Provider Cost Report Reimbursment Questionaire {CMS-339}

04-06 FORM CMS-339 1102.3 (Cont.) EXHIBIT 1 FORM APPROVED OMB NO. 0938-0301 This questionnaire is required under the authority of sections 1815(a) and 1833(e) of the Social Security Act. Failure to submit this questionnaire will result in suspension of Medicare payments. To the degree that the information in CMS-339: 1) constitutes commercial or financial information which is confidential, and/or 2) is of a highly sensitive personal nature, the information will be protected from release under the Freedom of Information Act. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0301. The time required to complete this information collection is estimated to average 17 hours and 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE (You MUST USE Instructions For Completing This Form Located In PRM-II, §§1100ff.) Provider Name: Provider Number(s): ______________________________________________________________________________ Filed with Form CMSPeriod: / /1728 / /2552 / /2088 / /2540 / / 2540S ____________________ // (Other - Specify) From To ____________________ INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS QUESTIONNAIRE MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S) I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying information prepared by _____________________________________________ (Provider name(s) and number(s)) for the cost report period beginning _____________________ and ending ________________, 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 provider(s) in accordance with applicable instructions, except as noted. (Signed) Officer or Administrator of Provider(s) Date Title Name and Telephone Number of Person to Contact for More Information Rev. 6 11-15 American LegalNet, Inc. www.USCourtForms.com 1102.3 (Cont.) EXHIBIT 1 (Cont.) 04-06 PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE YES NOTE: 42 CFR 413.20 and instructions contained in the PRM-1 require that the provider maintain adequate financial and statistical data necessary for the intermediary to use for a proper determination of costs payable under the program. Providers are, therefore, required to maintain and have available for audit all records necessary to verify the amounts and allowability of costs and equity capital included in the filed cost report. Failure to have such records available for review by fiscal intermediaries acting under the authority of the Secretary of the Department of Health and Human Services will render the amount claimed in the cost report unallowable. A. Provider Organization and Operation NOTE: Section A to be completed by all providers. 1. The provider has: a. Changed ownership. If "yes", submit name and address of new owner, date of change, copy of sales agreement, or any similar agreement affecting change of ownership. Terminated participation. If "yes", list date of termination, and reason (Voluntary/Involuntary). NO N/A b. 2. The provider, members of the board of directors, officers, medical staff or management personnel are associated with or involved in business transactions with the following: a. Related organizations, management contracts and services under arrangements as owners (stockholders), management, by family relationship, or any other similar type relationship. b. Management personnel of major suppliers of the provider (drug, medical supply companies, etc.). If "yes" to question 2a and/or 2b, attach a list of the individuals, the organizations involved, and description of the transactions. 11-16 Rev. 6 American LegalNet, Inc. www.USCourtForms.com 04-06 EXHIBIT 1 (Cont.) 1102.3 (Cont.) PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE YES B. Financial Data and Reports NOTE: Section B to be completed by all providers. 1. During this cost reporting period, the financial statements are prepared by Certified Public Accountants or Public Accountants (submit complete copy or indicate available date) and are: a. b. c. Audited; Compiled; and Reviewed. NO N/A NOTE: Where there is no affirmative response to the above described financial statements, attach a copy of the financial statements prepared and a description of the changes in accounting policies and practices if not mentioned in those statements. 2. Cost report total expenses and total revenues differ from those on the filed financial statement. If "yes", submit reconciliation. C. Capital Related Cost NOTE: Section C to be completed only by hospitals excluded from PPS (except Children's) and PPS hospitals that have a unit excluded from PPS. 1. Assets have been relifed for Medicare purposes. If "yes", attach detailed listing of these specific assets, by classes, as shown in the Fixed Asset Register. NOTE: For cost reporting periods beginning on or after October 1, 1991 and before October 1, 2001, under the capital - PPS consistency rule (42 CFR 412.302 (d)), PPS hospitals are precluded from relifing old capital. 2. Due to appraisals made during this cost reporting period, changes have occurred to Medicare depreciation expense. If "yes", attach copy of Appraisal Report and Appraisal Summary by class of asset. Rev. 6 11-17 American LegalNet, Inc. www.USCourtForms.com 1102.3 (Cont.) EXHIBIT 1 (Cont.) 04-06 PROVIDER COST REPORT REIMBURSMENT QUESTIONAIRE YES 3. New leases and/or amendments to existing leases for land, equipment, or facilities with annual rental payment in excess of the amounts listed in the instructions, have been entered into during this cost reporting period. If "yes", submit a listing of these new leases and/or amendments to existing leases that have the following information: o o o o o A new lease or lease renewal; Parties to the lease; Period covered by the lease; Description of the asset being leased; and Annual charge by the lessor. NO