87
   88 PRI. REFER.                                                                     88
   89 HOSPITAL LICENSED HEALTH CENTER(S)                                              89




                                                                           Page 174
                                                                       SCHEDULE-XV


HOSPITAL______________________
FOR FISCAL YEAR ENDED _______


        SCHEDULE XV
        DHCFP-403 VERSION 2005                STEPDOWN EXPENSES-INCLUDING CAPITAL
                                     (22)         (23)        (24)         (25)
                                 MED CARE       SOCIAL      OTHER      TOTAL EXP.
                                  REVIEW       SERVICES                AFTER STPDW


                                 NO. OF PAT    NO. CASES   (SPECIFY)
        OVERHEAD
   90                                                                                 90
   91                                                                                 91
   92 SUBTOTAL AMB                                                                    92
   93 TOT PAT                                                                         93
   94 TOT PAT+OTH                                                                     94


        NON-PATIENT CARE
   95 NON-PAT CARE ANC              X             X           X            X          95
   96 RESEARCH                                                                        96
   97 OTHER NON-PAT                                                                   97
   98 SUBTOTAL N/P                                                                    98


   99 RECOVERY OF EXP               X             X           X            X          99
  100 TOT PAT + N0N-PAT                                                              100
  101 PROV. FOR BAD DEBT            X             X           X            X         101
101.01 GR UCP ASSMT                 X             X           X            X         101
  102 TOTPAT+N/PAT+B/D              X             X           X                      102
         + GR UCP ASSMT




                                                                          Page 175
                                                   COVER-SCH-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XVI          PATIENT SERVICE STATISTICS
DHCFP-403 VERSION 2005



     INPATIENT CARE
1 MEDICAL+SURGICAL ACUTE
2 PEDIATRIC ACUTE
3 OBSTETRIC ACUTE
4 PSYCHIATRIC ACUTE
5 VENTILATOR UNIT
6 SKILLED NURSING FACILITIES
7
8
9
10 SUBTOTAL ACUTE
11 MEDICAL & SURGICAL INTENSIVE CARE
12 CORONARY INTENSIVE CARE
13 NEONATAL INTENSIVE CARE
14
15
16
17
18
19 SUBTOTAL INTENSIVE CARE
20 NEWBORN NURSERY
21 CHRONIC & REHABILITATION
22 SUBTOTAL INPATIENT CARE


     AMBULATORY CARE
23 EMERGENCY SERVICES
24 CLINIC OR AMBULATORY SERVICES
25 SATELLITE CLINIC SERVICES




                                                      Page 176
                                                              COVER-SCH-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XVI           PATIENT SERVICE STATISTICS
DHCFP-403 VERSION 2005



26 AMBULATORY SURGERY SERVICES
27 AMBULATORY RENAL DIALYSIS SERVICES
28 HOME DIALYSIS SERVICES
29 PSYCHIATRY
30 HOME HEALTH SERVICES
31 OBSERVATION BEDS
32 PRIVATE REFERRALS
33 HOSPITAL LICENSED HEALTH CENTER(S)
34
35
36 SUBTOTAL AMBULATORY CARE


37 TOTAL INPATIENT & AMBULATORY CARE (L.22 + L.36)


     NON-PATIENT CARE
38 NON-PATIENT ANCILLARY
39 RESEARCH
40 OTHER NON-PATIENT
41 SUBTOTAL NON-PATIENT


42 TOTAL PATIENT AND NON-PATIENT (L.37+L.41)
43
44


45 UNIT COST MULTIPLIER EXCLUDING CAPITAL (SCH.XIV, COL. 25
     DIVIDED BY SCH. XVI, L42)
46 UNIT COST MULTIPLIER INCLUDING CAPITAL (SCH.XV, COL. 25
     DIVIDED BY SCH. XVI, L 42)




                                                                 Page 177
                                                                       SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005                       PATIENT SERVICE STATISTICS


                                             (2)           (3)            (4)           (5)          (6)          (7)          (8)
                                                       ROUTINE                       SURGERY      LABOR &      RECOVERY   ANESTHES-
                                                                                                 DELIVERY        ROOM      IOLOGY
                                            -             -               -             -            -            -           -
                                                    PATIENT DAYS/                    SURGERY              R
                                                                                               PROCEDURES &ECOVERY ROOM   ANESTHESIA
                                                      OPD VISITS                     MINUTES   WGHTD.CIRCUM.   MINUTES     MINUTES


      ROUTINE INPATIENT CARE SERVICES
  1 MED/SURG                            ********                    ********
  2 PEDI                                ********                    ********
  3 OB                                  ********                    ********
  4 PSYCH                               ********                    ********
  5 VENT UNIT                           ********                    ********
  6 SNFs                                ********                    ********
  7                                     ********                    ********
  8                                     ********                    ********
  9                                     ********                    ********
 10 SUBTOTAL                            ********                    ********
 11 ICU                                 ********                    ********
 12 CCU                                 ********                    ********
 13 NEO                                 ********                    ********
 14                                     ********                    ********
 15                                     ********                    ********
 16                                     ********                    ********
 17                                     ********                    ********
 18                                     ********                    ********
 19 SUBTOTAL                            ********                    ********
 20 NEWB                                ********                    ********




                                                                          Page 178
                                                                   SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005                   PATIENT SERVICE STATISTICS


                                         (2)           (3)            (4)           (5)          (6)          (7)          (8)
                                                   ROUTINE                       SURGERY      LABOR &      RECOVERY   ANESTHES-
                                                                                             DELIVERY        ROOM      IOLOGY
                                         -            -               -             -            -            -           -
                                                PATIENT DAYS/                    SURGERY              R
                                                                                           PROCEDURES &ECOVERY ROOM   ANESTHESIA
                                                  OPD VISITS                     MINUTES   WGHTD.CIRCUM.   MINUTES     MINUTES


 21 CHR                            ********                     ********
 22 SUBTOTAL                       ********                     ********


      ROUTINE AMBULATORY CARE SERVICES
 23 EMERG                          ********                     ********
 24 CLINIC                         ********                     ********
 25 SATELLITE                      ********                     ********
 26 AMB SURGERY                    ********                     ********
 27 AMB DIAL.                      ********                     ********
 28 HOME DIAL.                     ********                     ********
 29 PSY                            ********                     ********
 30 HOME HEALTH                    ********                     ********
 31 OBS. BEDS                      ********                     ********
 32 PRI. REFER.                    ********                     ********
                                  ********
 33 HOSPITAL LICENSED HEALTH CENTER(S)                          ********
 34                                ********                     ********
 35                                ********                     ********
 36 SUBTOTAL                       ********                     ********
                                   ********                     ********
 37 TOT INP+AMB                    ********                     ********




                                                                      Page 179
                                                                    SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



     SCHEDULE XVI
     DHCFP-403 VERSION 2005                  PATIENT SERVICE STATISTICS


                                      (2)             (3)              (4)                (5)               (6)            (7)               (8)
                                                  ROUTINE                            SURGERY            LABOR &       RECOVERY         ANESTHES-
                                                                                                       DELIVERY          ROOM            IOLOGY
                                     -                -                -                  -                -              -                  -
                                               PATIENT DAYS/                         SURGERY                    R
                                                                                                     PROCEDURES &ECOVERY ROOM          ANESTHESIA
                                                 OPD VISITS                           MINUTES        WGHTD.CIRCUM.    MINUTES           MINUTES


     NON-PAT. CARE
 38 NON-PAT ANC                  ********                        ********
 39 RESEARCH                     ********                        ********
 40 OTH NON-PAT                  ********                        ********
 41 SUBTOTAL                     ********                        ********


 42 TOTPAT+NONP                  ********                        ********
 43 XXXXX                                     **************
                                 *********************************************   **************                    **************
                                                                                                      **************                 **************
 44 XXXXX                                     ***************
                                 **************                 **************   *****************                 ***************
                                                                                                      ***************                ***************


 45 UCM EXC.                     ********                        ********
 46 UCM INC.                     ********                        ********




                                                                        Page 180
                                                                    SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                             (9)          (10)           (11)          (12)       (13)        (14)       (15)
                                                IV   MED.SUPPLIES      DRUGS       LABORATORY   BLOOD    BLOOD PROC.    EKG
                                         THERAPY       #NAME?         #NAME?                             & STORAGE
                                            -             -              -             -          -           -          -
                                        IV BOTTLES     COSTED         COSTED         TESTS      UNITS       UNITS      TESTS
                                          USED       REQUISITIONS   REQUISITIONS


      ROUTINE INPATIENT CARE SERVICES
  1 MED/SURG
  2 PEDI
  3 OB
  4 PSYCH
  5 VENT UNIT
  6 SNFs
  7
  8
  9
 10 SUBTOTAL
 11 ICU
 12 CCU
 13 NEO
 14
 15
 16
 17
 18
 19 SUBTOTAL
 20 NEWB




                                                                       Page 181
                                                                  SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                           (9)          (10)           (11)          (12)       (13)        (14)       (15)
                                              IV   MED.SUPPLIES      DRUGS       LABORATORY   BLOOD    BLOOD PROC.    EKG
                                     THERAPY         #NAME?         #NAME?                             & STORAGE
                                          -             -              -             -          -           -          -
                                    IV BOTTLES       COSTED         COSTED         TESTS      UNITS       UNITS      TESTS
                                         USED      REQUISITIONS   REQUISITIONS


 21 CHR
 22 SUBTOTAL


      ROUTINE AMBULATORY CARE SERVICES
 23 EMERG
 24 CLINIC
 25 SATELLITE
 26 AMB SURGERY
 27 AMB DIAL.
 28 HOME DIAL.
 29 PSY
 30 HOME HEALTH
 31 OBS. BEDS
 32 PRI. REFER.
 33 HOSPITAL LICENSED HEALTH CENTER(S)
 34
 35
 36 SUBTOTAL


 37 TOT INP+AMB




                                                                     Page 182
                                                                      SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



     SCHEDULE XVI
     DHCFP-403 VERSION 2005


                                         (9)               (10)              (11)              (12)              (13)              (14)           (15)
                                             IV     MED.SUPPLIES          DRUGS          LABORATORY            BLOOD        BLOOD PROC.           EKG
                                     THERAPY           #NAME?            #NAME?                                              & STORAGE
                                         -                 -                 -                 -                 -                 -              -
                                   IV BOTTLES          COSTED            COSTED             TESTS             UNITS             UNITS           TESTS
                                      USED          REQUISITIONS      REQUISITIONS


     NON-PAT. CARE
 38 NON-PAT ANC
 39 RESEARCH
 40 OTH NON-PAT
 41 SUBTOTAL


 42 TOTPAT+NONP
 43 XXXXX                        **************    **************    **************    **************    **************    **************    **************
 44 XXXXX                        ***************   ***************   ***************   ***************   ***************   ***************   ***************


 45 UCM EXC.
 46 UCM INC.




                                                                          Page 183
                                                                     SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                              (16)          (17)         (18)         (19)       (20)        (21)        (22)      (23)
                                        CARDIAC CATH.   DIAGNOSTIC   THERAPEUTIC       CT     NUCLEAR RESPIRATORY PULMONARY        EEG
                                            LAB         RADIOLOGY    RADIOLOGY      SCANNER   MEDICINE     THERAPY    FUNCTION
                                              -             -             -           -          -           -           -         -
                                        PROCEDURES        TESTS        VISITS      PATIENTS   TESTS      TREATMENTS    TESTS     TESTS
                                                                                   SCANNED


      ROUTINE INPATIENT CARE SERVICES
  1 MED/SURG
  2 PEDI
  3 OB
  4 PSYCH
  5 VENT UNIT
  6 SNFs
  7
  8
  9
 10 SUBTOTAL
 11 ICU
 12 CCU
 13 NEO
 14
 15
 16
 17
 18
 19 SUBTOTAL
 20 NEWB




                                                                        Page 184
                                                                SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                          (16)         (17)         (18)         (19)       (20)        (21)        (22)      (23)
                                   CARDIAC CATH.   DIAGNOSTIC   THERAPEUTIC       CT     NUCLEAR RESPIRATORY PULMONARY        EEG
                                         LAB       RADIOLOGY    RADIOLOGY      SCANNER   MEDICINE     THERAPY    FUNCTION
                                          -            -             -           -          -           -           -         -
                                    PROCEDURES       TESTS        VISITS      PATIENTS   TESTS      TREATMENTS    TESTS     TESTS
                                                                              SCANNED


 21 CHR
 22 SUBTOTAL


      ROUTINE AMBULATORY CARE SERVICES
 23 EMERG
 24 CLINIC
 25 SATELLITE
 26 AMB SURGERY
 27 AMB DIAL.
 28 HOME DIAL.
 29 PSY
 30 HOME HEALTH
 31 OBS. BEDS
 32 PRI. REFER.
 33 HOSPITAL LICENSED HEALTH CENTER(S)
 34
 35
 36 SUBTOTAL


 37 TOT INP+AMB




                                                                   Page 185
                                                                     SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



     SCHEDULE XVI
     DHCFP-403 VERSION 2005


                                         (16)             (17)             (18)              (19)           (20)         (21)           (22)               (23)
                                  CARDIAC CATH.      DIAGNOSTIC      THERAPEUTIC             CT          NUCLEAR RESPIRATORY PULMONARY                     EEG
                                        LAB          RADIOLOGY        RADIOLOGY          SCANNER        MEDICINE     THERAPY        FUNCTION
                                         -                -                -                 -              -            -              -                  -
                                   PROCEDURES          TESTS            VISITS          PATIENTS          TESTS    TREATMENTS         TESTS             TESTS
                                                                                        SCANNED


     NON-PAT. CARE
 38 NON-PAT ANC
 39 RESEARCH
 40 OTH NON-PAT
 41 SUBTOTAL


 42 TOTPAT+NONP
 43 XXXXX                        **************    **************   **************   **************                 **************
                                                                                                       **************            **************    **************
 44 XXXXX                        ***************   **************   **************   ***************                ***************
                                                                                                       ***************           ***************   ***************


 45 UCM EXC.
 46 UCM INC.




                                                                         Page 186
                                                                  SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                           (24)         (25)          (26)          (27)         (28)          (29)        (30)
                                         ELECTRO-    PHYSICAL    OCCUPATIONALSPEECH-LAN-    RECREATIONAL    AUDIOLOGY PSYCHOLOGY/
                                        MYOGRAPHY     THERAPY      THERAPY GUAGE THERAPY      THERAPY                 PSYCHIATRY
                                           -            -             -             -            -             -           -
                                         TESTS      TREATMENTS   TREATMENTS      SESSIONS   TREATMENTS     PROCEDURES TREATMENTS



      ROUTINE INPATIENT CARE SERVICES
  1 MED/SURG
  2 PEDI
  3 OB
  4 PSYCH
  5 VENT UNIT
  6 SNFs
  7
  8
  9
 10 SUBTOTAL
 11 ICU
 12 CCU
 13 NEO
 14
 15
 16
 17
 18
 19 SUBTOTAL
 20 NEWB




                                                                      Page 187
                                                                SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                           (24)       (25)          (26)          (27)         (28)          (29)        (30)
                                     ELECTRO-      PHYSICAL    OCCUPATIONALSPEECH-LAN-    RECREATIONAL    AUDIOLOGY PSYCHOLOGY/
                                    MYOGRAPHY       THERAPY      THERAPY GUAGE THERAPY      THERAPY                 PSYCHIATRY
                                           -          -             -             -            -             -           -
                                         TESTS    TREATMENTS   TREATMENTS      SESSIONS   TREATMENTS     PROCEDURES TREATMENTS



 21 CHR
 22 SUBTOTAL


      ROUTINE AMBULATORY CARE SERVICES
 23 EMERG
 24 CLINIC
 25 SATELLITE
 26 AMB SURGERY
 27 AMB DIAL.
 28 HOME DIAL.
 29 PSY
 30 HOME HEALTH
 31 OBS. BEDS
 32 PRI. REFER.
 33 HOSPITAL LICENSED HEALTH CENTER(S)
 34
 35
 36 SUBTOTAL


 37 TOT INP+AMB




                                                                    Page 188
                                                                      SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



     SCHEDULE XVI
     DHCFP-403 VERSION 2005


                                         (24)             (25)             (26)           (27)                 (28)         (29)           (30)
                                     ELECTRO-         PHYSICAL      OCCUPATIONALSPEECH-LAN-             RECREATIONAL    AUDIOLOGY PSYCHOLOGY/
                                   MYOGRAPHY          THERAPY           THERAPY GUAGE THERAPY               THERAPY                  PSYCHIATRY
                                         -                -                -              -                    -            -              -
                                      TESTS         TREATMENTS       TREATMENTS       SESSIONS           TREATMENTS    PROCEDURES TREATMENTS



     NON-PAT. CARE
 38 NON-PAT ANC
 39 RESEARCH
 40 OTH NON-PAT
 41 SUBTOTAL


 42 TOTPAT+NONP
 43 XXXXX                        **************    **************   **************                **************
                                                                                     **************                                 **************
                                                                                                                       **************
 44 XXXXX                        ***************   **************   **************                **************
                                                                                     **************                                 **************
                                                                                                                       **************


 45 UCM EXC.
 46 UCM INC.




                                                                          Page 189
                                                                      SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                          (31)         (32)           (33)              (34)      (35)        (36)        (37)        (38)
                                         RENAL       ORGAN        AMBULANCE        OTHER        OTHER       OTHER       OTHER       OTHER
                                        DIALYSIS   ACQUISITION
                                           -           -              -                 -          -           -           -           -
                                   TREATMENTS       ORGANS       OCCASIONS OF     (SPECIFY)    (SPECIFY)   (SPECIFY)   (SPECIFY)   (SPECIFY)
                                                                   SERVICE


      ROUTINE INPATIENT CARE SERVICES
  1 MED/SURG
  2 PEDI
  3 OB
  4 PSYCH
  5 VENT UNIT
  6 SNFs
  7
  8
  9
 10 SUBTOTAL
 11 ICU
 12 CCU
 13 NEO
 14
 15
 16
 17
 18
 19 SUBTOTAL
 20 NEWB




                                                                             Page 190
                                                                   SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005


                                         (31)       (32)           (33)              (34)      (35)        (36)        (37)        (38)
                                     RENAL        ORGAN        AMBULANCE        OTHER        OTHER       OTHER       OTHER       OTHER
                                   DIALYSIS     ACQUISITION
                                         -          -              -                 -          -           -           -           -
                                 TREATMENTS      ORGANS       OCCASIONS OF     (SPECIFY)    (SPECIFY)   (SPECIFY)   (SPECIFY)   (SPECIFY)
                                                                SERVICE


 21 CHR
 22 SUBTOTAL


      ROUTINE AMBULATORY CARE SERVICES
 23 EMERG
 24 CLINIC
 25 SATELLITE
 26 AMB SURGERY
 27 AMB DIAL.
 28 HOME DIAL.
 29 PSY
 30 HOME HEALTH
 31 OBS. BEDS
 32 PRI. REFER.
 33 HOSPITAL LICENSED HEALTH CENTER(S)
 34
 35
 36 SUBTOTAL


 37 TOT INP+AMB




                                                                          Page 191
                                                                      SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



     SCHEDULE XVI
     DHCFP-403 VERSION 2005


                                      (31)           (32)             (33)              (34)            (35)            (36)           (37)                (38)
                                    RENAL          ORGAN         AMBULANCE          OTHER             OTHER          OTHER          OTHER               OTHER
                                   DIALYSIS    ACQUISITION
                                      -              -                -                 -                -              -              -                   -
                                 TREATMENTS      ORGANS        OCCASIONS OF        (SPECIFY)        (SPECIFY)       (SPECIFY)     (SPECIFY)            (SPECIFY)
                                                                  SERVICE


     NON-PAT. CARE
 38 NON-PAT ANC
 39 RESEARCH
 40 OTH NON-PAT
 41 SUBTOTAL


 42 TOTPAT+NONP
 43 XXXXX                                     **************
                                 **************                **************   **************   **************                 **************
                                                                                                                   **************                ********************
 44 XXXXX                                     **************
                                 **************                **************   **************   ***************                **************
                                                                                                                   **************                ************


 45 UCM EXC.
 46 UCM INC.




                                                                             Page 192
                                        SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005




      ROUTINE INPATIENT CARE SERVICES
  1 MED/SURG                        1
  2 PEDI                            2
  3 OB                              3
  4 PSYCH                           4
  5 VENT UNIT                       5
  6 SNFs                            6
  7                                 7
  8                                 8
  9                                 9
 10 SUBTOTAL                       10
 11 ICU                            11
 12 CCU                            12
 13 NEO                            13
 14                                14
 15                                15
 16                                16
 17                                17
 18                                18
 19 SUBTOTAL                       19
 20 NEWB                           20




                                          Page 193
                                         SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



      SCHEDULE XVI
      DHCFP-403 VERSION 2005




 21 CHR                          21
 22 SUBTOTAL                     22


      ROUTINE AMBULATORY CARE SERVICES
 23 EMERG                        23
 24 CLINIC                       24
 25 SATELLITE                    25
 26 AMB SURGERY                  26
 27 AMB DIAL.                    27
 28 HOME DIAL.                   28
 29 PSY                          29
 30 HOME HEALTH                  30
 31 OBS. BEDS                    31
 32 PRI. REFER.                  32
                                 33
 33 HOSPITAL LICENSED HEALTH CENTER(S)
 34                              34
 35                              35
 36 SUBTOTAL                     36


 37 TOT INP+AMB                  37




                                           Page 194
                                      SCHEDULE-XVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________



     SCHEDULE XVI
     DHCFP-403 VERSION 2005




     NON-PAT. CARE
 38 NON-PAT ANC                  38
 39 RESEARCH                     39
 40 OTH NON-PAT                  40
 41 SUBTOTAL                     41


 42 TOTPAT+NONP                  42
 43 XXXXX                        43
 44 XXXXX                        44


 45 UCM EXC.                     45
 46 UCM INC.                     46




                                        Page 195
                                                                     COVER-SCH-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________
           SCHEDULE XVII         PATIENT SERVICE EXPENSES- EXCLUDING CAPITAL
           DHCFP-403 VERSION 2005



                INPATIENT CARE
            1 MEDICAL+SURGICAL ACUTE
            2 PEDIATRIC ACUTE
            3 OBSTETRIC ACUTE
            4 PSYCHIATRIC ACUTE
            5 VENTILATOR UNIT
            6 SKILLED NURSING FACILITIES
            7
            8
            9
           10 SUBTOTAL ACUTE
           11 MEDICAL & SURGICAL INTENSIVE CARE
           12 CORONARY INTENSIVE CARE
           13 NEONATAL INTENSIVE CARE
           14
           15
           16
           17
           18
           19 SUBTOTAL INTENSIVE CARE
           20 NEWBORN NURSERY
           21 CHRONIC + REHABILITATION
           22 SUBTOTAL INPATIENT CARE


                AMBULATORY CARE
           23 EMERGENCY SERVICES
           24 CLINIC OR AMBULATORY SERVICES
           25 SATELLITE CLINIC SERVICES
           26 AMBULATORY SURGERY SERVICES




                                                                          Page 196
                                                                     COVER-SCH-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________
           SCHEDULE XVII         PATIENT SERVICE EXPENSES- EXCLUDING CAPITAL
           DHCFP-403 VERSION 2005



           27 AMBULATORY RENAL DIALYSIS SERVICES
           28 HOME DIALYSIS SERVICES
           29 PSYCHIATRY
           30 HOME HEALTH SERVICES
           31 OBSERVATION BEDS
           32 PRIVATE REFERRALS
           33 HOSPITAL LICENSED HEALTH CENTER(S)
           34
           35
           36 SUBTOTAL AMBULATORY CARE


           37 TOTAL INPATIENT & AMBULATORY CARE (L.22 + L.36)


                NON-PATIENT CARE
           38 NON-PATIENT ANCILLARY
           39 RESEARCH
           40 OTHER NON-PATIENT
           41 SUBTOTAL NON-PATIENT
           42 TOTAL PATIENT AND NON-PATIENT* (L.37+41)
           43 RECOVERY OF EXPENSES (SCH VII, C.3, L.50)
           44 PROVISION FOR BAD DEBT
        44. 01 GROSS UNCOMPENSATED CARE POOL ASSESSMENT
           45 TOTPAT/NPAT+REC+B/D+GROSS UNCOMPENSATED CARE POOL ASSESSMENT (L.42+43+44+44.01)
           46 GENERAL FUND EXPENSE (L.42+L.43)


           47 ***********
           48 ***********


                CALCULATION OF LOADING FACTOR




                                                                          Page 197
                                                                     COVER-SCH-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________
           SCHEDULE XVII         PATIENT SERVICE EXPENSES- EXCLUDING CAPITAL
           DHCFP-403 VERSION 2005



           49 CAPITAL AND LONG TERM INTEREST (SCH. IX COL.12,LINES 1+2+3+4)
           50 OPERATING EXPENSES (SCH XVII C2, LINE 42)
           51 LOADING FACTOR (LINE 49 DIVIDED BY LINE 50)


             *TOTAL ON LINE 42 FOR COLUMNS 5 THRU 38 MUST TIE TO SCHEDULE XIV, COLUMN 25.




                                                                          Page 198
                                                         SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                 (2)             (3)            (4)         (5)          (6)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   TOTAL        EXPENSES       ANCILLARY     SURGERY       LABOR
                                               EXPENSE      AFT STPDW      EXPENSES                     AND
                                               (C.3+4)     (SCH.14,C.25)   (C.5 TH 38)                DELIVERY
                                                 -               -             -            -            -
                                                                                         SURGERY   PROCEDURES &
                                                                                         MINUTES   WGHTD.CIRCUM.
         ROUTINE INPATIENT CARE SERVICES
     1 MED/SURG
     2 PEDI
     3 OB
     4 PSYCH
     5 VENT UNIT
     6 SNFs
     7
     8
     9
    10 SUBTOTAL
    11 ICU
    12 CCU
    13 NEO
    14
    15
    16
    17
    18
    19 SUBTOTAL
    20 NEWB
    21 CHR
    22 SUBTOTAL




                                                           Page 199
                                                         SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                 (2)             (3)            (4)         (5)          (6)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   TOTAL        EXPENSES       ANCILLARY     SURGERY       LABOR
                                               EXPENSE      AFT STPDW      EXPENSES                     AND
                                               (C.3+4)     (SCH.14,C.25)   (C.5 TH 38)                DELIVERY
                                                 -               -             -            -            -
                                                                                         SURGERY   PROCEDURES &
                                                                                         MINUTES   WGHTD.CIRCUM.



         ROUTINE AMBULATORY CARE SERVICES
    23 EMERG
    24 CLINIC
    25 SATELLITE
    26 AMB SURGERY
    27 AMB DIAL.
    28 HOME DIAL.
    29 PSY
    30 HOME HEALTH
    31 OBS. BEDS
    32 PRI. REFER.
    33 HOSPITAL LICENSED HEALTH CENTER(S)
    34
    35
    36 SUBTOTAL


    37 TOT INP+AMB


         NON-PAT. CARE
    38 NON-PAT ANC
    39 RESEARCH




                                                           Page 200
                                                                    SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVII
           DHCFP-403 VERSION 2005
                                                          (2)                (3)                   (4)                  (5)                   (6)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL           TOTAL             EXPENSES            ANCILLARY              SURGERY                LABOR
                                                      EXPENSE           AFT STPDW             EXPENSES                                       AND
                                                       (C.3+4)         (SCH.14,C.25)          (C.5 TH 38)                                DELIVERY
                                                         -                   -                    -                     -                    -
                                                                                                                   SURGERY            PROCEDURES &
                                                                                                                   MINUTES           WGHTD.CIRCUM.
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                                                 *****************    *****************    *****************    *****************
        44 PROV. B/D                                                *****************    *****************    *****************    *****************
44.01      GROSS UCP ASSMT                                          *****************    *****************    *****************    *****************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                ******************* ******************* *******************    *******************


        47 *****                               ******************   ******************   ******************   ******************   ******************
        48 *****                               ******************   ******************   ******************   ******************   ******************


        49 CAPITAL                                                  ******************* ******************* ******************** *********************
        50 OPERATING                                                ******************* ******************* ******************** *********************
        51 L.F                                                      ******************* ******************* ******************** *********************




                                                                       Page 201
                                                               SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                     (7)              (8)           (9)          (10)           (11)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL      RECOVERY       ANESTHESIO-           IV     MEDICAL          DRUGS
                                                    ROOM             LOGY       THERAPY       SUPPLIES        SPECIAL


                                                     -               -             -             -              -
                                               RECOVERY ROOM     ANESTHESIA    IV BOTTLES     COSTED         COSTED
                                                  MINUTES         MINUTES        USED       REQUISITIONS   REQUISITIONS
         ROUTINE INPATIENT CARE SERVICES
     1 MED/SURG
     2 PEDI
     3 OB
     4 PSYCH
     5 VENT UNIT
     6 SNFs
     7
     8
     9
    10 SUBTOTAL
    11 ICU
    12 CCU
    13 NEO
    14
    15
    16
    17
    18
    19 SUBTOTAL
    20 NEWB
    21 CHR
    22 SUBTOTAL




                                                                 Page 202
                                                               SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                     (7)              (8)           (9)          (10)           (11)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL      RECOVERY       ANESTHESIO-           IV     MEDICAL          DRUGS
                                                    ROOM             LOGY       THERAPY       SUPPLIES        SPECIAL


                                                     -               -             -             -              -
                                               RECOVERY ROOM     ANESTHESIA    IV BOTTLES     COSTED         COSTED
                                                  MINUTES         MINUTES        USED       REQUISITIONS   REQUISITIONS



         ROUTINE AMBULATORY CARE SERVICES
    23 EMERG
    24 CLINIC
    25 SATELLITE
    26 AMB SURGERY
    27 AMB DIAL.
    28 HOME DIAL.
    29 PSY
    30 HOME HEALTH
    31 OBS. BEDS
    32 PRI. REFER.
    33 HOSPITAL LICENSED HEALTH CENTER(S)
    34
    35
    36 SUBTOTAL


    37 TOT INP+AMB


         NON-PAT. CARE
    38 NON-PAT ANC
    39 RESEARCH




                                                                 Page 203
                                                                     SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVII
           DHCFP-403 VERSION 2005
                                                         (7)                   (8)                 (9)                 (10)                  (11)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL         RECOVERY           ANESTHESIO-                    IV           MEDICAL                DRUGS
                                                        ROOM                  LOGY             THERAPY             SUPPLIES               SPECIAL


                                                         -                    -                    -                   -                     -
                                                RECOVERY ROOM           ANESTHESIA           IV BOTTLES            COSTED                COSTED
                                                     MINUTES              MINUTES               USED             REQUISITIONS         REQUISITIONS
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                            *****************     *****************    *****************   *****************   *****************
        44 PROV. B/D                           *****************     *****************    *****************   *****************   *****************
44.01      GROSS UCP ASSMT                     *****************     *****************    *****************   *****************   *****************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                           *******************   ******************* ******************* ******************* *******************


        47 *****                               ******************    ******************   ****************** ******************   ******************
        48 *****                               ******************    ******************   ****************** ******************   ******************


        49 CAPITAL                             ********************* ******************* ******************* ******************* ***********************
        50 OPERATING                           ********************* ******************* ******************* ******************* ***********************
        51 L.F                                 ********************* ******************* ******************* ******************* ***********************




                                                                         Page 204
                                                            SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                   (12)         (13)            (14)       (15)       (16)         (17)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   LABORATORY     BLOOD           BLOOD       EKG       CARDIAC    DIAGNOSTIC
                                                                            PROCESSING             CATH LAB    RADIOLOGY
                                                                         AND STORAGE
                                                   -            -               -          -          -            -
                                                 TESTS        UNITS           UNITS      TESTS    PROCEDURES     TESTS


         ROUTINE INPATIENT CARE SERVICES
     1 MED/SURG
     2 PEDI
     3 OB
     4 PSYCH
     5 VENT UNIT
     6 SNFs
     7
     8
     9
    10 SUBTOTAL
    11 ICU
    12 CCU
    13 NEO
    14
    15
    16
    17
    18
    19 SUBTOTAL
    20 NEWB
    21 CHR
    22 SUBTOTAL




                                                              Page 205
                                                            SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                   (12)         (13)            (14)       (15)       (16)         (17)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   LABORATORY     BLOOD           BLOOD       EKG       CARDIAC    DIAGNOSTIC
                                                                            PROCESSING             CATH LAB    RADIOLOGY
                                                                         AND STORAGE
                                                   -            -               -          -          -            -
                                                 TESTS        UNITS           UNITS      TESTS    PROCEDURES     TESTS




         ROUTINE AMBULATORY CARE SERVICES
    23 EMERG
    24 CLINIC
    25 SATELLITE
    26 AMB SURGERY
    27 AMB DIAL.
    28 HOME DIAL.
    29 PSY
    30 HOME HEALTH
    31 OBS. BEDS
    32 PRI. REFER.
    33 HOSPITAL LICENSED HEALTH CENTER(S)
    34
    35
    36 SUBTOTAL


    37 TOT INP+AMB


         NON-PAT. CARE
    38 NON-PAT ANC
    39 RESEARCH




                                                              Page 206
                                                                     SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVII
           DHCFP-403 VERSION 2005
                                                        (12)               (13)               (14)               (15)              (16)              (17)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL      LABORATORY             BLOOD              BLOOD                EKG            CARDIAC         DIAGNOSTIC
                                                                                         PROCESSING                            CATH LAB         RADIOLOGY
                                                                                        AND STORAGE
                                                        -                  -                  -                  -                 -                  -
                                                     TESTS               UNITS              UNITS             TESTS          PROCEDURES            TESTS


        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                            *****************   ***************** *****************   ***************** ***************** *****************
        44 PROV. B/D                           *****************   ***************** *****************   ***************** ***************** *****************
44.01      GROSS UCP ASSMT                     *****************   ***************** *****************   ***************** ***************** *****************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                                                                       **************************************
                                               ******************* ************************************** *******************


        47 *****                                                                                                         ****************** ******************
                                               ****************** ****************** ****************** ******************
        48 *****                                                                                                         ****************** ******************
                                               ****************** ****************** ****************** ******************


        49 CAPITAL                             ******************* ****************** ******************* **************** ****************** ****************
        50 OPERATING                           ******************* ****************** ******************* **************** ****************** ****************
        51 L.F                                 ******************* ****************** ******************* **************** ****************** ****************




                                                                         Page 207
                                                             SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                   (18)          (19)           (20)        (21)          (22)      (23)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   THERAPEUTIC        CT         NUCLEAR    RESPIRATORY   PULMONARY     EEG
                                               RADIOLOGY       SCANNER       MEDICINE     THERAPY      FUNCTION


                                                    -            -              -            -            -         -
                                                 VISITS       PATIENTS       TESTS      TREATMENTS      TESTS     TESTS
                                                              SCANNED
         ROUTINE INPATIENT CARE SERVICES
     1 MED/SURG
     2 PEDI
     3 OB
     4 PSYCH
     5 VENT UNIT
     6 SNFs
     7
     8
     9
    10 SUBTOTAL
    11 ICU
    12 CCU
    13 NEO
    14
    15
    16
    17
    18
    19 SUBTOTAL
    20 NEWB
    21 CHR
    22 SUBTOTAL




                                                               Page 208
                                                             SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                   (18)          (19)           (20)        (21)          (22)      (23)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   THERAPEUTIC        CT         NUCLEAR    RESPIRATORY   PULMONARY     EEG
                                               RADIOLOGY       SCANNER       MEDICINE     THERAPY      FUNCTION


                                                    -            -              -            -            -         -
                                                 VISITS       PATIENTS       TESTS      TREATMENTS      TESTS     TESTS
                                                              SCANNED



         ROUTINE AMBULATORY CARE SERVICES
    23 EMERG
    24 CLINIC
    25 SATELLITE
    26 AMB SURGERY
    27 AMB DIAL.
    28 HOME DIAL.
    29 PSY
    30 HOME HEALTH
    31 OBS. BEDS
    32 PRI. REFER.
    33 HOSPITAL LICENSED HEALTH CENTER(S)
    34
    35
    36 SUBTOTAL


    37 TOT INP+AMB


         NON-PAT. CARE
    38 NON-PAT ANC
    39 RESEARCH




                                                               Page 209
                                                                     SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVII
           DHCFP-403 VERSION 2005
                                                        (18)                (19)               (20)                (21)            (22)           (23)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL     THERAPEUTIC                 CT             NUCLEAR          RESPIRATORY      PULMONARY           EEG
                                                   RADIOLOGY             SCANNER            MEDICINE            THERAPY        FUNCTION


                                                        -                   -                   -                  -               -               -
                                                     VISITS             PATIENTS             TESTS           TREATMENTS          TESTS          TESTS
                                                                        SCANNED
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                            *****************   *****************   ***************** *****************                 *****************
                                                                                                                              *****************
        44 PROV. B/D                           *****************   *****************   ***************** *****************                 *****************
                                                                                                                              *****************
44.01      GROSS UCP ASSMT                     *****************   *****************   ***************** *****************                 *****************
                                                                                                                              *****************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                                                                                       *******************
                                               ******************* ******************* ************************************** *******************


        47 *****                               ****************** ******************                                                      ******************
                                                                                       ****************** ****************** ******************
        48 *****                               ****************** ******************                                                      ******************
                                                                                       ****************** ****************** ******************


        49 CAPITAL                             ******************* ******************* ****************** ******************* ************ ****************
        50 OPERATING                           ******************* ******************* ****************** ******************* ************ ****************
        51 L.F                                 ******************* ******************* ****************** ******************* ************ ****************




                                                                         Page 210
                                                           SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                  (24)         (25)           (26)         (27)         (28)          (29)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL    ELECTRO-    PHYSICAL     OCCUPATIONAL    SPEECH-   RECREATIONAL    AUDIOLOGY
                                               MYOGRAPHY     THERAPY       THERAPY      LANGUAGE     THERAPY
                                                                                        THERAPY
                                                  -            -              -            -            -             -
                                                TESTS      TREATMENTS    TREATMENTS     SESSIONS   TREATMENTS     PROCEDURES


         ROUTINE INPATIENT CARE SERVICES
     1 MED/SURG
     2 PEDI
     3 OB
     4 PSYCH
     5 VENT UNIT
     6 SNFs
     7
     8
     9
    10 SUBTOTAL
    11 ICU
    12 CCU
    13 NEO
    14
    15
    16
    17
    18
    19 SUBTOTAL
    20 NEWB
    21 CHR
    22 SUBTOTAL




                                                              Page 211
                                                           SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                  (24)         (25)           (26)         (27)         (28)          (29)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL    ELECTRO-    PHYSICAL     OCCUPATIONAL    SPEECH-   RECREATIONAL    AUDIOLOGY
                                               MYOGRAPHY     THERAPY       THERAPY      LANGUAGE     THERAPY
                                                                                        THERAPY
                                                  -            -              -            -            -             -
                                                TESTS      TREATMENTS    TREATMENTS     SESSIONS   TREATMENTS     PROCEDURES




         ROUTINE AMBULATORY CARE SERVICES
    23 EMERG
    24 CLINIC
    25 SATELLITE
    26 AMB SURGERY
    27 AMB DIAL.
    28 HOME DIAL.
    29 PSY
    30 HOME HEALTH
    31 OBS. BEDS
    32 PRI. REFER.
    33 HOSPITAL LICENSED HEALTH CENTER(S)
    34
    35
    36 SUBTOTAL


    37 TOT INP+AMB


         NON-PAT. CARE
    38 NON-PAT ANC
    39 RESEARCH




                                                              Page 212
                                                                     SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVII
           DHCFP-403 VERSION 2005
                                                        (24)               (25)               (26)               (27)               (28)               (29)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL        ELECTRO-           PHYSICAL        OCCUPATIONAL           SPEECH-        RECREATIONAL          AUDIOLOGY
                                                  MYOGRAPHY            THERAPY             THERAPY           LANGUAGE           THERAPY
                                                                                                              THERAPY
                                                        -                  -                  -                   -                 -                  -
                                                     TESTS           TREATMENTS         TREATMENTS           SESSIONS         TREATMENTS         PROCEDURES


        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                            *****************   ***************** *****************   ***************** ***************** *****************
        44 PROV. B/D                           *****************   ***************** *****************   ***************** ***************** *****************
44.01      GROSS UCP ASSMT                     *****************   ***************** *****************   ***************** ***************** *****************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                                 *                                      **************************************
                                               ******************* ******************* ****************** *******************


        47 *****                               ****************** ************************************   ************************************ ******************
        48 *****                               ****************** ************************************   ************************************ ******************


        49 CAPITAL                             ******************* ***************** ******************* ***************** ****************** *******************
        50 OPERATING                           ******************* ***************** ******************* ***************** ****************** *******************
        51 L.F                                 ******************* ***************** ******************* ***************** ****************** *******************




                                                                         Page 213
                                                             SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                    (30)          (31)           (32)           (33)          (34)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   PSYCHOLOGY/      RENAL          ORGAN        AMBULANCE      OTHER
                                               PSYCHIATRY      DIALYSIS      ACQUISITION


                                                    -             -              -              -             -
                                               TREATMENTS    TREATMENTS       ORGANS       OCCASIONS OF   (SPECIFY)
                                                                                             SERVICE
         ROUTINE INPATIENT CARE SERVICES
     1 MED/SURG
     2 PEDI
     3 OB
     4 PSYCH
     5 VENT UNIT
     6 SNFs
     7
     8
     9
    10 SUBTOTAL
    11 ICU
    12 CCU
    13 NEO
    14
    15
    16
    17
    18
    19 SUBTOTAL
    20 NEWB
    21 CHR
    22 SUBTOTAL




                                                               Page 214
                                                             SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                    (30)          (31)           (32)           (33)          (34)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL   PSYCHOLOGY/      RENAL          ORGAN        AMBULANCE      OTHER
                                               PSYCHIATRY      DIALYSIS      ACQUISITION


                                                    -             -              -              -             -
                                               TREATMENTS    TREATMENTS       ORGANS       OCCASIONS OF   (SPECIFY)
                                                                                             SERVICE



         ROUTINE AMBULATORY CARE SERVICES
    23 EMERG
    24 CLINIC
    25 SATELLITE
    26 AMB SURGERY
    27 AMB DIAL.
    28 HOME DIAL.
    29 PSY
    30 HOME HEALTH
    31 OBS. BEDS
    32 PRI. REFER.
    33 HOSPITAL LICENSED HEALTH CENTER(S)
    34
    35
    36 SUBTOTAL


    37 TOT INP+AMB


         NON-PAT. CARE
    38 NON-PAT ANC
    39 RESEARCH




                                                               Page 215
                                                                     SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVII
           DHCFP-403 VERSION 2005
                                                        (30)                 (31)                  (32)                    (33)                  (34)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL     PSYCHOLOGY/               RENAL                 ORGAN                AMBULANCE               OTHER
                                                  PSYCHIATRY             DIALYSIS             ACQUISITION


                                                       -                     -                     -                       -                     -
                                                 TREATMENTS           TREATMENTS                ORGANS              OCCASIONS OF             (SPECIFY)
                                                                                                                       SERVICE
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                            ***************** *****************       *****************     *****************       *****************
        44 PROV. B/D                           ***************** *****************       *****************     *****************       *****************
44.01      GROSS UCP ASSMT                     ***************** *****************       *****************     *****************       *****************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                           **************************************    *******************   *******************     *******************


        47 *****                               ****************** ******************     ******************    ******************      ******************
        48 *****                               ****************** ******************     ******************    ******************      ******************


        49 CAPITAL                             ****************** *********************** ********************* *********************** *******************
        50 OPERATING                           ****************** *********************** ********************* *********************** *******************
        51 L.F                                 ****************** *********************** ********************* *********************** *******************




                                                                         Page 216
                                                            SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                  (35)        (36)               (37)        (38)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL    OTHER       OTHER              OTHER       OTHER



                                                   -           -                  -           -
                                               (SPECIFY)   (SPECIFY)          (SPECIFY)   (SPECIFY)


         ROUTINE INPATIENT CARE SERVICES
     1 MED/SURG                                                                                        1
     2 PEDI                                                                                            2
     3 OB                                                                                              3
     4 PSYCH                                                                                           4
     5 VENT UNIT                                                                                       5
     6 SNFs                                                                                            6
     7                                                                                                 7
     8                                                                                                 8
     9                                                                                                 9
    10 SUBTOTAL                                                                                       10
    11 ICU                                                                                            11
    12 CCU                                                                                            12
    13 NEO                                                                                            13
    14                                                                                                14
    15                                                                                                15
    16                                                                                                16
    17                                                                                                17
    18                                                                                                18
    19 SUBTOTAL                                                                                       19
    20 NEWB                                                                                           20
    21 CHR                                                                                            21
    22 SUBTOTAL                                                                                       22




                                                                   Page 217
                                                            SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


         SCHEDULE XVII
         DHCFP-403 VERSION 2005
                                                  (35)        (36)               (37)        (38)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL    OTHER       OTHER              OTHER       OTHER



                                                   -           -                  -           -
                                               (SPECIFY)   (SPECIFY)          (SPECIFY)   (SPECIFY)




         ROUTINE AMBULATORY CARE SERVICES
    23 EMERG                                                                                          23
    24 CLINIC                                                                                         24
    25 SATELLITE                                                                                      25
    26 AMB SURGERY                                                                                    26
    27 AMB DIAL.                                                                                      27
    28 HOME DIAL.                                                                                     28
    29 PSY                                                                                            29
    30 HOME HEALTH                                                                                    30
    31 OBS. BEDS                                                                                      31
    32 PRI. REFER.                                                                                    32
    33 HOSPITAL LICENSED HEALTH CENTER(S)                                                             33
    34                                                                                                34
    35                                                                                                35
    36 SUBTOTAL                                                                                       36


    37 TOT INP+AMB                                                                                    37


         NON-PAT. CARE
    38 NON-PAT ANC                                                                                    38
    39 RESEARCH                                                                                       39




                                                                   Page 218
                                                                     SCHEDULE-XVII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVII
           DHCFP-403 VERSION 2005
                                                      (35)             (36)                (37)                (38)
PATIENT SERVICE EXPENSES - EXCLUDING CAPITAL       OTHER            OTHER               OTHER                OTHER



                                                      -                -                   -                    -
                                                  (SPECIFY)        (SPECIFY)           (SPECIFY)           (SPECIFY)


        40 OTH NON-PAT                                                                                                              40
        41 SUBTOTAL                                                                                                                 41


        42 TOTPAT+NONP                                                                                                              42
        43 RECOVERY                                            ***************** *****************
                                               *****************                                       *****************            43
        44 PROV. B/D                                           ***************** *****************
                                               *****************                                       *****************            44
44.01      GROSS UCP ASSMT                                     ***************** *****************
                                               *****************                                       *****************    44.01
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT                                                                                             45
        46 GEN. FUND                                           *******************
                                               *******************               ******************* *******************            46


        47 *****                                               ****************** ******************
                                               ******************                                      ******************           47
        48 *****                                               ****************** ******************
                                               ******************                                      ******************           48


        49 CAPITAL                             *************** ***************** ******************* *******************            49
        50 OPERATING                           *************** ***************** ******************* *******************            50
        51 L.F                                 *************** ***************** ******************* *******************            51




                                                                           Page 219
                                                                                                                                   SCHEDULE-XVIIA




HOSPITAL______________________
FOR FISCAL YEAR ENDED_______


    SCHEDULE XVII-A                                    ROUTINE INPATIENT EXPENSES NET OF NONDISTINCT UNIT OBSERVATION BEDS EXPENSES-EXCLUDING CAPITAL
    DHCFP-403 VERSION 2005


    COMPUTATION OF TOTAL OBSERVATION BEDS EXPENSES
                                                            COL.1              COL.2             COL.3


                                                          ROUTINE           ANCILLARY           TOTAL
                                                          EXPENSE            EXPENSE          EXPENSES
                                                          AMOUNT             AMOUNT            AMOUNT
                                                                                             (Col.1 + Col.2)


A SCHEDULE XVII, COL 3 & 4, LINE 10
B   SCHEDULE XVII, COLUMNS 3 & 4, LINE 6
C   SUBTOTAL (LINE A MINUS LINE B)
D SCHEDULE III-B, COL 3, LINE 7                                                              xxxxxxxxxxxxxx
E   OBSERVATION BEDS EXPENSES (LINE C X LINE D)
F   EXPENSES NET OF OBSER. EXP (LINE A MINUS LINE E)



    COL.4                                                   COL 5              COL.6             COL 7           COL 8               COL 9                   COL 10                  COL 11                COL 12                 COL 13


                                                       TOTAL EXPENSES     TOTAL EXPENSES       I/P DAYS          RATIO          ALLOCATION OF           ALLOCATION OF            TOTAL ROUTINE       TOTAL ANCILLARY              TOTAL
    ROUTINE INPATIENT CARE SERVICES                       ROUTINE           ANCILLARY           (SCH III       OF I/P DAYS    OBSERVATION BEDS        OBSERVATION BEDS          EXPENSE NET OF        EXPENSE NET OF         EXPENSE NET OF
                                                       (SCH XVII COL.3)   (SCH XVII COL.4)      COL 6)                        ROUTINE EXPENSES       ANCILLARY EXPENSES        OBS. BEDS EXPENSES    OBS. BEDS EXPENSES     OBS. BEDS EXPENSES
                                                                                                                             (COL 8 X LINE E, COL-1) (COL 8 X LINE E, COL-2)   (COL 5 minus COL 9)   (COL 6 minus COL 10)    (COL 11 + COL 12)


1 MED/SURG
2 PEDIATRIC
3 OBSTETRIC
4 PSYCHIATRIC
5 VENT UNIT
6 SNFs                                                  XXXXXXXXXXXX      XXXXXXXXXXXXX XXXXXXXXXX             XXXXXXXXX      XXXXXXXXXXXXXXX          XXXXXXXXXXXXXXXX         XXXXXXXXXXXXXXX      XXXXXXXXXXXXXXX        XXXXXXXXXXXXXXX
7
8
9
## SUBTOTAL ACUTE




SCHEDULE REQUIRED ONLY FOR HOSPITALS WHICH DO NOT HAVE A DISTINCT UNIT FOR OBSERVATION BEDS.




                                                                                                                                        Page 220
                                                                    COVER-SCH-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII        PATIENT SERVICE EXPENSES-INCLUDING CAPITAL
           DHCFP-403 VERSION 2005



                INPATIENT CARE
            1 MEDICAL+SURGICAL ACUTE
            2 PEDIATRIC ACUTE
            3 OBSTETRIC ACUTE
            4 PSYCHIATRIC ACUTE
            5 VENTILATOR UNIT
            6 SKILLED NURSING FACILITIES
            7
            8
            9
           10 SUBTOTAL ACUTE
           11 MEDICAL & SURGICAL INTENSIVE CARE
           12 CORONARY INTENSIVE CARE
           13 NEONATAL INTENSIVE CARE
           14
           15
           16
           17
           18
           19 SUBTOTAL INTENSIVE CARE
           20 NEWBORN NURSERY
           21 CHRONIC + REHABILITATION
           22 SUBTOTAL INPATIENT CARE


                AMBULATORY CARE
           23 EMERGENCY SERVICES
           24 CLINIC OR AMBULATORY SERVICES
           25 SATELLITE CLINIC SERVICES




                                                                         Page 221
                                                                                 COVER-SCH-XVIII


           HOSPITAL______________________
           FOR FISCAL YEAR ENDED ________


                      SCHEDULE XVIII          PATIENT SERVICE EXPENSES-INCLUDING CAPITAL
                      DHCFP-403 VERSION 2005



                      26 AMBULATORY SURGERY SERVICES
                      27 AMBULATORY RENAL DIALYSIS SERVICES
                      28 HOME DIALYSIS SERVICES
                      29 PSYCHIATRY
                      30 HOME HEALTH SERVICES
                      31 OBSERVATION BEDS
                      32 PRIVATE REFERRALS
                      33 HOSPITAL LICENSED HEALTH CENTER(S)
                      34
                      35
                      36 SUBTOTAL AMBULATORY CARE


                      37 TOTAL INPATIENT & AMBULATORY CARE (L.22 + L.36)


                           NON-PATIENT CARE
                      38 NON-PATIENT ANCILLARY
                      39 RESEARCH
                      40 OTHER NON-PATIENT
                      41 SUBTOTAL NON-PATIENT


                      42 TOTAL PATIENT AND NON-PATIENT (L.37+L.41)
                      43 RECOVERY OF EXPENSES (SCH VII, C.3, L.50)
                      44 PROVISION FOR BAD DEBT
                   44.
OMPENSATED CARE POOL ASSESSMENT
                      45 TOTPAT+NPAT+REC+B/D+GR UNCOM CARE POOL ASSMT (LINE 42,43,44+44.01)
                      46 GENERAL FUND EXPENSE (L.42+L.43)


                      47 ***********




                                                                                      Page 222
                                                                    COVER-SCH-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII        PATIENT SERVICE EXPENSES-INCLUDING CAPITAL
           DHCFP-403 VERSION 2005



           48 ***********




                                                                         Page 223
                                                         SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII                                 PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
             DHCFP-403 VERSION 2005
                                                 (2)                (3)             (4)           (5)            (6)             (7)
                                               TOTAL            EXPENSES       ANCILLARY      SURGERY          LABOR          RECOVERY
                                               EXPENSE         AFT STPDW        EXPENSES                        AND             ROOM
                                               (C.3+4)        (SCH.15,C.25)    (C.5 TH 38)                    DELIVERY
                                                 -                  -              -             -               -               -
                                                                                             SURGERY       PROCEDURES &    RECOVERY ROOM
                                                                                              MINUTES      WGHTD.CIRCUM.      MINUTES
             ROUTINE INPATIENT CARE SERVICES
         1 MED/SURG
         2 PEDI
         3 OB
         4 PSYCH
         5 VENT UNIT
         6 SNFs
         7
         8
         9
        10 SUBTOTAL
        11 ICU
        12 CCU
        13 NEO
        14
        15
        16
        17
        18
        19 SUBTOTAL
        20 NEWB
        21 CHR
        22 SUBTOTAL




                                                            Page 224
                                                          SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII                                  PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
             DHCFP-403 VERSION 2005
                                                  (2)                (3)             (4)           (5)            (6)            (7)
                                                TOTAL            EXPENSES       ANCILLARY      SURGERY          LABOR         RECOVERY
                                                EXPENSE         AFT STPDW        EXPENSES                        AND            ROOM
                                                (C.3+4)        (SCH.15,C.25)    (C.5 TH 38)                   DELIVERY
                                                  -                  -              -             -              -               -
                                                                                              SURGERY       PROCEDURES &   RECOVERY ROOM




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERG
        24 CLINIC
        25 SATELLITE
        26 AMB SURGERY
        27 AMB DIAL.
        28 HOME DIAL.
        29 PSY
        30 HOME HEALTH
        31 OBS. BEDS
        32 PRI. REFER.
        33 HOSPITAL LICENSED HEALTH CENTER(S)
        34
        35
        36 SUBTOTAL




                                                             Page 225
                                                          SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII                                    PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
           DHCFP-403 VERSION 2005
                                                   (2)                (3)               (4)            (5)              (6)                 (7)
                                                TOTAL            EXPENSES         ANCILLARY        SURGERY           LABOR             RECOVERY
                                               EXPENSE           AFT STPDW         EXPENSES                            AND                ROOM
                                                (C.3+4)        (SCH.15,C.25)       (C.5 TH 38)                     DELIVERY
                                                  -                  -                 -               -               -                   -
                                                                                                  SURGERY       PROCEDURES &       RECOVERY ROOM


        37 TOT INP+AMB


           NON-PAT. CARE
        38 NON-PAT ANC
        39 RESEARCH
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                                                                              ******************
                                                             ****************** ******************             ****************** ******************
        44 PROV. B/D                                                                             ******************
                                                             ****************** ******************             ****************** ******************
      44.01 GROSS UCP ASSMT                                                                      ******************
                                                             ****************** ******************             ****************** ******************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                                             ******************
                                                             ****************** ******************             ****************** ******************


        47 *****                                             *************************
                                          *************************                              *************************
                                                                                *************************                         *************************
                                                                                                               *************************
        48 *****                                             *************************
                                          *************************                              *************************
                                                                                *************************                         *************************
                                                                                                               *************************




                                                             Page 226
                                                          SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005
                                                    (8)             (9)          (10)           (11)          (12)       (13)
                                               ANESTHESIO-             IV     MEDICAL          DRUGS      LABORATORY   BLOOD
                                                   LOGY         THERAPY       SUPPLIES        SPECIAL


                                                   -               -             -              -             -          -
                                               ANESTHESIA      IV BOTTLES     COSTED         COSTED         TESTS      UNITS
                                                MINUTES          USED       REQUISITIONS   REQUISITIONS
             ROUTINE INPATIENT CARE SERVICES
         1 MED/SURG
         2 PEDI
         3 OB
         4 PSYCH
         5 VENT UNIT
         6 SNFs
         7
         8
         9
        10 SUBTOTAL
        11 ICU
        12 CCU
        13 NEO
        14
        15
        16
        17
        18
        19 SUBTOTAL
        20 NEWB
        21 CHR
        22 SUBTOTAL




                                                             Page 227
                                                           SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005
                                                     (8)             (9)        (10)      (11)        (12)       (13)
                                                ANESTHESIO-             IV   MEDICAL     DRUGS    LABORATORY   BLOOD
                                                    LOGY         THERAPY     SUPPLIES   SPECIAL


                                                    -               -           -         -           -          -
                                                ANESTHESIA      IV BOTTLES   COSTED     COSTED      TESTS      UNITS




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERG
        24 CLINIC
        25 SATELLITE
        26 AMB SURGERY
        27 AMB DIAL.
        28 HOME DIAL.
        29 PSY
        30 HOME HEALTH
        31 OBS. BEDS
        32 PRI. REFER.
        33 HOSPITAL LICENSED HEALTH CENTER(S)
        34
        35
        36 SUBTOTAL




                                                              Page 228
                                                         SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII
           DHCFP-403 VERSION 2005
                                                   (8)                 (9)              (10)               (11)                (12)              (13)
                                             ANESTHESIO-                   IV       MEDICAL              DRUGS           LABORATORY            BLOOD
                                                   LOGY            THERAPY          SUPPLIES            SPECIAL


                                                   -                   -                -                  -                   -                 -
                                             ANESTHESIA          IV BOTTLES         COSTED             COSTED                TESTS            UNITS


        37 TOT INP+AMB


           NON-PAT. CARE
        38 NON-PAT ANC
        39 RESEARCH
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                       ******************                    ************************************
                                                                ******************                                     ****************** ******************
        44 PROV. B/D                      ******************                    ************************************
                                                                ******************                                     ****************** ******************
      44.01 GROSS UCP ASSMT               ******************                    ************************************
                                                                ******************                                     ****************** ******************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                      ******************                    ************************************
                                                                ******************                                     ****************** ******************


        47 *****                                              *************************
                                          *************************                             *************************
                                                                              *************************                                *************************
                                                                                                                    *************************
        48 *****                                              *************************
                                          *************************                             *************************
                                                                              *************************                                *************************
                                                                                                                    *************************




                                                               Page 229
                                                           SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII                                   PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
             DHCFP-403 VERSION 2005
                                                    (14)           (15)           (16)          (17)             (18)         (19)
                                                  BLOOD            EKG         CARDIAC      DIAGNOSTIC       THERAPEUTIC       CT
                                               PROCESSING                     CATH LAB      RADIOLOGY        RADIOLOGY     SCANNER
                                               AND STORAGE
                                                    -               -             -             -                 -           -
                                                  UNITS          TESTS      PROCEDURES        TESTS            VISITS      PATIENTS
                                                                                                                           SCANNED
             ROUTINE INPATIENT CARE SERVICES
         1 MED/SURG
         2 PEDI
         3 OB
         4 PSYCH
         5 VENT UNIT
         6 SNFs
         7
         8
         9
        10 SUBTOTAL
        11 ICU
        12 CCU
        13 NEO
        14
        15
        16
        17
        18
        19 SUBTOTAL
        20 NEWB
        21 CHR
        22 SUBTOTAL




                                                              Page 230
                                                            SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII                                    PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
             DHCFP-403 VERSION 2005
                                                     (14)           (15)           (16)          (17)             (18)         (19)
                                                   BLOOD            EKG         CARDIAC      DIAGNOSTIC       THERAPEUTIC       CT
                                                PROCESSING                     CATH LAB      RADIOLOGY        RADIOLOGY     SCANNER
                                                AND STORAGE
                                                     -               -             -             -                 -           -
                                                   UNITS          TESTS      PROCEDURES        TESTS            VISITS      PATIENTS




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERG
        24 CLINIC
        25 SATELLITE
        26 AMB SURGERY
        27 AMB DIAL.
        28 HOME DIAL.
        29 PSY
        30 HOME HEALTH
        31 OBS. BEDS
        32 PRI. REFER.
        33 HOSPITAL LICENSED HEALTH CENTER(S)
        34
        35
        36 SUBTOTAL




                                                               Page 231
                                                         SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII                                   PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
           DHCFP-403 VERSION 2005
                                                  (14)             (15)            (16)             (17)             (18)             (19)
                                                BLOOD              EKG          CARDIAC       DIAGNOSTIC       THERAPEUTIC            CT
                                             PROCESSING                        CATH LAB        RADIOLOGY        RADIOLOGY          SCANNER
                                            AND STORAGE
                                                  -                -               -                -                -                -
                                                UNITS            TESTS       PROCEDURES          TESTS            VISITS         PATIENTS


        37 TOT INP+AMB


           NON-PAT. CARE
        38 NON-PAT ANC
        39 RESEARCH
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                                                         ***********************************
                                          ****************** ******************              *               ************************************
        44 PROV. B/D                                                        ***********************************
                                          ****************** ******************              *               ************************************
      44.01 GROSS UCP ASSMT                                                 ***********************************
                                          ****************** ******************              *               ************************************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                        ***********************************
                                          ****************** ******************              *               ************************************


        47 *****                                             *************************
                                          *************************                          *************************
                                                                            *************************                          *************************
                                                                                                             *************************
        48 *****                                             *************************
                                          *************************                          *************************
                                                                            *************************                          *************************
                                                                                                             *************************




                                                            Page 232
                                                          SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005
                                                  (20)           (21)          (22)      (23)      (24)         (25)
                                               NUCLEAR      RESPIRATORY    PULMONARY     EEG     ELECTRO-    PHYSICAL
                                               MEDICINE       THERAPY       FUNCTION            MYOGRAPHY     THERAPY


                                                  -              -             -         -         -            -
                                               TESTS        TREATMENTS       TESTS     TESTS     TESTS      TREATMENTS


             ROUTINE INPATIENT CARE SERVICES
         1 MED/SURG
         2 PEDI
         3 OB
         4 PSYCH
         5 VENT UNIT
         6 SNFs
         7
         8
         9
        10 SUBTOTAL
        11 ICU
        12 CCU
        13 NEO
        14
        15
        16
        17
        18
        19 SUBTOTAL
        20 NEWB
        21 CHR
        22 SUBTOTAL




                                                             Page 233
                                                           SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005
                                                   (20)           (21)          (22)      (23)      (24)         (25)
                                                NUCLEAR      RESPIRATORY    PULMONARY     EEG     ELECTRO-    PHYSICAL
                                                MEDICINE       THERAPY       FUNCTION            MYOGRAPHY     THERAPY


                                                   -              -             -         -         -            -
                                                TESTS        TREATMENTS       TESTS     TESTS     TESTS      TREATMENTS




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERG
        24 CLINIC
        25 SATELLITE
        26 AMB SURGERY
        27 AMB DIAL.
        28 HOME DIAL.
        29 PSY
        30 HOME HEALTH
        31 OBS. BEDS
        32 PRI. REFER.
        33 HOSPITAL LICENSED HEALTH CENTER(S)
        34
        35
        36 SUBTOTAL




                                                              Page 234
                                                        SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII
           DHCFP-403 VERSION 2005
                                                 (20)             (21)              (22)            (23)            (24)              (25)
                                             NUCLEAR        RESPIRATORY        PULMONARY            EEG          ELECTRO-          PHYSICAL
                                             MEDICINE          THERAPY          FUNCTION                       MYOGRAPHY           THERAPY


                                                 -                -                 -               -                -                 -
                                              TESTS         TREATMENTS           TESTS           TESTS            TESTS         TREATMENTS


        37 TOT INP+AMB


           NON-PAT. CARE
        38 NON-PAT ANC
        39 RESEARCH
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                                       ****************** ******************
                                          ******************                                                ****************** ******************
                                                                                              ******************
        44 PROV. B/D                                      ****************** ******************
                                          ******************                                                ****************** ******************
                                                                                              ******************
      44.01 GROSS UCP ASSMT                               ****************** ******************
                                          ******************                                                ****************** ******************
                                                                                              ******************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                      ****************** ******************
                                          ******************                                                ****************** ******************
                                                                                              ******************


        47 *****                                          *************************
                                          *************************                           *************************
                                                                             *************************                         *************************
                                                                                                            *************************
        48 *****                                          *************************
                                          *************************                           *************************
                                                                             *************************                         *************************
                                                                                                            *************************




                                                            Page 235
                                                           SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII                                               PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
             DHCFP-403 VERSION 2005
                                                    (26)          (27)           (28)            (29)           (30)         (31)
                                               OCCUPATIONAL     SPEECH-     RECREATIONAL    AUDIOLOGY     PSYCHOLOGY/       RENAL
                                                 THERAPY       LANGUAGE       THERAPY                      PSYCHIATRY      DIALYSIS
                                                                THERAPY
                                                    -              -             -               -              -             -
                                               TREATMENTS      SESSIONS     TREATMENTS     PROCEDURES     TREATMENTS     TREATMENTS


             ROUTINE INPATIENT CARE SERVICES
         1 MED/SURG
         2 PEDI
         3 OB
         4 PSYCH
         5 VENT UNIT
         6 SNFs
         7
         8
         9
        10 SUBTOTAL
        11 ICU
        12 CCU
        13 NEO
        14
        15
        16
        17
        18
        19 SUBTOTAL
        20 NEWB
        21 CHR
        22 SUBTOTAL




                                                              Page 236
                                                            SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII                                                PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
             DHCFP-403 VERSION 2005
                                                     (26)          (27)           (28)            (29)           (30)         (31)
                                                OCCUPATIONAL     SPEECH-     RECREATIONAL    AUDIOLOGY     PSYCHOLOGY/       RENAL
                                                  THERAPY       LANGUAGE       THERAPY                      PSYCHIATRY      DIALYSIS
                                                                 THERAPY
                                                     -              -             -               -              -             -
                                                TREATMENTS      SESSIONS     TREATMENTS     PROCEDURES     TREATMENTS     TREATMENTS




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERG
        24 CLINIC
        25 SATELLITE
        26 AMB SURGERY
        27 AMB DIAL.
        28 HOME DIAL.
        29 PSY
        30 HOME HEALTH
        31 OBS. BEDS
        32 PRI. REFER.
        33 HOSPITAL LICENSED HEALTH CENTER(S)
        34
        35
        36 SUBTOTAL




                                                               Page 237
                                                         SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII                                                  PATIENT SERVICE EXPENSES - INCLUDING CAPITAL
           DHCFP-403 VERSION 2005
                                                  (26)             (27)             (28)             (29)              (30)             (31)
                                           OCCUPATIONAL         SPEECH-      RECREATIONAL       AUDIOLOGY       PSYCHOLOGY/            RENAL
                                               THERAPY         LANGUAGE         THERAPY                          PSYCHIATRY          DIALYSIS
                                                                THERAPY
                                                  -                -                -                -                 -                 -
                                            TREATMENTS         SESSIONS      TREATMENTS        PROCEDURES       TREATMENTS        TREATMENTS


        37 TOT INP+AMB


           NON-PAT. CARE
        38 NON-PAT ANC
        39 RESEARCH
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                                                         ************************************
                                          ****************** ******************                                ************************************
        44 PROV. B/D                                                        ************************************
                                          ****************** ******************                                ************************************
      44.01 GROSS UCP ASSMT                                                 ************************************
                                          ****************** ******************                                ************************************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                        ************************************
                                          ****************** ******************                                ************************************


        47 *****                                             *************************
                                          *************************                           *************************
                                                                            *************************                            *************************
                                                                                                               *************************
        48 *****                                             *************************
                                          *************************                           *************************
                                                                            *************************                            *************************
                                                                                                               *************************




                                                            Page 238
                                                          SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005
                                                   (32)           (33)     (34)           (35)        (36)        (37)        (38)
                                                 ORGAN        AMBULANCE     OTHER       OTHER       OTHER       OTHER       OTHER
                                               ACQUISITION


                                                   -              -               -        -           -           -           -
                                                ORGANS        OCCASIONS    (SPECIFY)   (SPECIFY)   (SPECIFY)   (SPECIFY)   (SPECIFY)
                                                              OF SERVICE
             ROUTINE INPATIENT CARE SERVICES
         1 MED/SURG
         2 PEDI
         3 OB
         4 PSYCH
         5 VENT UNIT
         6 SNFs
         7
         8
         9
        10 SUBTOTAL
        11 ICU
        12 CCU
        13 NEO
        14
        15
        16
        17
        18
        19 SUBTOTAL
        20 NEWB
        21 CHR
        22 SUBTOTAL




                                                             Page 239
                                                           SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005
                                                    (32)           (33)     (34)           (35)        (36)        (37)        (38)
                                                  ORGAN        AMBULANCE     OTHER       OTHER       OTHER       OTHER       OTHER
                                                ACQUISITION


                                                    -              -               -        -           -           -           -
                                                 ORGANS        OCCASIONS    (SPECIFY)   (SPECIFY)   (SPECIFY)   (SPECIFY)   (SPECIFY)




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERG
        24 CLINIC
        25 SATELLITE
        26 AMB SURGERY
        27 AMB DIAL.
        28 HOME DIAL.
        29 PSY
        30 HOME HEALTH
        31 OBS. BEDS
        32 PRI. REFER.
        33 HOSPITAL LICENSED HEALTH CENTER(S)
        34
        35
        36 SUBTOTAL




                                                              Page 240
                                                         SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII
           DHCFP-403 VERSION 2005
                                                  (32)             (33)        (34)             (35)         (36)         (37)          (38)
                                                ORGAN         AMBULANCE         OTHER         OTHER        OTHER        OTHER        OTHER
                                            ACQUISITION


                                                  -                -                  -          -            -            -            -
                                              ORGANS          OCCASIONS        (SPECIFY)    (SPECIFY)     (SPECIFY)   (SPECIFY)     (SPECIFY)


        37 TOT INP+AMB


           NON-PAT. CARE
        38 NON-PAT ANC
        39 RESEARCH
        40 OTH NON-PAT
        41 SUBTOTAL


        42 TOTPAT+NONP
        43 RECOVERY                                                          ******************
                                          ************************************                          ******************
                                                                                           ******************                     ******************
                                                                                                                     ******************
        44 PROV. B/D                                                         ******************
                                          ************************************                          ******************
                                                                                           ******************                     ******************
                                                                                                                     ******************
      44.01 GROSS UCP ASSMT                                                  ******************
                                          ************************************                          ******************
                                                                                           ******************                     ******************
                                                                                                                     ******************
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT
        46 GEN. FUND                                                         ******************
                                          ************************************                          ******************
                                                                                           ******************                     ******************
                                                                                                                     ******************


        47 *****                                            *************************
                                          *************************                        ************************* *************************
                                                                             ************************* ************************* *************************
        48 *****                                            *************************
                                          *************************                        ************************* *************************
                                                                             ************************* ************************* *************************




                                                            Page 241
                                                    SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005




             ROUTINE INPATIENT CARE SERVICES
         1 MED/SURG                             1
         2 PEDI                                 2
         3 OB                                   3
         4 PSYCH                                4
         5 VENT UNIT                            5
         6 SNFs                                 6
         7                                      7
         8                                      8
         9                                      9
        10 SUBTOTAL                            10
        11 ICU                                 11
        12 CCU                                 12
        13 NEO                                 13
        14                                     14
        15                                     15
        16                                     16
        17                                     17
        18                                     18
        19 SUBTOTAL                            19
        20 NEWB                                20
        21 CHR                                 21
        22 SUBTOTAL                            22




                                                       Page 242
                                                     SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


             SCHEDULE XVIII
             DHCFP-403 VERSION 2005




             ROUTINE AMBULATORY CARE SERVICES
        23 EMERG                                23
        24 CLINIC                               24
        25 SATELLITE                            25
        26 AMB SURGERY                          26
        27 AMB DIAL.                            27
        28 HOME DIAL.                           28
        29 PSY                                  29
        30 HOME HEALTH                          30
        31 OBS. BEDS                            31
        32 PRI. REFER.                          32
        33 HOSPITAL LICENSED HEALTH CENTER(S)   33
        34                                      34
        35                                      35
        36 SUBTOTAL                             36




                                                        Page 243
                                                  SCHEDULE-XVIII


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


           SCHEDULE XVIII
           DHCFP-403 VERSION 2005




        37 TOT INP+AMB                      37


           NON-PAT. CARE
        38 NON-PAT ANC                      38
        39 RESEARCH                         39
        40 OTH NON-PAT                      40
        41 SUBTOTAL                         41


        42 TOTPAT+NONP                      42
        43 RECOVERY                         43
        44 PROV. B/D                        44
      44.01 GROSS UCP ASSMT               44.01
        45 TOTPAT+NPAT+B/D+GR UCP ASSMT     45
        46 GEN. FUND                        46


        47 *****                            47
        48 *****                            48




                                                     Page 244
                                                                                                                             SCHEDULE-XVIIIA




HOSPITAL______________________
FOR FISCAL YEAR ENDED_________


        SCHEDULE XVIII-A                                   ROUTINE INPATIENT EXPENSES NET OF NONDISTINCT UNIT OBSERVATION BEDS EXPENSES-INCLUDING CAPITAL
        DHCFP-403 VERSION 2005


        COMPUTATION OF TOTAL OBSERVATION BEDS EXPENSES
                                                           COL.1              COL.2              COL.3


                                                           ROUTINE            ANCILLARY          TOTAL
                                                           EXPENSE            EXPENSE            EXPENSES
                                                           AMOUNT             AMOUNT             AMOUNT
                                                                                                 (Col.1 + Col.2)


A       SCHEDULE XVIII, COL 3 & 4, LINE 10
B       SCHEDULE XVIII, COLUMNS 3 & 4, LINE 6
C       SUBTOTAL (LINE A MINUS LINE B)
D       SCHEDULE III-B, COL 3, LINE 7                                                            xxxxxxxxxxxxxx
E       OBSERVATION BEDS EXPENSES (LINE C X LINE D)
F       EXPENSES NET OF OBSER. EXP (LINE A MINUS LINE E)



                                 COL.4                          COL 5             COL.6              COL 7           COL 8               COL 9                   COL 10                  COL 11                COL 12                 COL 13


                                                           TOTAL EXPENSES TOTAL EXPENSES           I/P DAYS          RATIO          ALLOCATION OF           ALLOCATION OF            TOTAL ROUTINE       TOTAL ANCILLARY              TOTAL
        ROUTINE INPATIENT CARE SERVICES                        ROUTINE         ANCILLARY            (SCH III       OF I/P DAYS    OBSERVATION BEDS        OBSERVATION BEDS          EXPENSE NET OF        EXPENSE NET OF         EXPENSE NET OF
                                                           (SCH XVIII COL.3) (SCH XVIII COL.4)       COL 6)                       ROUTINE EXPENSES       ANCILLARY EXPENSES        OBS. BEDS EXPENSES    OBS. BEDS EXPENSES     OBS. BEDS EXPENSES
                                                                                                                                 (COL 8 X LINE E, COL-1) (COL 8 X LINE E, COL-2)   (COL 5 minus COL 9)   (COL 6 minus COL 10)    (COL 11 + COL 12)


    1 MED/SURG
    2 PEDIATRIC
    3 OBSTETRIC
    4 PSYCHIATRIC
    5 VENT UNIT
    6 SNFs                                                  XXXXXXXXXXXX XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXX XXXXXXXXXXXXXX                                               XXXXXXXXXXXXXXX       XXXXXXXXXXXXXXX
    7
    8
    9
10 SUBTOTAL ACUTE



SCHEDULE REQUIRED ONLY FOR HOSPITALS WHICH DO NOT HAVE A DISTINCT UNIT FOR OBSERVATION BEDS.




                                                                                                                                 Page 245
                                                                        SCHEDULE-XXIII



HOSPITAL ______________________
FOR FISCAL YEAR ENDED ________

    SCHEDULE XXIII     FINANCIAL STATEMENTS: NON-ACUTE HOSPITALS ONLY
    DHCFP-403 VERSION 2005
                                       (A)                                               (B)                                                    (C)
  1 Hospital Name                                                                                                                                                                  1
  2 CPA Name                                                                                                                                                                       2
  3 Fiscal Year                                                                       FY2005                                                  FY2004                               3


  4                                           BALANCE SHEET                                                                                                                        4
  5   CURRENT ASSETS                                                                                                                                                               5
  6    Cash and cash equivalents                                                                                                                                                   6
  7    Short-term Investments                                                                                                                                                      7
  8    Current Assets Whose Use Is Limited                                                                                                                                         8
  9    Receivables:                                                                                                                                                                9
 10     Net Patient Accounts Receivable                                                                                                                                           10
 11     Due from Affiliates                                                                                                                                                       11
 12     Third Party Settlements Receivable                                                                                                                                        12
 13     Other Accounts Receivable                                                                                                                                                 13
 14   Inventory                                                                                                                                                                   14
 15   Other Current Assets                                                                                                                                                        15
 16   Total Current Assets                                                                        SUM(COL.B,L.6 THRU COL.B,L15)                SUM(COL.C,L.6 THRU COL.C,L.15)     16
 17   NONCURRENT ASSETS                                                                                                                                                           17
 18   Assets Whose Use Is Limited                                                                                                                                                 18
 19   Receivables from donors/grantors for Specific Purpose                                                                                                                       19
 20   Permanently Restricted Funds                                                                                                                                                20
 21    Due From Affiliates                                                                                                                                                        21
 22    Investment in Affiliates                                                                                                                                                   22
 23    Undesignated Noncurrent Investments                                                                                                                                        23
 24    Other Noncurrent Assets                                                                                                                                                    24
 25    Gross PP&E                                                                                                                                                                 25
 26    Accum. Depreciation                                                                                                                                                        26
 27    Net PP&E                                                                                         COL.B,L.25 - COL.B, L. 26                     COL.C,L.25 - COL.C, L. 26   27
 28   Total Noncurrent Assets                                                         SUM(COL.B,L.18 THRU COL.B,L24)+COL.B,L.27     SUM(COL.C,L.18 THRU COL.C,L24)+COL.C,L.27     28
 29   TOTAL ASSETS                                                                                       COL.B,L.16 + COL.B,L28                        COL.C,L.16 + COL.C,L28     29



 30   LIABILITIES AND NET ASSETS                                                                                                                                                  30
 31   CURRENT LIABILITIES                                                                                                                                                         31
 32   Current Long Term Debt                                                                                                                                                      32
 33   Accounts Payable + Accrued Expenses                                                                                                                                         33
 34   Estimated Third-Party Settlements                                                                                                                                           34
 35   Due to Affiliates                                                                                                                                                           35
 36   Other Current Liabilities                                                                                                                                                   36
 37   Total Current Liabilities                                                                 SUM(COL.B,L.32 THRU COL.B,L.36)               SUM(COL.C,L.32 THRU COL.C,L.36)     37
 38   NONCURRENT LIABILITIES                                                                                                                                                      38
 39   Long term debt-Net of current portion                                                                                                                                       39
 40   Self-Insurance Fund                                                                                                                                                         40
 41   Estimated Third Party Settlements                                                                                                                                           41
 42   Due to Affiliates                                                                                                                                                           42
 43   Accrued Pension & Post-Retirement Health Benefits                                                                                                                           43
 44   Other noncurrent liabilities                                                                                                                                                44




                                                                           Page 246
                                                                                                SCHEDULE-XXIII



HOSPITAL ______________________
FOR FISCAL YEAR ENDED ________

    SCHEDULE XXIII     FINANCIAL STATEMENTS: NON-ACUTE HOSPITALS ONLY
    DHCFP-403 VERSION 2005
                                       (A)                                                                       (B)                                        (C)
  1 Hospital Name                                                                                                                                                                             1
  2 CPA Name                                                                                                                                                                                  2
  3 Fiscal Year                                                                                               FY2005                                      FY2004                              3


 45   Total Noncurrent Liabilities                                                                                      SUM(COL.B,L.39 THRU COL.B,L.44)    SUM(COL.C,L.39 THRU COL.C,L.44)   45
 46   Total Liabilities                                                                                                          COL.B,L.37 + COL.B,L45             COL.C,L.37 + COL.C,L45   46
 47   Net Assets                                                                                                                                                                             47
 48   Unrestricted                                                                                                                                                                           48
 49   Temporarily Restricted                                                                                                                                                                 49
 50   Permanently Restricted                                                                                                                                                                 50
 51   Total Net Assets                                                                                                  SUM(COL.B,L.48 THRU COL.B,L.50)    SUM(COL.C,L.48 THRU COL.C,L.50)   51
 52   TOTAL LIABILITIES AND NET ASSETS                                                                                           COL.B,L.46 + COL.B,L51             COL.C,L.46 + COL.C,L51   52




 53                                     STATEMENTS OF OPERATIONS                                                                                                                             53
 54   Unrestricted Revenue, Gains and Other Support:                                                                                                                                         54
 55   Net Patient Service Revenue                                                                                                                                                            55
 56   Premium Revenue                                                                                                                                                                        56
 57   Other Revenue                                                                                                                                                                          57
 58   Investment income                                                                                                                                                                      58
 59   Nonoperating Gains(Losses)                                                                                                                                                             59
 60   Net assets released from restriction used for operations:                                                                                                                              60
 61   Satisfaction of Program restrictions                                                                                                                                                   61
 62   Satisfaction of Equipment restrictions                                                                                                                                                 62
 63   Expiration of Time restrictions                                                                                                                                                        63
 64   Other restricted assets released for operations                                                                                                                                        64
 65   Total Unrestricted Revenue, Gains and Other Support                                                               SUM(COL.B,L.55 THRU COL.B,L.64)    SUM(COL.C,L.55 THRU COL.C,L.64)   65
 66   Expenses:                                                                                                                                                                              66
 67    Depreciation                                                                                                                                                                          67
 68    Depreciation and Amortization                                                                                                                                                         68
 69    Interest                                                                                                                                                                              69
 70    UCC Pool Assessment                                                                                                                                                                   70
 71    Provision for Bad Debts                                                                                                                                                               71
 72    Other expenses                                                                                                                                                                        72
 73   Total expenses                                                                                                   SUM(COL.B,L.67 THRU COL.B,L.72)    SUM(COL.C,L.67 THRU COL.C,L.72)    73
 74   Excess of Revenue, Gains and Other Support Over Expenses                                                                  COL.B,L.65 - COL.B,L.73            COL.C,L.65 - COL.C,L.73   74
 75   Changes in net unrealized gains and losses on investments other than trading securities                                                                                                75
 76   Net Assets Released from restrictions for purchase of property and equipment                                                                                                           76
 77   Contribution from hospital foundation for property acquisitions                                                                                                                        77
 78   Transfers from (to) parent                                                                                                                                                             78
 79   Increase in unrestricted net assets, before extraordinary item                                                   SUM(COL.B,L.74 THRU COL.B,L.78)    SUM(COL.C,L.74 THRU COL.C,L.78)    79
 80   Extraordinary Gains (losses) from extinguishment of debt                                                                                                                               80
 81   Changes in Accounting Principle/other                                                                                                                                                  81




                                                                                                   Page 247
                                                                                                    SCHEDULE-XXIII



HOSPITAL ______________________
FOR FISCAL YEAR ENDED ________

    SCHEDULE XXIII     FINANCIAL STATEMENTS: NON-ACUTE HOSPITALS ONLY
    DHCFP-403 VERSION 2005
                                       (A)                                                                           (B)                                                     (C)
  1 Hospital Name                                                                                                                                                                                                1
  2 CPA Name                                                                                                                                                                                                     2
  3 Fiscal Year                                                                                                   FY2005                                                   FY2004                                3


 82 Increase in unrestricted net assets                                                                                     SUM( COL.B,L.79 THRU COL.B,L.81)             SUM( COL.C,L.79 THRU COL.C,L.81)       82



 83                             STATEMENTS OF CHANGES IN NET ASSETS                                                                                                                                             83
 84   Unrestricted net assets:                                                                                                                                                                                  84
 85   Excess of Revenue, Gains and Other Support Over Expenses                                                                                    COL.B,L.74                                   COL.C,L.74       85
 86   Net unrealized gains and losses on investments other than trading securities                                                                COL.B,L.75                                   COL.C,L.75       86
 87   Net Assets Released from restrictions for purchase of property and equipment                                                                COL.B,L.76                                   COL.C,L.76       87
 88   Contribution from hospital foundation for property acquisitions                                                                             COL.B,L.77                                   COL.C,L.77       88
 89   Transfers from (to) parent                                                                                                                  COL.B,L.78                                   COL.C,L.78       89
 90   Increase in unrestricted net assets, before extraordinary item                                                         SUM(COL.B,L.85 THRU COL.B,L.89)              SUM(COL.C,L.85 THRU COL.C,L.89)       90
 91   Extraordinary Gains (losses) from extinguishment of debt                                                                                    COL.B,L.80                                   COL.C,L.80       91
 92   Changes in Accounting Principle/Other                                                                                                       COL.B,L.81                                   COL.C,L.81       92
 93   Increase in unrestricted net assets                                                                                    SUM(COL.B,L.90 THRU COL.B,L.92)              SUM(COL.C,L.90 THRU COL.C,L.92)       93
 94   Temporarily restricted net assets:                                                                                                                                                                        94
 95   Contribution for charity care                                                                                                                                                                             95
 96   Net realized and unrealized gains on investments                                                                                                                                                          96
 97   Net assets released from restrictions                                                                                                                                                                     97
 98   Increase (Decrease) in temporarily restricted net assets                                                               SUM(COL.B,L.95 THRU COL.B,L.97)              SUM(COL.C,L.95 THRU COL.C,L.97)       98
 99   Permanently restricted net assets:                                                                                                                                                                        99
100   Contributions for endowment funds                                                                                                                                                                        100
101   Net realized and unrealized gains on investments                                                                                                                                                         101
102   Increase in permanently restricted net assets                                                                       SUM(COL.B,L.100 THRU COL.B,L.101)            SUM(COL.C,L.100 THRU COL.C,L.101)       102
103   Increase (decrease) in net assets                                                                              SUM(COL.B,L.93 + COL.B,L.98 + COL.B,L.102)   SUM(COL.C,L.93 + COL.C,L.98 + COL.C,L.102)   103
104   Net assets at beginning of the year                                                                                                           COL.C,L.105     NET ASSETS AT THE END OF PRIOR YEAR        104
105   Net assets at end of the year                                                                                                  COL.B,L.103 + COL.B,L.104                    COL.C,L.103 + COL.C,L.104    105


106                                   STATEMENTS OF CASH FLOW                                                                                                                                                  106
107 Cash flows from operating activities:                                                                                                                                                                      107
108    Change in net assets                                                                                                                                                                                    108
109    Adjustments to reconcile change in net assets to net cash provided by operating activities                                                                                                              109
110    Extraordinary (Gains) Losses                                                                                                                                                                            110
111    Changes in Accounting Principle/Other                                                                                                                                                                   111
112    Depreciation and amortization                                                                                                                                                                           112
113    Net realized and unrealized gains on investments, other than trading                                                                                                                                    113
114    Transfers from (to) parent                                                                                                                                                                              114
115    Provision for bad debts                                                                                                                                                                                 115
116    Restricted contributions and investment income received                                                                                                                                                 116
117 (Increase) Decrease in:                                                                                                                                                                                    117
118    Current assets-whose use is limited                                                                                                                                                                     118
119    Accounts receivable                                                                                                                                                                                     119
120    Due from affiliates                                                                                                                                                                                     120
121    Third party settlements receivable-Current                                                                                                                                                              121




                                                                                                       Page 248
                                                                                   SCHEDULE-XXIII



HOSPITAL ______________________
FOR FISCAL YEAR ENDED ________

    SCHEDULE XXIII     FINANCIAL STATEMENTS: NON-ACUTE HOSPITALS ONLY
    DHCFP-403 VERSION 2005
                                       (A)                                                          (B)                                              (C)
  1 Hospital Name                                                                                                                                                                       1
  2 CPA Name                                                                                                                                                                            2
  3 Fiscal Year                                                                                  FY2005                                            FY2004                               3


122     Inventory                                                                                                                                                                     122
123     Other current assets                                                                                                                                                          123
124   Increase (Decrease) in:                                                                                                                                                         124
125      Accounts payable and accrued expenses                                                                                                                                        125
126      Estimated third-party payor settlements                                                                                                                                      126
127      Due to affiliates                                                                                                                                                            127
128      Other current liabilities                                                                                                                                                    128
129      Self-insurance fund-Noncurrent                                                                                                                                               129
130      Third party settlements - Noncurrent                                                                                                                                         130
131      Due to affiliates-Noncurrent                                                                                                                                                 131
132      Accrued pension and Post-retirement health benefits                                                                                                                          132
133      Trading                                                                                                                                                                      133
134                                                                                                                                                                                   134
135                                                                                                                                                                                   135
136                                                                                                                                                                                   136
137                                                                                                                                                                                   137
138                                                                                                                                                                                   138
139   Net cash provided by operating activities                                                                 @SUM(COL.B,L.108.COL.B,L.138)         @SUM(COL.C,L.108.COL.C,L.138)   139
140   Cash flows from investing activities:                                                                                                                                           140
141     Noncurrent Assets whose use is limited                                                                                                                                        141
142     Noncurrent Assets- Due from Affiliates                                                                                                                                        142
143     Investment in Affiliates                                                                                                                                                      143
144     Undesignated Noncurrent Investments                                                                                                                                           144
145     Other Noncurrent Assets                                                                                                                                                       145
146     Capital expenditures                                                                                                                                                          146
147     Sales of Fixed Assets                                                                                                                                                         147
148                                                                                                                                                                                   148
149                                                                                                                                                                                   149
150                                                                                                                                                                                   150
151                                                                                                                                                                                   151
152                                                                                                                                                                                   152
153   Net cash used in investing activities                                                               @SUM(COL.B,L.141 THRU COL.B,L.152)    @SUM(COL.C,L.141 THRU COL.C,L.152)    153
154   Cash flows from financing activities:                                                                                                                                           154
155      Proceeds from issuance of long-term debt                                                                                                                                     155
156      Payments on long-term debt and capital lease obligations                                                                                                                     156
157      Other Noncurrent liabilities                                                                                                                                                 157
158     Transfers from ( to) parent                                                                                                                                                   158
159      Proceeds from restricted contributions and restricted investment income                                                                                                      159
160                                                                                                                                                                                   160
161                                                                                                                                                                                   161
162                                                                                                                                                                                   162
163                                                                                                                                                                                   163
164                                                                                                                                                                                   164




                                                                                      Page 249
                                                                                                                  SCHEDULE-XXIII



HOSPITAL ______________________
FOR FISCAL YEAR ENDED ________

    SCHEDULE XXIII     FINANCIAL STATEMENTS: NON-ACUTE HOSPITALS ONLY
    DHCFP-403 VERSION 2005
                                       (A)                                                                                              (B)                                                                            (C)
  1 Hospital Name                                                                                                                                                                                                                                             1
  2 CPA Name                                                                                                                                                                                                                                                  2
  3 Fiscal Year                                                                                                                       FY2005                                                                        FY2004                                    3


165   Net cash used in financing activities                                                                                                    @SUM(COL.B,L.155 THRU .COL.B,L.164)                             @SUM(COL.C,L.155 THRU .COL.C,L.164)          165
166   Net (decrease) increase in cash and cash equivalents                                                                                    COL.B,L.139 + COL.B,L.153 + COL.B,L.165                         COL.C,L.139 + COL.C,L.153 + COL.C,L.165       166
167   Cash and cash equivalents, beginning of the year                                                                                                                    COL.C,L.168                        NET ASSETS AT THE END OF PRIOR YEAR            167
168   Cash and cash equivalents, end of year                                                                                                                COL.B,L.166 + COL.B,L.167                                       COL.C,L.166 + COL.C,L.167       168


169               SUPPLEMENTAL DISCLOSURES OF CASH FLOW INFORMATION                                                                                                                                                                                         169
170 Other significant transactions not affecting cash                                                                                                                                                                                                       170
171 Transfer of assets from (to) Affiliates                                                                                                                                                                                                                 171
172 Other Noncash (Specify)                                                                                                                                                                                                                                 172



      Lines 173 & beyond are ratios which will be automatically computed after the
      completion of the financial statements.


                                    FINANCIAL STATEMENTS RATIOS
173   Total Margin                                                                                                                                               COL.B,L74 / COL.B,L.65                                           COL.C,L74 / COL.C,L.65    173
174   Operating Margin                                                                                                                    (COL.B,L.74 - (COL.B,L.58+L.59)) / COL.B,L.65                     (COL.C,L.74 - (COL.C,L.58+L.59)) / COL.C,L.65   174
175   Nonoperating Margin                                                                                                                                (COL.B,L.58+L.59) / COL.B,L.65                                    (COL.C,L.58+L.59) / COL.C,L.65   175
176   Current Ratio with Assets whose Use is Limited & Undesignated Noncurrent Investments                                                       (COL.B,L.16+COL.B,L.23) / COL. B,L.37                             (COL.C,L.16+COL.C,L.23) / COL. C,L.37    176
177   Current Ratio without Assets whose Use is Limited & Undesignated Noncurrent Investments                                                      (COL.B,L.16-COL.B,L.8) / COL. B,L.37                              (COL.C,L.16-COL.C,L.8) / COL. C,L.37   177
178   Quick Ratio with Undesignated Noncurrent Assets                                                                   (COL.B,L.6 + COL.B,L.7 + COL.B,L.10 + COL.B,L.23) / COL.B,L.37    (COL.C,L.6 + COL.C,L.7 + COL.C,L.10 + COL.C,L.23) / COL.C,L.37    178
179   Quick Ratio without Undesignated Noncurrent Assets                                                                             (COL.B,L.6 + COL.B,L.7 + COL.B,L.10) / COL.B,L.37                 (COL.C,L.6 + COL.C,L.7 + COL.C,L.10) / COL.C,L.37    179
180   Average Pay Period (Depreciation only) with Third party settlements                                                                       @IF(B67>0, B37 / ((B73-B67) / 366)," ")                           @IF(C67>0, C37 / ((C73-C67) / 365)," ")   180
181   Average Pay Period (Depreciation & Amortization) with Third party settlements                                                             @IF(B68>0, B37 / ((B73-B68) / 366)," ")                           @IF(C68>0, C37 / ((C73-C68) / 365)," ")   181
182   Average Pay Period (Depreciation only without Third party settlements                                                             @IF(B67>0, (B37-B34) / ((B73-B67) / 366)," ")                     @IF(C67>0, (C37-C34) / ((C73-C67) / 365)," ")     182
183   Average Pay Period (Depreciation & Amortization) without Third party settlements                                                   @IF(B68>0, (B37-B34) / ((B73-B68) / 366)," ")                     @IF(C68>0, (C37-C34) / ((C73-C68) / 365)," ")    183
184   Net Assets Financing Ratio                                                                                                                                COL.B,L.48 / COL.B,L.29                                          COL.C,L.48 / COL.C,L.29    184
185   Cash Flow to total Debts Ratio                                                                                            (COL.B,L.74 + COL.B,L.112) / (COL.B,L37 + COL.B,L.39)            (COL.C,L.74 + COL.C,L.112) / (COL.C,L37 + COL.C,L.39)      185
186   Long-Term Debt to Net Assets Ratio                                                                                                                        COL.B,L.45 / COL.B,L.48                                          COL.C,L.45 / COL.C,L.48    186
187   Debt Service Coverage Ratio- Operating                                                    ((COL.B,L.74 - (COL.B,L.58+L.59))+COL.B,L.69+COL.B,L.112) / (COL.B,L.69 + COL.C,L.32)              XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                       187
188   Debt Service Coverage Ratio- Total                                                                             (COL.B,L.74+COL.B,L.69+COL.B,L.112) / (COL.B,L.69 + COL.C,L.32)               XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                       188
189   Average Age of Plant(Depreciation only)                                                                                                                   COL.B,L.26 / COL.B,L.67                                          COL.C,L.26 / COL.C,L.67    189
190   Average Age of Plant(Depreciation & Amortization)                                                                                                         COL.B,L.26 / COL.B,L.68                                          COL.C,L.26 / COL.C,L.68    190
191   Reported Income Index                                                                                                                       COL.B,L.74 / (COL.BL.48 - COL.C,L.48)                                                                     191




                                                                                                                        Page 250
                                                                  COVER-SCH-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV         PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


           OVERHEAD
         1 BUILDING AND FIXED EQUIPMENT DEPRECIATION
         2 CAPITAL LEASES- AMORTIZATION ON BUILDING + FIXED EQUIPMENT
         3 INTEREST-LONG TERM
         4 AMORTIZATION of BOND ISSUE COSTS
         5 SUBTOTAL
         6 FRINGE BENEFITS
         7 ADMINISTRATION
         8 PURCHASING
         9 GENERAL ACCOUNTING
        10 PATIENT ACCOUNTS AND INPATIENT ADMITTING
        11 INSURANCE-PROFESSIONAL MALPRACTICE
        12 INSURANCE-HOSPITAL MALPRACTICE
        13 INSURANCE-OTHER
        14 INTEREST-SHORT TERM
        15 SUBTOTAL
        16 PLANT MAINTENANCE AND REPAIRS
        17 PLANT OPERATIONS
        18 SECURITY
        19 PARKING
        20 LICENSES AND TAXES (OTHER THAN INCOME)
        21 SUBTOTAL
        22 LAUNDRY AND LINEN
        23 HOUSEKEEPING
        24 CAFETERIA
        25 DIETARY SERVICES
        26 MAINTENANCE OF PERSONNEL
        27 NURSING ADMINISTRATION
        28 INSERVICE EDUCATION-NURSING




                                                                        Page 251
                                             COVER-SCH-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV        PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


        29 SUBTOTAL
        30 NURSING FLOAT
        31 RN + LPN EDUCATION
        32 MEDICAL STAFF-TEACHING
        33 MEDICAL STAFF-ADMINISTRATION
        34 SUBTOTAL
        35 POSTGRADUATE MEDICAL EDUCATION
        36 CENTRAL SERVICE AND SUPPLIES
        37 PHARMACY
        38 MEDICAL RECORDS
        39 MEDICAL CARE REVIEW
        40 SOCIAL SERVICES
        41 CENTRAL PATIENT TRANSPORTATION
        42 OTHER OVERHEAD
        43 SUBTOTAL OVERHEAD



           ANCILLARY CARE SERVICES
        44 SURGERY
        45 LABOR AND DELIVERY
        46 RECOVERY ROOM
        47 ANESTHESIOLOGY
        48 IV THERAPY
        49 MEDICAL SUPPLIES-SPECIAL
        50 DRUGS-SPECIAL
        51 LABORATORY
        52 BLOOD
        53 BLOOD PROCESSING + STORAGE
        54 ELECTROCARDIOLOGY (EKG)




                                                Page 252
                                               COVER-SCH-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV         PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


        55 CARDIAC CATHERIZATION LABORATORY
        56 DIAGNOSTIC RADIOLOGY
        57 THERAPEUTIC RADIOLOGY
        58 COMPUTERIZED TOMOGRAPHY
        59 NUCLEAR MEDICINE
        60 RESPIRATORY THERAPY
        61 PULMONARY FUNCTION TESTING
        62 ELECTROENCEPHALOGRAPHY (EEG)
        63 ELECTROMYOGRAPHY
        64 PHYSICAL THERAPY
        65 OCCUPATIONAL THERAPY
        66 SPEECH-LANGUAGE THERAPY
        67 RECREATIONAL THERAPY
        68 AUDIOLOGY
        69 PSYCHOLOGY/PSYCHIATRY
        70 RENAL DIALYSIS
        71 ORGAN ACQUISITION
        72 AMBULANCE
        73
        74
        75
        76
        77
        78 SUBTOTAL ANCILLARY



             ROUTINE INPATIENT CARE SERVICES
        79 MEDICAL + SURGICAL ACUTE
        80 PEDIATRIC ACUTE




                                                  Page 253
                                                COVER-SCH-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV        PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


        81 OBSTETRIC ACUTE
        82 PSYCHIATRIC ACUTE
        83 VENTILATOR UNIT
        84 SKILLED NURSING FACILITIES
        85
        86
        87
        88   SUBTOTAL ACUTE
        89 MEDICAL + SURGICAL INTENSIVE CARE
        90 CORONARY INTENSIVE CARE
        91 NEONATAL INTENSIVE CARE
        92
        93
        94
        95
        96
        97   SUBTOTAL INTENSIVE CARE
        98 NEWBORN NURSERY
        99 CHRONIC AND REHABILITATION
       100 SUBTOTAL ROUTINE INPATIENT CARE



             ROUTINE AMBULATORY CARE SERVICES
       101 EMERGENCY SERVICES
       102 CLINIC OR AMBULATORY SERVICES
       103 SATELLITE CLINIC SERVICES
       104 AMBULATORY SURGICAL SERVICES
       105 AMBULATORY RENAL DIALYSIS SERVICES
       106 HOME DIALYSIS SERVICES




                                                   Page 254
                                                          COVER-SCH-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV        PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


       107 PSYCHIATRY
       108 HOME HEALTH SERVICES
       109 OBSERVATION BEDS
       110 PRIVATE REFERRALS
       111
       112
       113
       114 SUBTOTAL ROUTINE AMBULATORY SERVICES


       115 TOTAL PATIENT CARE (Lines 78 + 100 +114)
      116 TOTAL PATIENT CARE AND OVERHEAD (Lines 43 + 115)


             NON-PATIENT CARE
      117    NON-PATIENT ANCILLARY
      118    RESEARCH
      119    OTHER NON-PATIENT
      120    SUBTOTAL NON-PATIENT

      121 RECOVERY OF EXPENSES (SCH. VII, C.3, L.50)
      122 TOTAL PATIENT AND NON-PATIENT (Lines 116 + 120 + 121)




                                                              Page 255
                                                                         SCHEDULE-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV         PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


                                                 (2)            (3)           (4)             (5)
                                          PHYSICIAN       PROFESSIONAL   COST CENTER        OTHER
                                       COMPENSATION            FEES      SUPERVISION        DIRECT
                                              (C.3+4+5)



          OVERHEAD
      1 DEP                                                                                               1
      2 LEASE                                                                                             2
      3 INT-LT                                                                                            3
      4 AMOR. BOND ISSUE COSTS                                                                            4
      5 SUB                            xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx    5
      6 FRINGE                                                                                            6
      7 ADM                                                                                               7
      8 PURCH                                                                                             8
      9 GEN. ACCT.                                                                                        9
     10 PAT. ACCT.                                                                                       10
     11 INS-PROF                                                                                         11
     12 INS-HOSP                                                                                         12
     13 INS-OTHER                                                                                        13
     14 INT-ST                                                                                           14
     15 SUB                            xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx 15
     16 PL MAINT                                                                                         16
     17 PL OP                                                                                            17
     18 SEC                                                                                              18
     19 PARK                                                                                             19
     20 LIC                                                                                              20
     21 SUB                            xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx 21
     22 LAUND                                                                                            22




                                                                           Page 256
                                                                        SCHEDULE-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV        PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


                                                (2)            (3)           (4)             (5)
                                         PHYSICIAN       PROFESSIONAL   COST CENTER       OTHER
                                      COMPENSATION            FEES      SUPERVISION       DIRECT
                                             (C.3+4+5)



     23 HSKP                                                                                         23
     24 CAFE                                                                                         24
     25 DIET                                                                                         25
     26 MAINT PER                                                                                    26
     27 NURS ADM                                                                                     27
     28 INSVC ED                                                                                     28
     29 SUB                           xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx 29
     30 NURS FL                                                                                      30
     31 RN+LPN                                                                                       31
     32 MED-TEACH                                                                                    32
     33 MED-ADM                                                                                      33
     34 SUB                           xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx 34
     35 POST GRAD                                                                                    35
     36 CENT SER                                                                                     36
     37 PHARM                                                                                        37
     38 MED REC                                                                                      38
     39 MED CARE                                                                                     39
     40 SOC SER                                                                                      40
     41 CENT TRAN                                                                                    41
     42 OTHER OH                                                                                     42
     43 SUBTOTAL OH                                                                                  43




                                                                          Page 257
                                                                        SCHEDULE-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV        PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


                                                (2)            (3)           (4)         (5)
                                         PHYSICIAN       PROFESSIONAL   COST CENTER    OTHER
                                      COMPENSATION            FEES      SUPERVISION    DIRECT
                                             (C.3+4+5)



        ANCILLARY CARE SERVICES
     44 SURG                                                                                    44
     45 LABOR                                                                                   45
     46 REC RM                                                                                  46
     47 ANEST                                                                                   47
     48 IV THER                                                                                 48
     49 MED SUP                                                                                 49
     50 DRUG                                                                                    50
     51 LAB                                                                                     51
     52 BLOOD                                                                                   52
     53 BL PROC                                                                                 53
     54 EKG                                                                                     54
     55 CARD CATH                                                                               55
     56 DIAG RAD                                                                                56
     57 THER RAD                                                                                57
     58 CT SCAN                                                                                 58
     59 NUC MED                                                                                 59
     60 RESP THER                                                                               60
     61 PULM                                                                                    61
     62 EEG                                                                                     62
     63 ELEC                                                                                    63
     64 PHY THER                                                                                64
     65 OCC THER                                                                                65




                                                                          Page 258
                                                                        SCHEDULE-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV        PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


                                                (2)            (3)           (4)         (5)
                                            PHYSICIAN    PROFESSIONAL   COST CENTER    OTHER
                                        COMPENSATION          FEES      SUPERVISION    DIRECT
                                             (C.3+4+5)



     66 SPEECH                                                                                  66
     67 REC THER                                                                                67
     68 AUD                                                                                     68
     69 PSYCH                                                                                   69
     70 REN DIAL                                                                                70
     71 ORGAN ACQ                                                                               71
     72 AMB                                                                                     72
     73                                                                                         73
     74                                                                                         74
     75                                                                                         75
     76                                                                                         76
     77                                                                                         77
     78 SUBTOTAL ANCI                                                                           78



          ROUTINE INPATIENT CARE SERVICES
     79 MED/SURG                                                                                79
     80 PED                                                                                     80
     81 OB                                                                                      81
     82 PSY                                                                                     82
     83 VENT UNIT                                                                               83
     84 SNFs                                                                                    84
     85                                                                                         85




                                                                          Page 259
                                                                       SCHEDULE-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV       PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


                                               (2)            (3)           (4)         (5)
                                        PHYSICIAN       PROFESSIONAL   COST CENTER    OTHER
                                      COMPENSATION           FEES      SUPERVISION    DIRECT
                                            (C.3+4+5)



     86                                                                                        86
     87                                                                                        87
     88 SUBTOTAL ACUTE                                                                         88
     89 ICU                                                                                    89
     90 CCU                                                                                    90
     91 NEO                                                                                    91
     92                                                                                        92
     93                                                                                        93
     94                                                                                        94
     95                                                                                        95
     96                                                                                        96
     97 SUBTOTAL ICU                                                                           97
     98 NEWB                                                                                   98
     99 CHR                                                                                    99
    100 SUBTOTAL I/P                                                                           ###



          ROUTINE AMBULATORY CARE SERVICES
    101 EMERG                                                                                  ###
    102 CLINIC                                                                                 ###
    103 SAT                                                                                    ###
    104 SURG                                                                                   ###
    105 A. DIAL.                                                                               ###




                                                                         Page 260
                                                                            SCHEDULE-XXV


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXV          PHYSICIAN COMPENSATION
DHCFP-403 VERSION 2005


                                                   (2)             (3)             (4)             (5)
                                               PHYSICIAN    PROFESSIONAL     COST CENTER         OTHER
                                            COMPENSATION          FEES       SUPERVISION        DIRECT
                                                (C.3+4+5)



    106 H. DIAL.                                                                                            ###
    107 PSY                                                                                                 ###
    108 H. HEALTH                                                                                           ###
    109 OBS. BEDS                                                                                           ###
    110 PRI. REFER.                                                                                         ###
    111 HOSPITAL LICENSED HEALTH CENTER(S)                                                                  ###
    112                                                                                                     ###
    113                                                                                                     ###
    114 SUBTOTAL AMB                                                                                        ###


    115 TOT. PAT.                                                                                           ###
    116 TOT PAT+OH                                                                                          ###



          NON-PATIENT CARE
    117 NON-PAT ANC                                                                                         ###
                         ****************************************************************************************************************
    118 RESEARCH                                                                                            ###
    119 OTH.NON-PAT                                                                                         ###
    120 SUBTOTAL N/P                                                                                        ###


    121 RECOVERY                                                                                            ###
                        ***************************************************************************************************************


    122 TOTPAT+NPAT                                                                                         ###




                                                                                Page 261
                                                                                            SCHEDULE-XXVI


HOSPITAL______________________
FOR FISCAL YEAR ENDED ________


SCHEDULE XXVI
DHCFP-403 VERSION 2005


                         CERTIFICATION STATEMENT
                                   -------------------------
                         -----------------------


                 MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION
                 CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY
                 FINE AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW.


I, ________________________________ with authority specifically invested in me by the governing body, HEREBY
    (Please Print Full Name)


CERTIFY that I have read the above statement of _________________________________________ Hospital and that I have


examined the accompanying DHCFP-403 Report and supporting schedules prepared by ____________________________________,
                                                                                          (name)
__________________________________, for the DHCFP-403 Report period beginning___________________________ and ending
       (title)
___________________________ and that to the best of my knowledge and belief, the statement, accompanying DHCFP- 403,


and supporting schedules are true, accurate and complete and prepared in accordance with applicable regulations


and instructions, and that the statement, DHCFP-403 and supporting schedules are prepared from the books and


records of the Hospital, except as noted. This declaration is based upon all information of which I have knowledge.


This certification is signed under the pains and penalties of perjury.


                 Signed ________________________________


                 Title   ________________________________




                                                                                                   Page 262
                                          SCHEDULE-XXVI



Date   ________________________________




                                             Page 263

				
DOCUMENT INFO
Description: Intravenous Therapy for Licensed Practical Nurse document sample