Sample Forensic Report Forms - Excel by ooa17818

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									                                                      COST REPORT - FY 2006-07                                                                     Appendix L

                                                       INDEX TO MOREFORMS:


Listed below are all the additional forms which must accompany the Cost Report. If you like, you can copy other files into this workbook to
keep all your forms together (if this is a viable option for you).


FORM #                                                   NAME OF FORM WITH DESCRIPTION & NOTES
    1        Transmittal Checklist Cover Sheet (Mandatory)
                   On this form all providers should check off all the items and the "As Filed" box at the bottom when they have submitted with their Cost Report by the
                   due date. When all reviews have been completed by the Controller's Office, providers will be notified and must send in this Transmittal checklist
                   again with the "Final Desk Audit" box checked and dated. Providers should also have their Director/CEO & Finance Officer/CFO sign off indicating
                   they have reviewed the Cost Report. Signatures are required. A Cost Report contact person needs to be given so we know who to direct Cost
                   Report questions to. If a CPA was use, please provide their name, phone number and email address. This will be used if we need to obtain copies
                   of the accountants workpapers regarding issues that look questionable.



    2        CPT Detail Worksheet
                   Use this form to provide a list of all the CPT codes billed and the count by code. The total for the CPT Detail should tie to the Total Units on the
                   Schedule 2 for the CPT Code service objective. This form works the same way as the "Reconciliation of Cost Report Actual Units to Units derived
                   from the Unit Validation Data" (Ref. Units Memo). Users are welcome to delete row(s) in the list if a code is not used by organization.


    3        Schedule of Moveable Asset Depreciation
                   This is an optional format for all providers to place their Moveable Asset Depreciation figures. If you have this same information but in a different
                   arrangement and in Excel format, you can copy your schedule right into the workbook on this page (over the format provided); otherwise this
                   information should be provided in a paper copy. The depreciation method used must be straight-line, and please ensure your depreciation useful
                   lives are consistent with the AHA guidelines provided by DMA. Please do not include any items that have been fully depreciated in prior years. If you
                   have deviations, please explain.

    4        Schedule of Fixed Asset Depreciation
                   This is an optional format for all providers to place their Fixed Asset Depreciation figures. If you have this same information but in a different
                   arrangement and in Excel format, you can copy your schedule right into the workbook on this page (over the format provided); otherwise this
                   information should be provided in a paper copy. The depreciation method used must be straight-line, and please ensure your depreciation useful
                   lives are consistent with the AHA guidelines provided by DMA. Please do not include any items that have been fully depreciated in prior years. If you
                   have deviations, please explain.

    5        Explanation of "Non Medicaid Services" Costs
                   The dollar and unit figures provided on this explanation form should match the figures on the Summary Schedule 2 for the respective service
                   objective. Please make sure that you indicate the units associated with the costs placed on this form, especially for Medicaid units. This form should
                   include costs for services that are not specific cost found services such as State and IPRS funded services and Financial Assistance contracts.
                   Please provide a clear/detailed description of your service(s). Include on this form, any units that do not have a date of service during the current
                   reporting period, even if paid during the current reporting period.

    6        Explanation of "General Non-UCR Expenditures"
                   The dollar and unit figures provided on this explanation form should match the figures on the Summary Schedule 2 for the respective service
                   objective. This form was added to assist with the Cost Settlement process and for matching expenditures with funds received. This worksheet
                   should display all Non-UCR Expenditures which do include CTSP (Willie M.) or MR/MI (Thomas S.) Non-UCR expenditures. For LMEs the dollars
                   on this form and the respective service objective on Schedule 2 must match or exceed FSR expenditures. Please provide a clear/detailed
                   description of your service(s).
    7        Reconciliation of Audit Costs to Cost Report Total Costs (Mandatory)
                   All providers must use this form to reconcile the amounts on the Cost Report compared to the Audit figures and this form must be submitted with
                   your final Cost Report packet. You should refer to your published audit total costs as well as the total costs in the "Totals per Audit" column on the
                   Schedule 2 to make sure that all figures are in agreement.

    8        Schedule of Revenue by Source (optional format/page for you to copy in your schedule)
                   All providers may complete the format provided or provide this schedule as a paper copy or if you have it in a format which is compatible with Excel,
                   you may copy it in to this new worksheet in the MoreForms file and send it in electronically with your Cost Report. We would prefer attempts be
                   made to send this electronically. This is a sample format that can be modified or another format may be used but we must be able to determine how
                   much State, Federal, and Local funding (by category) you receive for the CAP Administration Settlement process.




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  8/1/2011                                                               Page 1 of 16                                                    Index to Moreformsfile
                                                     COST REPORT - FY 2006-07                                                                    Appendix L

                                                      INDEX TO MOREFORMS:

FORM #                                                  NAME OF FORM WITH DESCRIPTION & NOTES
   9        Contract Provider Information
                   Please provide a list of all contract agencies where your organization billed Medicaid on behalf of the agencies. List their Federal Tax ID number,
                   agency name, complete address, the total Medicaid money billed by you and passed on to the contract agency, a contact name, phone number, and
            LMEs   if available - email address. If you chose not to use this form to submit the required information, you must use the same format and electronically
            Only   submit the file in Excel. If an LME wishes to obtain a waiver for filing a Cost Report, this form must be sent in with the waiver request.


  10        Notes Worksheet
                   This worksheet should explain any Other Adjustments, Out-of-Compliance Non-Personnel adjustment items, departures from AHA for depreciation,
                   and any units indicated on the Schedule 2 line item "Other Units Provided; Not in Costs (these units are not required to be explained by Cost Center
                   but must be explained by service). Also any other questionable items which the providers believes warrants an explanation should be on this page.




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 8/1/2011                                                                Page 2 of 16                                                   Index to Moreformsfile
                                                                      Cost Report FY 2006-07                                                            Appendix L
                                                                                                                                                          FORM #1
                                                          Transmittal Checklist Cover Sheet
LME or Provider: _______________________________
                        3.5" Diskette, CD or email of Cost Finding data
                        3.5" Diskette or CD of the Actual Units data (see Appendix AJ for required fields)
                        Transmittal Checklist Cover Sheet (with certification by LME Director & Finance Officer)
                        CPT Detail Worksheet service code
                        Schedule of Moveable Asset Depreciation
                        Schedule of Fixed Asset Depreciation
                        Explanation of "Non Medicaid Services" Costs
                        Explanation of "General Non-UCR Expenditures"
                        Reconciliation of Audit Costs to Cost Finding Total Costs
                        Schedule of Revenue by Source
                        Notes

                        Copy of Audit, if you have one, or draft of audit and copies of your ending Income Statement and/or Balance
                        Sheet, if no audit
                        Copy of Relevant pages of County/Corporate Cost Allocation Plan (All Counties)
                        Copy of Depreciation Policy is included and all unusual changes or corrections have been explained
                        Crosswalk tying Schedule 2 cost centers, Expense Center List (1XX - 8XX) ,
                        and Schedule of Revenues by Source to Audit or CAFR has been included
                        Support for Medicaid refunds not reflected in Cost Finding units
                        Reviewed Cost Finding using the Cost Finding Review Worksheet

 Intentional misrepresentation or falsification of any information contained in this cost report may be punishable by criminal, civil and administrative action,
                                             fine and/or imprisonment under federal and state laws and regulations.

I certify that I have read the above statement and that I have examined the accompanying cost report prepared by myself and/or my staff. To the best of
my knowledge and belief, it is a true, correct and complete cost report, containing no material misstatement and no material omissions, prepared from the
books and records of the provider in accordance with applicable instructions except as noted. I further certify that I am familiar with the laws and
regulations regarding the provision of mental health services, and that the services identified in this cost report were provided in compliance with such laws
and regulations.

I hereby certify that the Access file created using the cost reporting software provided by the Office of the Controller has not been modified in any manner
except through the use of the cost reporting software.

Signed: ___________________________________, Director/CEO                               Date: ____________________

Signed: ___________________________________, Finance Officer/CFO                        Date: ____________________

Contact Person:                                                                       CPA Contact: _________________________
LME/Provider Name:                                                                    Telephone Number: ____________________
             Address:                                                                 E-Mail Address: _______________________




Telephone Number:
E-Mail Address:


Note: Each cost report must have an original signed signature page when the cost report is initially turned in. Another original signed
signature page must be turned in when all reviews by the Controller's Office have been completed and all corrections to the database and
spreadsheets made. When the Controller's Office is satisfied that all corrections have been made, your program will be notified to send
an updated signature page. Please check and date below which version of the signature page this is. Thank you.

             As Filed          Date:                                                            Final Desk Audited               Date:




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          8/1/2011                                                               Page 3 of 16                                                   1-Transmittal Checklist
                                                                                                      Cost Report - FY 2006-07                                                                                                    Appendix L
                                                                                                                                                                                                                                    Form #2
LME or Provider: _______________________________                                                       CPT Detail Worksheet




                                                                             Units from Validation Data                         VARIANCE                         Actual Units from Cost Report

                                                                                                                                                  Total Actual Units   Actual Units    Non Medicaid    Gen. Non-
                                                                                                                                                 (Summary of Sch 2,                   Services (NMS)     UCR
                                                                     Internally       Externally                               Cost Report vs.   NMS and Non-UCR                       Actual Units     Actual
  Code                            Service                          Provided Units   Provided Units
                                                                                                     Total Actual Units
                                                                                                                               Validated Units          units)                                           Units


          Therapeutic, prophylactic or diagnostic injection (SA,
    90772 subcue), valid 1/1/06                                                                                        0               -                          0
          Therapeutic, prophylactic or diagnostic injection (SA,
    90773 intra-arterial), valid 1/1/06                                                                                0               -                          0
          Therapeutic, prophylactic or diagnostic injection (SA,
    90774 each additional intravenous), valid 1/1/06                                                                   0               -                          0
          Therapeutic, prophylactic or diagnostic injection (SA,
    90775 intravenous), valid 1/1/06                                                                                   0               -                          0

    90782 Medication Administration                                                                                    0               -                          0
    90801 Clinical Intake                                                                                              0               -                          0
    90802 Interactive Evaluation                                                                                       0               -                          0
    90804 Individual Therapy (20-30 min)                                                                               0               -                          0
    90805 Individual Therapy (20-30 min) MD                                                                            0               -                          0
    90806 Individual Therapy (45-50 min)                                                                               0               -                          0

    90807 Individual Therapy (45-50 min) MD                                                                            0               -                          0

    90808 Individual Therapy (75+ min)                                                                                 0               -                          0
    90809 Individual Therapy (75+ min) MD                                                                              0               -                          0
    90810 Interactive Therapy (30 min)                                                                                 0               -                          0

    90811 Interactive Therapy (30 min) MD                                                                              0               -                          0
    90812 Interactive Therapy (50 min)                                                                                 0               -                          0

    90813   Interactive Therapy (50 min) MD                                                                            0               -                          0
    90814   Interactive Therapy (80 min)                                                                               0               -                          0
    90815   Interactive Therapy (80 min w/eval & mgmt svcs)                                                            0               -                          0
    90816   Individual Therapy (30 min)                                                                                0               -                          0
    90817   Individual Therapy (30 min) MD                                                                             0               -                          0
    90818   Individual Therapy (50 min)                                                                                0               -                          0

    90819   Individual Therapy (50 min) MD                                                                             0               -                          0
    90821   Individual Therapy (80 min)                                                                                0               -                          0
    90822   Individual Therapy (80 min w/eval & mgmt svcs)                                                             0               -                          0
    90823   Interactive Therapy (30 min)                                                                               0               -                          0
    90824   Interactive Therapy (30 min w/eval & mgmt svcs)                                                            0               -                          0

    90826 Interactive Therapy (50 min)                                                                                 0               -                          0

    90827 Interactive Therapy (50 min w/eval & mgmt svcs)                                                              0               -                          0

    90828 Interactive Therapy (80 min)                                                                                 0               -                          0

    90827 Interactive Therapy (80 min w/eval & mgmt svcs)                                                              0               -                          0

    90846 Family Therapy wo/patient                                                                                    0               -                          0


                                                                                                 Please delete services not used by Center
                                                                                                                                                                                                        1fda95a2-9375-40e3-be7b-c9ee0c84c246.xls
              8/1/2011                                                                                          Page 4 of 16                                                                                                       2 - CPT Detail
                                                                                              Cost Report - FY 2006-07                                                                                                    Appendix L
                                                                                                                                                                                                                            Form #2
LME or Provider: _______________________________                                               CPT Detail Worksheet




                                                                     Units from Validation Data                         VARIANCE                         Actual Units from Cost Report

                                                                                                                                          Total Actual Units   Actual Units    Non Medicaid    Gen. Non-
                                                                                                                                         (Summary of Sch 2,                   Services (NMS)     UCR
                                                             Internally       Externally                               Cost Report vs.   NMS and Non-UCR                       Actual Units     Actual
  Code                             Service                 Provided Units   Provided Units
                                                                                             Total Actual Units
                                                                                                                       Validated Units          units)                                           Units



    90847 Family Therapy w/patient                                                                             0               -                          0

    90849 Group Therapy                                                                                        0               -                          0

    90853 Group Therapy                                                                                        0               -                          0

    90857 Interactive Group Psychotherapy                                                                      0               -                          0

    90862 Medication Check - Individual                                                                        0               -                          0

    92506 Speech Evaluation                                                                                    0               -                          0

    92507 Speech Therapy                                                                                       0               -                          0

    92508 Speech Therapy Group                                                                                 0               -                          0

    92630 Auditory Rehab: pre-lingual hearing loss                                                             0               -                          0

    92633 Auditory Rehab: post-lingual hearing loss                                                            0               -                          0

    96100 Psychological Testing                                                                                0               -                          0

    96101 Psychological Testing                                                                                0               -                          0

    96105 Aphasia assessment w/interp & report, per hour                                                       0               -                          0

    96110 Developmental Testing                                                                                0               -                          0

    96111 Developmental Testing                                                                                0               -                          0

    96115 Neurobehavioral Exam                                                                                 0               -                          0

    96117 Neurobehavioral Testing                                                                              0               -                          0

    97001 Physical Therapy Evaluation                                                                          0               -                          0

    97002 Physical Therapy Re-Evaluation                                                                       0               -                          0

    97003 Occupational Therapy Eval                                                                            0               -                          0

    97004 Occupational Therapy Re-Eval                                                                         0               -                          0

    97110 Physical Therapy                                                                                     0               -                          0

    97112 Physical Therapy                                                                                     0               -                          0

    97113 Physical Therapy aquatic w/exercise                                                                  0               -                          0

    97116 Gait Training                                                                                        0               -                          0

    97124 Massage Therapy                                                                                      0               -                          0

    97140 Manual Therapy                                                                                       0               -                          0

    97520 Prosthetic Training (15 min)                                                                         0               -                          0

    97530 Therapeutic activities                                                                               0               -                          0

    97703 Orthotic/prosthetic use checkout                                                                     0               -                          0

                                                                                         Please delete services not used by Center
                                                                                                                                                                                                1fda95a2-9375-40e3-be7b-c9ee0c84c246.xls
            8/1/2011                                                                                    Page 5 of 16                                                                                                       2 - CPT Detail
                                                                                                      Cost Report - FY 2006-07                                                                                                    Appendix L
                                                                                                                                                                                                                                    Form #2
LME or Provider: _______________________________                                                       CPT Detail Worksheet




                                                                             Units from Validation Data                         VARIANCE                         Actual Units from Cost Report

                                                                                                                                                  Total Actual Units   Actual Units    Non Medicaid    Gen. Non-
                                                                                                                                                 (Summary of Sch 2,                   Services (NMS)     UCR
                                                                     Internally       Externally                               Cost Report vs.   NMS and Non-UCR                       Actual Units     Actual
  Code                            Service                          Provided Units   Provided Units
                                                                                                     Total Actual Units
                                                                                                                               Validated Units          units)                                           Units



    97750 Physical Performance test w/report (15 min)                                                                  0               -                          0
          Prosthetic training upper and/or lower extremity(s) 15
    97761 min, valid 1/1/06                                                                                            0               -                          0
          Checkout for orthotic/prosthetic use 15 min, valid
    97762 1/1/06                                                                                                       0               -                          0

    99201 E&M Problem Focused New Patient                                                                              0               -                          0

    99202 E&M Expanded, New Patient                                                                                    0               -                          0

    99203 E&M Detailed, New Patient                                                                                    0               -                          0

    99204 E&M Moderate, New Patient                                                                                    0               -                          0

    99205 E&M High, New Patient                                                                                        0               -                          0

    99211 E&M Problem Focused Estab Patient                                                                            0               -                          0

    99212 E&M Expanded, Estab Patient                                                                                  0               -                          0

    99213 E&M Detailed, Estab Patient                                                                                  0               -                          0

    99214 E&M Moderate, Estab Patient                                                                                  0               -                          0

    99215 E&M High, Estab Patient                                                                                      0               -                          0

    99221 Initial Hospital Care Low severity                                                                           0               -                          0

    99222 Initial Hospital Care Moderate severity                                                                      0               -                          0

    99223 Initial Hospital Care High severity                                                                          0               -                          0

    99231 Subsequent Hospital Care per day (15 min)                                                                    0               -                          0

    99232 Subsequent Hospital Care per day (25 min)                                                                    0               -                          0

    99233 Subsequent Hospital Care per day (35 min)                                                                    0               -                          0


    99234 Observation or inpatient Hospital care, low complexity                                                       0               -                          0
          Observation or inpatient Hospital care, Moderate
    99235 complexity                                                                                                   0               -                          0
          Observation or inpatient Hospital care, High
    99236 complexity                                                                                                   0               -                          0

    99238 Hospital discharge day (30 min or less)                                                                      0               -                          0

    99239 Hospital discharge day (more than 30 min)                                                                    0               -                          0

    99241 Office sonsultation (15 min)                                                                                 0               -                          0

    99242 Office sonsultation (30 min)                                                                                 0               -                          0

    99243 Office sonsultation (40 min)                                                                                 0               -                          0

    99244 Office sonsultation (60 min)                                                                                 0               -                          0

                                                                                                 Please delete services not used by Center
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            8/1/2011                                                                                            Page 6 of 16                                                                                                       2 - CPT Detail
                                                                                         Cost Report - FY 2006-07                                                                                                    Appendix L
                                                                                                                                                                                                                       Form #2
LME or Provider: _______________________________                                          CPT Detail Worksheet




                                                                Units from Validation Data                         VARIANCE                         Actual Units from Cost Report

                                                                                                                                     Total Actual Units   Actual Units    Non Medicaid    Gen. Non-
                                                                                                                                    (Summary of Sch 2,                   Services (NMS)     UCR
                                                        Internally       Externally                               Cost Report vs.   NMS and Non-UCR                       Actual Units     Actual
  Code                            Service             Provided Units   Provided Units
                                                                                        Total Actual Units
                                                                                                                  Validated Units          units)                                           Units



    99245 Office sonsultation (80 min)                                                                    0               -                          0

    99251 Initial inpatient consultation (20 min)                                                         0               -                          0

    99252 Initial inpatient consultation (40 min)                                                         0               -                          0

    99253 Initial inpatient consultation (55 min)                                                         0               -                          0

    99254 Initial inpatient consultation (80 min)                                                         0               -                          0

    99255 Initial inpatient consultation (110 min)                                                        0               -                          0

    99261 Follow-up Inpatient consultation (10 min)                                                       0               -                          0

    99262 Follow-up Inpatient consultation (20 min)                                                       0               -                          0

    99263 Follow-up Inpatient consultation (30 min)                                                       0               -                          0




                                                                                    Please delete services not used by Center
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             8/1/2011                                                                              Page 7 of 16                                                                                                       2 - CPT Detail
                                                                                                                                                                                            Appendix L
                                                                  Cost Report - FY 2006-07                                                                                                    FORM #3
                                                        SCHEDULE OF MOVEABLE ASSET DEPRECIATION

LME or Provider: _______________________________

                                                                                                                         Prior Year         DISTRIBUTED      Year End
                                                                                                                                                                            (LME's Only)
                                                                                                                               TOTAL                                     System
                                                                                                   Date of      Accumulated (Current year                   Accumulated
             Description                              Cost Center                    Cost                  Life                                                          Management Disposal Disposal
                                                                                                  Purchase        Deprec'n  depreciation)                     Deprec'n
                                                                                                                                                                         Deprec'n   Date     Amount
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -

                                                                                                                                        -               -               -               -                   -
Note: You must use the Straight-Line depreciation method, and if you did NOT follow AHA Guidelines, please explain why on the Notes Worksheet - Form #10
Please indicate the convention used for Straight-Line depreciation (i.e. Mid-Month, Full-Month, etc.) and add your Capitalization Policy to Form #10.
If any assets were disposed of during the year, Please note how and when it was disposed of.
                                                                                                                                                                 1fda95a2-9375-40e3-be7b-c9ee0c84c246.xls
          8/1/2011                                                                                        Page 8 of 16                                                              3-Moveable Asset Depr
                                                                                                                                                                                             Appendix L
                                                                      Cost Report - FY 2006-07                                                                                                 FORM #4
                                                               SCHEDULE OF FIXED ASSET DEPRECIATION

LME or Provider: _______________________________

                                                                                                                         Prior Year         DISTRIBUTED      Year End
                                                                                                                                                                            (LME's Only)
                                                                                                                               TOTAL                                     System
                                                                                                   Date of      Accumulated (Current year                   Accumulated
             Description                              Cost Center                    Cost                  Life                                                          Management Disposal Disposal
                                                                                                  Purchase        Deprec'n  depreciation)                     Deprec'n
                                                                                                                                                                         Deprec'n   Date     Amount
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -
                                                                                                                                                                       -

                                                                                                                                        -               -               -                -                   -
Note: You must use the Straight-Line depreciation method, and if you did NOT follow AHA Guidelines, please explain why on the Notes Worksheet - Form #10
Please indicate the convention used for Straight-Line depreciation (i.e. Mid-Month, Full-Month, etc.) and add your Capitalization Policy to Form #10.
If any assets were disposed of during the year, Please note how and when it was disposed of.
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          8/1/2011                                                                                        Page 9 of 16                                                                  4-Fixed Asset Depr
                                                   Cost Report - FY 2006- 07                                                                              Appendix L
                                                                                                                                                            FORM #5
                                          EXPLANATION of "Non Medicaid Services" Costs


   LME or Provider: _______________________________
   List any amounts shown on Schedule 2 in the service objective columns for "Non Medicaid Services" and describe the nature of the expenditures included in
   these amounts. Non Medicaid Services costs should be service costs not associated with any of the specific services available to cost find (such as Financial
   Assistance Contracts).




                                              (A)              (B)                 (C)
                                        Not Cost Found      Total NCF     Service Objective - Bill
              Cost Center               Dollar Amount         Units               Code                                     Explanation




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8/1/2011                                                                     Page 10 of 16                                                                5-Non Medicaid
                                                           Cost Report - FY 2006-07                                                                              Appendix L
                                                                                                                                                                   FORM #6
                                                 EXPLANATION of "General Non-UCR Expenditures"



LME or Provider: _______________________________
List any amounts shown on Schedule 2 as "General Non-UCR Expenditures" and describe the nature of the expenditures included in these amounts
and which grant they relate to.

                                                                  Expenditure
                                                                     Dollar
                                                                   Amount in
                                                                   Non-UCR    LME or Provider    If applicable,   If applicable, the
                                                                  Expenditure Cost Center this number of units       service name
                                                                    service    expenditure     associated with    with which units
     Division Fund Title    State Account #   Fund       FRC       objective    came from            costs          are associated     Explanation of Non-UCR expenditure




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     8/1/2011                                                                    Page 11 of 16                                                    6 - Gen. Non-UCR Expenditures
                                                 Cost Report - FY 2006-07                                                                      Appendix L
                              RECONCILIATION OF AUDIT COSTS TO COST REPORT TOTAL COSTS                                                           FORM #7



           LME or Provider: _______________________________


                                                                                    Increases       Decreases


               Total Expenditures per Audit                                                                     $                         -

               Adjustments:
                      Plus Fixed Asset Depreciation                           $             -
                      Plus Moveable Asset Depreciation                        $             -
                      Less Non-Personnel Adjustments (examples follow)
                              (LESS) FIXED ASSETS TO BE DEPRECIATED                             $           -
                              (LESS) M/ABLE ASSETS TO BE DEPRECIATED                            $           -
                              (LESS) OUT-of-COMPLIANCE AMOUNTS                                  $           -
                              (LESS) MORTGAGE PAYMENTS                                          $           -
                              (LESS) OTHER ADJUSTMENTS (EXPLAIN)                                $           -
                              (LESS) CONTRACT PRODUCTION EXPENSES                               $           -
                              (PLUS) COUNTY ALLOCATION                        $             -
                              OTHER                                           $             -   $           -



               Total Increases / Decreases                                    $             -   $           -   $                     -

               Total Expenditures per Audit Less Adjustments                                                    $                     -

               Total Expenditures per Cost Finding
               (Schedule 2, Total Cost for Rates line, Distributed Total column)                                $                     -

               Difference From Audit to Cost Finding (Should be $0)                                             $                     -




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8/1/2011                                                            Page 12 of 16                                                         7-Recon Audit to CF
                                                                                                       Appendix L
                           Cost Report - FY 2006-07                                                      FORM #8
                      SCHEDULE OF REVENUE BY SOURCE

LME or Provider: _______________________________

Description                                                                               Budget       Actual

Third Party Revenue
                 Medicare
                 Medicaid
                 Medicaid (Assaultive Children- CTSP (old Willie M))
                 Medicaid (MR/MI - Thomas S)
                 CAP/MRDD (Medicaid)
                 CAP/MRDD (Medicaid) (MR/MI - Thomas S)
                 Insurance
                 ICF-MR/DD
                 Other 100% Medicaid receipts
                 Contract receipts from other LMEs
                             Total Third Party Revenue                                $       -    $        -

Client Fees and Other Client Revenue

Local Revenue
                  County Appropriations
                  Interest Income
                  Local Public Agency Receipts
                  Drug Sales
                  Cafeteria and Thrift Sales
                  Refunds from State tax payments
                  Thomas S. Payments for Client Services
                  Grants from state and federal gov't agencies that are
                   not allocated through the Division of MH/DD/SA
                  SSI
                  Other Local/Miscellaneous Revenue



                                 Total Local Revenue                                  $       -    $        -

State Revenue
                  Mental Health - Adult (UCR)
                  Mental Health - Child (UCR)
                  Substance Abuse - Adult (UCR)
                  Substance Abuse - Child (UCR)
                  Developmental Disability - Adult (UCR)
                  Developmental Disability - Child (UCR)
                  General Non-UCR
                  Supported Employment
                  Domiciliary Care
                  Forensic Screening
                  Other State revenue
                  LME System Management
                                  Total State Revenue                                 $       -    $        -
                                                                          1fda95a2-9375-40e3-be7b-c9ee0c84c246.xls
8/1/2011                                        Page 13 of 16                                 8 - Revenue by Source
                                                                                                   Appendix L
                           Cost Report - FY 2006-07                                                  FORM #8
                      SCHEDULE OF REVENUE BY SOURCE


Assaultive Children (Willie M) Revenue
                  Assaultive Children's Fund (Willie M) (UCR)
                  Assaultive Children's Fund (Willie M) (Non-UCR)
                  Total Assaultive Children (Willie M) Revenue                    $       -    $        -

MR/MI (Thomas S) Revenue
                MR/MI (Thomas S) (UCR)
                MR/MI (Thomas S) (Non-UCR)
                        Total MR/MI (Thomas S) Revenue                            $       -    $        -

Federal Revenue
                   Mental Health - Adult (UCR)
                   Mental Health - Child (UCR)
                   Substance Abuse - Adult (UCR)
                   Substance Abuse - Child (UCR)
                   Developmental Disability - Adult (UCR)
                   Developmental Disability - Child (UCR)
                   General Non-UCR
                   Other Federal Revenue
                                 Total Federal Revenue                            $       -    $        -

Total Revenues                                                                    $       -    $        -


Note: Although this form is optional, we must be able to identify how much State, Federal, and Local funding
(by category) you receive for the CAP Administration Settlement




                                                                      1fda95a2-9375-40e3-be7b-c9ee0c84c246.xls
8/1/2011                                        Page 14 of 16                             8 - Revenue by Source
                                                Cost Reporting - FY 2006-07                                                         Appendix L
                                                                                                                                      Form #9
                                               Contract Provider Information

LME Only

                                                                                                 Total Medicaid
                                                                                                    $ Passed
  Federal                                                                                          through to
  Tax ID    Contract Provider Name   Address                     City              State   Zip      Provider                Email




                                                                                                      1fda95a2-9375-40e3-be7b-c9ee0c84c246.xls
8/1/2011                                          Add Additional Lines as needed                                          9 - Contract Providers
                                                               Cost Report - FY 2006-07                                                               Appendix L
                                                                                                                                                       FORM #10
                                                                       NOTES
           LME or Provider: _______________________________




                      If applicable,
                     Cost Center or
                    Service Objective           Item to be explained    Dollar Amount                     Explanation of Expenditure(s)




           Note: Explanations for "Other Units Provided; Not in Costs" do not have to be by cost center, only by service.




                                                                                                                            1fda95a2-9375-40e3-be7b-c9ee0c84c246.xls
8/1/2011                                                                    Page 16 of 16                                                                 10 - Notes

								
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