Organ Procurement Organization Histocompatibility Laboratory General Data And Certification Statement {CMS-216}

11-05 Form CMS-216-94 3390(Cont.) FORM APPROVED OMB NO. 0938-0102 PERIOD: FROM:_______ WORKSHEET S This report is required by law (42 USC 1395g) and 42CFR 413.20 and 413.24. Failure to report can result in all payments made during the reporting period being deemed overpayments (42 USC 1395g). ORGAN PROCUREMENT ORGANIZATION HISTOCOMPATIBILITY LABORATORY GENERAL DATA AND CERTIFICATION STATEMENT Intermediary Use Only: [ [ ] Audited ] Desk Reviewed Date Received ________________ Intermediary No. ______________ [ [ ] Initial ] Final [ ] Re-opened PROVIDER NO. _______________ TO:__________ PART I - GENERAL Check applicable box 1 Name: 1.01 Street: 1.02 City: 2 Name: 2.01 Street: 2.02 City: 3 Reporting Period: From State: To State: Medicare Number: P.O. Box: Zip Code: [ [ ] Electronic filed cost report ] Manually submitted cost report Medicare Number: P.O. Box: Zip Code: Date: Time: 1 1.01 1.02 2 2.01 2.02 3 Type of Control (see instructions) 1 4 2 Type of Provider (see instructions) 3 Participation Date 4 4 PART II-CERTIFICATION BY OFFICER OR ADMINISTRATOR OF FACILITY 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 LAW. FUTHERMORE, IF SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLYOF A KICKBACK OR WERE OTHERWIS ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATION ACTION, FINES AND/OR IMPRISONMENT MAY RESULT CERTIFICATION BY OFFICER, ADMINISTRATOR OR DIRECTOR OF ORGANIZATION/LABORATORY I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Statement of Reimbursable Cost and the Balance Sheet and Statement of Revenue and Expenses prepared by _____________________________________________ _________________________________________________________________________________________ (name(s) and number(s) for the cost reporting period beginning _____________________ and ending_________________________, and that to the best of my knowledge and belief, it is a true, correct and complete ststement prepared from the books and records of the Organization/Laboratory in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and regulations. (Signed) ______________________________________________ Officer, Administrator or Director ______________________________________________ Title ______________________________________________ Date PART III - SETTLEMENT SUMMARY TITLE XVIII Organ Acquisition Tissue Typing 1 2 1 OPO/Lab 1 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 0938-0102. The time required to complete this information collection is estimated to average 45 hours 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: Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimor, Maryland 21244-1850. FORM CMS-216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3302,3302.1 and 3302.2) Rev. 4 33-303 American LegalNet, Inc. www.USCourtForms.com 3390 (Cont.) ORGAN PROCUREMENT ORGANIZATION/ HISTOCOMPATIBILITY LABORATORY IDENTIFICATION DATA PART I-OPO STATISTICS Form CMS 216-94 MEDICARE PERIOD: NUMBER FROM_______________ ___________________ TO________________ 1 Local 2 Imported 11-05 WORKSHEET S 3 Total (Columns 1 & 2) 1 2 3 1 2 3 Total number of kidneys retrieved (viable and non-viable) Total number of kidneys included in line 1 that were non-viable. Net number of kidneys for which payment should have been received (line 1 minus line 2). USA Foreign Country Total Total number of kidneys included in line 3, column 3 that were exported out of local retrieval areas Military VA Total Total number of kidneys sent to military or DVA hospitals that were included in line 3,column 3. Amount received for kidneys listed in line 5. 4 4 5 6 7 5 Number Amount Received Number of Kidneys Amount Received 7 6 Was payment received for kidneys furnished to foreign countries and included on line 4,column 2. Enter "Y" for yes or "N" for no. If yes, enter the total number of kidneys and amount received in columns 2 and 3, respectively. Total number of organs/tissue other than kidneys retrieved and administratively processed. In the amount received column enter the total amount of payment received for each type of organ. Organ Total Nonviable Amount Received 8 Cornea 8.01 Liver 8.02 Pancreas 8.03 Pancreas Islet 8.04 Heart 8.05 Heart Valves 8.06 Heart/Lung 8.07 Bone 8.08 Skin 8.09 Lung 8.10 Other 8.20 Total PART II-LAB STATISTICS 1 Total number of tests performed- all laboratory. 2 Total number of tests performed-tissue typing laboratory. 3 Total number of pre-transplant tests performed for kidney transplantation that are included in line 2. Tissue typing pre-transplant tests performed for kidney transplant: Test Name Number of Tests 4 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.20 Total Tests PART III-FTEs Number of full-time equivalent employees Administrative OPO Histo-Lab 1 2 3 4 5 6 1 Medical Director Medical Director Lab Director 1.01 Exec. Director Procurement Coordinator Technicians 1.02 Clerical Preservation Technicians Tissue Typing Tech. 1.03 Other Other Other 2 Total FTEs 8 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.20 1 2 3 4 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.20 1 1.01 1.02 1.03 2 FORM CMS 216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II SECTIONS 3303, 3303.1, 3303.2 and 3303.3) 33-304 Rev. 4 American LegalNet, Inc. www.USCourtForms.com S-1 American LegalNet, Inc. www.USCourtForms.com 11-05 RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES Form CMS-216-94 MEDICARE NUMBER _________________ 3390 (Cont.) REPORTING PERIOD FROM:_______________________ TO:____________________ RECLASS. TO EXPENSES RECLASSIFIED TRIAL BALANCE (COL.3 +/- COL.4)