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Long Term Care Cost Report Forms

Long Term Care Cost Report Forms

Long Term Care Facility Cost Report Forms – Integrated

Title File Name Caption Date
Checklist Checklist.xlsx May 12, 2014 1:31 pm
Form 1: General information Form1.xlsx May 12, 2014 1:34 pm
Form 2: Certification by officer or administrator of provider Form2.xlsx May 12, 2014 1:34 pm
Form 3: Statistical data Form3.xlsx May 12, 2014 1:34 pm
Form 4: Patient day statistics Form4.xlsx May 12, 2014 1:34 pm
Form 5: Statement of revenues and expenses Form5.xlsx May 12, 2014 1:35 pm
Form 6: Schedule of expenses Form6.xlsx May 12, 2014 1:36 pm
Form 7: Schedule of fixed assets and depreciation (1 of 2) Form7.xlsx May 12, 2014 1:37 pm
Form 7: Schedule of fixed assets and depreciation (2 of 2) Form7-2.xlsx May 12, 2014 1:37 pm
Form 8: Facility transactions with related organizations Form8.xlsx May 12, 2014 1:37 pm
Form 9: Rental of vehicles and property Form9.xlsx May 12, 2014 1:38 pm
Form 10: Analysis of interest bearing debt and related interest expense Form10.xlsx May 12, 2014 1:38 pm
Form 11: Balance sheet Form11.xlsx May 12, 2014 1:38 pm
Form 12: Capital reconciliation Form12.xlsx May 12, 2014 1:39 pm
Form 13: Computation of return on equity Form13.xlsx May 12, 2014 1:39 pm
Form 14: Computation of per diem cost for facilities with less than 80% occupancy Form14.xlsx May 12, 2014 1:39 pm
Form 15: Owners, officers and directors compensation Form15.xlsx May 12, 2014 1:40 pm
Form 16: Disclosure of ownership Form16.xlsx May 12, 2014 2:19 pm
Form 17: Home office or related management company cost report expense allocation summary Form17.xlsx May 12, 2014 2:19 pm
Form 18: Computation of return on equity for home office Form18.xlsx May 12, 2014 2:20 pm
Schedule 1: Other income Schedule-501_1-eff.-05272010.xlsx May 12, 2014 2:20 pm
Schedule 2: Direct care allocated costs – hospital based and state facilities Schedule-501_2.xlsx May 12, 2014 2:21 pm
Schedule 3: Therapy allocated costs – hospital based and state facilities Schedule-501_3.xlsx May 12, 2014 2:21 pm
Schedule 4: Care related allocated costs – hospital based and state facilities Schedule-501_4.xlsx May 12, 2014 2:21 pm
Schedule 5: Miscellaneous Schedule-501_5.xlsx May 12, 2014 2:22 pm
Schedule 6: Administrative and operating allocated costs – hospital based and state facilities Schedule-501_6.xlsx May 12, 2014 2:22 pm
Schedule 7: Property and equipment allocated costs – hospital based and state facilities Schedule-501_7.xlsx May 12, 2014 2:22 pm
Schedule 8: Other non-allowable costs Schedule-501_8.xlsx May 12, 2014 2:22 pm
Schedule 9: Form 6 cost variances Schedule-501_9.xlsx May 12, 2014 2:23 pm
Schedule 10: Deposits Schedule-501_10.xlsx May 12, 2014 2:23 pm
Schedule 11: Home office/related management company other income Schedule-501_11.xlsx May 12, 2014 2:23 pm
Schedule 12: Home office/related management company other expense Schedule-501_12.xlsx May 12, 2014 2:23 pm
Form 19: Ventilator Dependent Care Expenses Form19.xlsx April 14, 2015 9:00 pm
Schedule 13: Employee Benefits Allocation – Hospital Based & State Facilities Schedule-501_13.xlsx February 18, 2016 7:53 pm
Schedule 14: Apportionment of Care Related Allocated Costs – Hospital Based And State Facilities Schedule-501_14.xlsx February 18, 2016 7:54 pm
Schedule 15: Apportionment Of Administrative And Operating Allocated Costs – Hospital Based And State Facilities Schedule-501_15.xlsx February 18, 2016 7:54 pm
Schedule 16: Apportionment Of Capital Allocated Costs – Hospital Based and State Facilities ( Supplement to Schedule 7) Schedule-501_16.xlsx February 18, 2016 7:55 pm
Schedule 17: Apportionment of Raw Food Costs – Hospital Based And State Facilities (Form 6, Line 3-20) Schedule-501_17.xlsx February 18, 2016 7:55 pm
Schedule 13A: Employee benefits allocation – hospital based and state facilities Schedule-501_13A.xlsx April 6, 2016 9:51 pm
Cost Report Instructions CostReportInstructions.pdf April 6, 2016 9:51 pm