Identification, Utilization, Statistical Data

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Wkst. S Independent RHC/FQHC Statistical Data and Certification Statement 2903
Wkst. S, Parts I Statistical Data 2903.1
Wkst. S, Parts II Certification Statement 2903.2

Reclassification And Adjustment Of Trial Balance Of Expenses

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Wkst. A Reclassification and Adjustment of Trial Balance of Expenses 2904
Wkst. A-1 Reclassification 2905
Wkst. A-2 Adjustments to Expenses 2906
Wkst. A-2-1 “Statement of Costs of Services From Related Organizations 2909
Wkst. A-2-1, Part I Introduction 2909.1
Wkst. A-2-1, Part II Costs Incurred and Adjustments Required 2909.2
Wkst. A-2-1, Part III Interrelationship of Facility to Related Organization(s) 2909.3

Cost and Cost Allocation

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Wkst. B Visits and Overhead Cost For RHCs/FQHCs 2907
Wkst. B, Part I Visits and Productivity 2907.1
Wkst. B, Part I I “Determination of Total Allowable Cost Applicable To RHC/FQHC Services 2907.2
Wkst. B-1 Computation of Pneumococcal and Influenza Vaccine Cost 2910

Computation of Ratio of Costs to Charges

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Wkst. C Determination of Medicare Payment 2908
Wkst. C, Part I Determination of Rate For RHC/FQHC Services 2908.1
Wkst. C, Part II Determination of Total Payment 2908.2