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Statement of Financial Support Medicaid

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					DEPARTMENT OF HEALTH SERVICES                                                                              STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-11129B (04/09)


                                                    WISCONSIN MEDICAID
                                    FEDERALLY QUALIFIED HEALTH CENTER
                                         CERTIFICATION STATEMENT

Instructions: Type or print clearly. Refer to the Federally Qualified Health Center Cost Report Completion Instructions, F-
11129A, for detailed information on completing this form.
SECTION I — PROVIDER AND PREPARER INFORMATION
Name — Federally Qualified Health Center (FQHC)                                Provider Number



Name and Title — Person Preparing Cost Report                     Telephone Number                       Fax Number



Reporting Period



From                                        To
SECTION II — CERTIFICATION AND SIGNATURE

Intentional misrepresentation or falsification or any information contained in these worksheets may be punishable by fine and/or
imprisonment under federal law.


I hereby certify that I have read the above statement and that I have examined the accompanying worksheets for the indicated
reporting period, and that to the best of my knowledge and belief it is a true, correct, and complete statement prepared from the
books and records of the FQHC in accordance with applicable instructions.
Name — FQHC Officer or Administrator                                           Title — FQHC Officer or Administrator



SIGNATURE — FQHC Officer or Administrator                                      Date Signed
DEPARTMENT OF HEALTH SERVICES                                                                                 STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-11129C (04/09)


                                                        WISCONSIN MEDICAID
                                     FEDERALLY QUALIFIED HEALTH CENTER
                                        STATISTICAL DATA WORKSHEET

Instructions: Type or print clearly. Refer to the Federally Qualified Health Center Cost Report Completion Instructions, F-
11129A, for detailed information on completing this form.

SECTION I — PROVIDER INFORMATION
1. Name — Federally Qualified Health Center (FQHC)

                                                                         0

2. Provider Number

                                                                         0

3. Address — FQHC




4. Type of Organizational Structure
       Government (specify)                         Federal                  State               Tribal
       Voluntary Nonprofit Corporation              County                   City                Other

5. Name — FQHC Owner



6. Reporting Period

From                      1/0/1900           To               1/0/1900
SECTION II — OTHER ENTITIES OF THE FQHC OWNER
7. List all other FQHCs and providers of services, including rural health clinics, hospitals, skilled nursing facilities, home health
agencies, suppliers, or other entities that are owned or related through common ownership or control to the individual or entity
listed in Element 5.


           Name — Provider                                     Location                           Provider Number




SECTION III — PHYSICIANS DIRECTLY EMPLOYED BY THE FQHC
8. List the Medicaid-certified physicians furnishing services at the FQHC who are directly employed by the FQHC.
                         Name — Physician                                                   Provider Number




                                                                                                                            Continued
FEDERALLY QUALIFIED HEALTH CENTER STATISTICAL DATA WORKSHEET                                                        Page 2 of 2
F-11129C (XX/09)

SECTION IV — OTHER PROVIDERS DIRECTLY EMPLOYED BY THE FQHC
9. List any other Medicaid-certified providers furnishing services at the FQHC who are not physicians but are directly employed
by the FQHC.
          Name — Provider                      Medicaid Provider Type                         Provider Number




SECTION V — PHYSICIANS AND OTHER PROVIDERS UNDER CONTRACT WITH THE FQHC
10. List the Medicaid-certified physicians and other providers furnishing services at the FQHC who are under contract with the
FQHC.
          Name — Provider                      Medicaid Provider Type                         Provider Number




SECTION VI — OTHER FQHC MEDICAID PROVIDER NUMBERS
11. List any National Provider Identifiers or Medicaid provider numbers included in the FQHC’s expenses, excluding the
provider number listed in Element 2.
                    Medicaid Provider Type                                              Provider Number
DEPARTMENT OF HEALTH SERVICES                                                                                                                                         STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-11129D (04/09)

                                                                               WISCONSIN MEDICAID
                                                        FEDERALLY QUALIFIED HEALTH CENTER
                                          RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
                                                                  WORKSHEET 1

Instructions: Type or print clearly. Refer to the Federally Qualified Health Center (FQHC) Cost Report Completion Instructions, F-11129A, for detailed information on completing this
form.
SECTION I — GENERAL INFORMATION
Provider Number                                        Reporting Period                                 Trial Balance Expenses Are (Check One)
                            0                           From          01/00/00 To           1/0/00                Estimated                        Actual / Audited
SECTION II — FACILITY HEALTH CARE COSTS

                                                                                                                                          G. Reclassified
                                                                                                                                                                 H.       I. Net Expenses
                                                                      C. Purchased                       E. Total (Total                   Trial Balance
                                                          B. Fringe                                                        F. Reclassifi-                   Adjustments       (Total of
Cost Center                           A. Compensation                 and Contract         D. Other      of Columns A                         (Total of
                                                          Benefits                                                            cations                         Increase    Columns G and
                                                                        Services                          Through D)                      Columns E and
                                                                                                                                                             [Decrease]           H)
                                                                                                                                                 F)

PRIMARY PROVIDER
1. Physician                                                                                                        0.00                            0.00                                0.00
2. Physician Assistant                                                                                              0.00                            0.00                                0.00
3. Nurse Practitioner                                                                                               0.00                            0.00                                0.00
4. Clinical Psychologist                                                                                            0.00                            0.00                                0.00
5. Clinical Social Worker                                                                                           0.00                            0.00                                0.00
6. Dentist                                                                                                          0.00                            0.00                                0.00
7. Nursing Care to Homebound                                                                                        0.00                            0.00                                0.00
8. Speech and Hearing                                                                                               0.00                            0.00                                0.00
9. Occupational Therapist                                                                                           0.00                            0.00                                0.00
10. Physical Therapist                                                                                              0.00                            0.00                                0.00
11. Vocational Therapist                                                                                            0.00                            0.00                                0.00
12. Optometrist                                                                                                     0.00                            0.00                                0.00
13. Podiatrist                                                                                                      0.00                            0.00                                0.00
14. Psychotherapist                                                                                                 0.00                            0.00                                0.00
15. Chiropractor                                                                                                    0.00                            0.00                                0.00
16. Substance Abuse Services                                                                                        0.00                            0.00                                0.00
                                                                                                                                                                                Continued
        b896e355-0f27-4ec6-95a8-f26d3d3b1a1e.xls, Worksheet 1                                                                                                  8/18/2011, 5:37 PM
FEDERALLY QUALIFIED HEALTH CENTER RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES                                                                    Page 2 of 4
F-11129D (04/09)


                                                                                                                             G. Reclassified
                                                                                                                                                    H.       I. Net Expenses
                                                               C. Purchased                 E. Total (Total                   Trial Balance
                                                 B. Fringe                                                    F. Reclassifi-                   Adjustments       (Total of
Cost Center                    A. Compensation                 and Contract    D. Other     of Columns A                         (Total of
                                                 Benefits                                                        cations                         Increase    Columns G and
                                                                 Services                    Through D)                      Columns E and
                                                                                                                                                [Decrease]           H)
                                                                                                                                    F)

17. Other (Specify) _______                                                                            0.00                            0.00                             0.00
18. TOTAL — Primary
Providers (Sum of Lines 1
through 17)                              0.00          0.00            0.00          0.00            0.00            0.00             0.00           0.00              0.00
INDIRECT COSTS
19. Laboratory-Medical                                                                               0.00                             0.00                             0.00
20. X-Ray-Medical                                                                                    0.00                             0.00                             0.00
21. Pharmacy                                                                                         0.00                             0.00                             0.00
22. Nurses                                                                                           0.00                             0.00                             0.00
23. Patient Transportation                                                                           0.00                             0.00                             0.00
24. Translator                                                                                       0.00                             0.00                             0.00
25. Health Education                                                                                 0.00                             0.00                             0.00
26. Medical Records                                                                                  0.00                             0.00                             0.00
27. Medical Social Worker                                                                            0.00                             0.00                             0.00
28. Other (Specify) ________                                                                         0.00                             0.00                             0.00
29. Other (Specify) ________                                                                         0.00                             0.00                             0.00
30. TOTAL — Indirect Costs
(Sum of Lines 19 through 29)             0.00          0.00            0.00          0.00            0.00            0.00             0.00           0.00              0.00
31. TOTAL — Health Care
(Sum of Lines 18 and 30                  0.00          0.00            0.00          0.00            0.00            0.00             0.00           0.00              0.00
NON-REIMBURSABLE COSTS
32. Education                                                                                        0.00                             0.00                             0.00
33. Outreach                                                                                         0.00                             0.00                             0.00
34. Community Services                                                                               0.00                             0.00                             0.00
35. Environment                                                                                      0.00                             0.00                             0.00
36. Research                                                                                         0.00                             0.00                             0.00
37. Nonmedical Social Worker                                                                         0.00                             0.00                             0.00
38. Other (Specify) ______                                                                           0.00                             0.00                             0.00
39. TOTAL — Nonreimbursable
Costs (Sum of Lines 32 through
38)                                      0.00          0.00             0.00         0.00             0.00            0.00             0.00           0.00             0.00
       b896e355-0f27-4ec6-95a8-f26d3d3b1a1e.xls, Worksheet 1                                                                                      8/18/2011, 5:37 PM
                                                                                                                                                                   Continued
FEDERALLY QUALIFIED HEALTH CENTER RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES                                                                     Page 3 of 4
F-11129D (04/09)

                                                                                                                              G. Reclassified
                                                                                                                                                     H.       I. Net Expenses
                                                                 C. Purchased                E. Total (Total                   Trial Balance
                                                   B. Fringe                                                   F. Reclassifi-                   Adjustments       (Total of
Cost Center                     A. Compensation                  and Contract   D. Other     of Columns A                         (Total of
                                                   Benefits                                                       cations                         Increase    Columns G and
                                                                   Services                   Through D)                      Columns E and
                                                                                                                                                 [Decrease]           H)
                                                                                                                                     F)

LOCALLY MATCHED WISCONSIN MEDICAID SERVICES CATEGORY


40. Community Support Program              0.00          0.00            0.00         0.00            0.00                             0.00                             0.00

41. Targeted Case Management                                                                          0.00                             0.00                             0.00

42. TOTAL — Locally Matched
Wisconsin Medicaid Services
(Sum of Lines 40 and 41)                   0.00          0.00            0.00         0.00            0.00            0.00             0.00           0.00              0.00
OVERHEAD COSTS
43. Administration                                                                                    0.00                             0.00                             0.00
44. Receptionist                                                                                      0.00                             0.00                             0.00
45. Billing                                                                                           0.00                             0.00                             0.00
46. Financial                                                                                         0.00                             0.00                             0.00
47. Marketing                                                                                         0.00                             0.00                             0.00
48. Legal                                                                                             0.00                             0.00                             0.00
49. Data Processing                                                                                   0.00                             0.00                             0.00
50. Housekeeping                                                                                      0.00                             0.00                             0.00
51. Maintenance                                                                                       0.00                             0.00                             0.00
52. Security                                                                                          0.00                             0.00                             0.00
53. Supplies                                                                                          0.00                             0.00                             0.00
54. Insurance                                                                                         0.00                             0.00                             0.00
55. Telephone                                                                                         0.00                             0.00                             0.00
56. Utilities                                                                                         0.00                             0.00                             0.00
57. Rent                                                                                              0.00                             0.00                             0.00
58. Maintenance and Repair                                                                            0.00                             0.00                             0.00
59. Depreciation                                                                                      0.00                             0.00                             0.00
60. Amortization                                                                                      0.00                             0.00                             0.00
61. Contributors                                                                                      0.00                             0.00                             0.00
                                                                                                                                                                    Continued


         b896e355-0f27-4ec6-95a8-f26d3d3b1a1e.xls, Worksheet 1                                                                                     8/18/2011, 5:37 PM
FEDERALLY QUALIFIED HEALTH CENTER RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES                                                                   Page 4 of 4
F-11129D (04/09)


                                                                                                                            G. Reclassified
                                                                                                                                                   H.       I. Net Expenses
                                                               C. Purchased                E. Total (Total                   Trial Balance
                                                 B. Fringe                                                   F. Reclassifi-                   Adjustments       (Total of
Cost Center                    A. Compensation                 and Contract   D. Other     of Columns A                         (Total of
                                                 Benefits                                                       cations                         Increase    Columns G and
                                                                 Services                   Through D)                      Columns E and
                                                                                                                                               [Decrease]           H)
                                                                                                                                   F)

62. Transportation                                                                                  0.00                             0.00                             0.00
63. Mortgage Interest                                                                               0.00                             0.00                             0.00
64. Other (Specify) ________                                                                        0.00                             0.00                             0.00
65. TOTAL — Overhead (Sum
of Lines 43 through 64)                  0.00          0.00            0.00         0.00            0.00            0.00             0.00           0.00              0.00
66. TOTAL COSTS (Sum of
Lines 31, 39, 42, 65)                    0.00          0.00            0.00         0.00            0.00            0.00             0.00           0.00              0.00




       b896e355-0f27-4ec6-95a8-f26d3d3b1a1e.xls, Worksheet 1                                                                                     8/18/2011, 5:37 PM
DEPARTMENT OF HEALTH SERVICES                                                                                        STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-11129E (04/09)


                                                        WISCONSIN MEDICAID
                               FEDERALLY QUALIFIED HEALTH CENTER
                          STAFF, ENCOUNTERS, PRODUCTIVITY, AND CHARGES
                                         WORKSHEET 2

Instructions: Type or print clearly. Refer to the Federally Qualified Health Center Cost Report Completion Instructions, F-
11129A, for detailed information on completing this form.
SECTION I — GENERAL INFORMATION
Provider Number                                                                       Figures Are (Check One)

                                          0
Reporting Period                                                                           Estimated

                                                                                           Actual / Audited
From                     1/0/1900             To                   1/0/1900
SECTION II — STAFF AND ENCOUNTERS
                                                   Full Time Equivalent (FTE) Personnel                           Encounters
                                                                                                      D. Non-
                                               A. Under                                                        E. Wisconsin
                                                             B. Staff         C. Staff Total         Wisconsin                    F. Total
                                               Contract                                                          Medicaid
                                                                                                     Medicaid
1. Physician                                                                                   0.0                                           0
2. Physician Assistant                                                                         0.0                                           0
3. Nurse Practitioner                                                                          0.0                                           0
4. Clinical Psychologist                                                                       0.0                                           0
5. Clinical Social Worker                                                                      0.0                                           0
6. Dentist                                                                                     0.0                                           0
7. Nursing Care to Homebound                                                                   0.0                                           0
8. Speech and Hearing                                                                          0.0                                           0
9. Occupational Therapist                                                                      0.0                                           0
10. Physical Therapist                                                                         0.0                                           0
11. Vocational Therapist                                                                       0.0                                           0
12. Optometrist                                                                                0.0                                           0
13. Podiatrist                                                                                 0.0                                           0
14. Psychotherapist                                                                            0.0                                           0
15. Chiropractor                                                                               0.0                                           0
16. Substance Abuse Services                                                                   0.0                                           0
17. Other (Specify) _____________                                                              0.0                                           0
18. TOTAL — FTE and Encounters                        0.0         0.0                          0.0            0            0                 0
SECTION III — CHARGE INFORMATION
                                                    Medicaid-Enrolled Member Charges                          Total All Charges
19. Charges for Reporting Period                               $15,000.00                                         $30,000.00
DEPARTMENT OF HEALTH SERVICES                                                                                     STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-11129F (04/09)


                                                        WISCONSIN MEDICAID
                            FEDERALLY QUALIFIED HEALTH CENTER
                    DETERMINATION OF OVERHEAD, RATE, AND REIMBURSEMENT
                                       WORKSHEET 3

Instructions: Type or print clearly. Refer to the Federally Qualified Health Center Cost Report Completion Instructions, F-11129A, for
detailed information on completing this form.
SECTION I — GENERAL INFORMATION
Provider Number                                                    Figures Are (Check One)

                                 0
                                                                       Estimated
Reporting Period

                                                                       Actual / Audited
From           01/00/00    To                       01/00/00
SECTION II — DETERMINATION OF OVERHEAD APPLICABLE TO FQHC SERVICES
1. Cost of FQHC services excluding overhead (Worksheet 1; Column I, sum of Line 31 and Line 42)                                    $0.00
2. Non-reimbursable FQHC costs excluding overhead (Worksheet 1; Column I, Line 39)                                                 $0.00
3. Cost of all services excluding overhead (sum of Line 1 and Line 2)                                                              $0.00
4. Percentage of non-reimbursable FQHC costs (Line 2 divided by Line 3)                                                       #DIV/0!
5. Total overhead (Worksheet 1; Column I, Line 65)                                                                                 $0.00
6. Total cost of all services and overhead (sum of Line 3 and Line 5)                                                              $0.00
7. Maximum allowable overhead (Line 6 multiplied by 30%)                                                                           $0.00
8. Overhead allowed (lesser of Line 5 or Line 7)                                                                                   $0.00
9. Overhead applicable to non-reimbursable FQHC costs (Line 4 multiplied by Line 8)                                           #DIV/0!
10. Overhead applicable to FQHC services (Line 8 less Line 9)                                                                 #DIV/0!
11. Total cost of FQHC services (sum of Line 1 and Line 10)                                                                   #DIV/0!
SECTION III — DETERMINATION OF FQHC RATE
12. Total cost of FQHC services (Line 11)                                                                                     #DIV/0!
13. Total FQHC adjusted encounters (Worksheet 2; Column F, Line 18)                                                                      0
14. FQHC rate per encounter (Line 12 divided by Line 13)                                                                      #DIV/0!
SECTION IV — DETERMINATION OF TOTAL REIMBURSEMENT
15. FQHC rate per encounter (Line 14)                                                                                         #DIV/0!
16. FQHC Medicaid and Medicare / Medicaid crossover encounters during the reporting period (Worksheet 2; Column
E, Line 18)                                                                                                                              0
17. Medicaid reasonable costs including crossovers (Line 15 multiplied by Line 16)                                            #DIV/0!
18. Less Payments received by FQHC for services during this reporting period
       a. Payments from Medicare Part C to FQHC for crossovers during the reporting period
       b. Payments from Medicare (excluding Part C) to FQHC for crossovers during the reporting period
       c. Payments from Medicaid fee-for-service to FQHC during the reporting period
       d. Payments from Medicaid for interim FQHC payments during the reporting period
       e. Payments by or due from Medicaid managed care organizations to FQHC during the reporting period                          $0.00
       f. Payments by or due from other third parties (insurance, HMOs) to FQHC for Medicaid members
       g. Copayments from Medicaid members during this reporting period
19. TOTAL — Payments received by FQHC for services during this reporting period (sum of Lines 18a-18g)                             $0.00
20. Balance due to or from Medicaid (Line 17 less Line 19)                                                                    #DIV/0!
21. Outstationed enrollment expenses (Worksheet 5; Line 30)                                                                        $0.00
22. Total balance due (sum of Line 20 and Line 21)                                                                            #DIV/0!
DEPARTMENT OF HEALTH SERVICES                                                                            STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-11129G (04/09)


                                                    WISCONSIN MEDICAID
                                   FEDERALLY QUALIFIED HEALTH CENTER
                                    MANAGED CARE INCOME REPORTING
                                             WORKSHEET 4

Instructions: Type or print clearly. Refer to the Federally Qualified Health Center Cost Report Completion Instructions, F-
11129A, for detailed information on completing this form.
SECTION I — GENERAL INFORMATION
Provider Number                                                          Reporting Period

                                      0
                                                                         From               01/00/00        To       01/00/00
SECTION II — MANAGED CARE INCOME INFORMATION
                                                                                                         Total Dollar
                     Managed Care Entity                       Total Medicaid Encounters               Amount Received*
                                                                                                        (Accrual Basis)
Abri Health Plan
Atrium Health Plan
Dean Health Plan
Group Health Cooperative of Eau Claire
Group Health Cooperative of South Central Wisconsin
Health Tradition Health Plan
Independent Care Health Plan (i Care)
Managed Health Services
MercyCare Insurance Company
Network Health Plan
Security Health Plan
Touchpoint Health Plan
UnitedHealthcare of Wisconsin
Unity Health Plans
Valley Health Plan
Other (Specify) _____________________________
Other (Specify) _____________________________
Other (Specify) _____________________________
Other (Specify) _____________________________
TOTAL
* The total line of this column should equal the amount reported on Worksheet 3, Line 18e.
DEPARTMENT OF HEALTH SERVICES                                                                               STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-11129H (04/09)


                                                       WISCONSIN MEDICAID
                                     FEDERALLY QUALIFIED HEALTH CENTER
                                     OUTSTATIONED ENROLLMENT EXPENSES
                                               WORKSHEET 5

Instructions: Type or print clearly. Refer to the Federally Qualified Health Center Cost Report Completion Instructions, F-
11129A, for detailed information on completing this form.
SECTION I — GENERAL INFORMATION
Provider Number                                                        Figures Are (Check One)
                                     0
Reporting Period                                                          Estimated

                                                                          Actual / Audited
From                   01/00/00          To               01/00/00
SECTION II — OUTSTATIONED ENROLLMENT EXPENSES
                                         Worksheet 1                      Fringe       Purchased and
                                                        Compensation                                       Other        TOTAL
                                         Line Number                     Benefits     Contract Services
PERSONNEL LISTED ON WORKSHEET 1
1. Clinical Social Worker        5                                                                                            0.00
2. Other (Specify) __________   17                                                                                            0.00
3. Nurses                       22                                                                                            0.00
4. Translator                   24                                                                                            0.00
5. Health Education             25                                                                                            0.00
6. Medical Social Worker        27                                                                                            0.00
7. Other (Specify) __________   28                                                                                            0.00
8. Other (Specify) __________   29                                                                                            0.00
9. Outreach                     33                                                                                            0.00
10. Community Services          34                                                                                            0.00
11. Nonmedical Social Worker    37                                                                                            0.00
12. Other (Specify) __________  38                                                                                            0.00
13. Administration              43                                                                                            0.00
PERSONNEL NOT LISTED ON WORKSHEET 1
14. Clinical Social Worker                                                                                                    0.00
15. Nurses                                                                                                                    0.00
16. Translator                                                                                                                0.00
17. Health Education                                                                                                          0.00
18. Medical Social Worker                                                                                                     0.00
19. Outreach                                                                                                                  0.00
20. Community Services                                                                                                        0.00
21. Nonmedical Social Worker                                                                                                  0.00
22. Other (Specify) __________                                                                                                0.00
23. Other (Specify) __________                                                                                                0.00
MATERIALS AND SUPPLIES
24. Pamphlets and Materials                                                                                                   0.00
25. Supplies                                                                                                                  0.00
26. Telephone                                                                                                                 0.00
27. Other (Specify) __________                                                                                                0.00
28. Other (Specify) __________                                                                                                0.00
29. TOTAL (Sum of Lines 1-28)                 0.00       0.00                                     0.00        0.00            0.00
30. REIMBURSABLE AMOUNT                                                                                                       0.00
31. TOTAL APPLICATIONS PROCESSED DURING REPORTING PERIOD

				
DOCUMENT INFO
Description: Statement of Financial Support Medicaid document sample