Get Hospitals Statement Of Costs Form

This guide provides clear instructions on how to successfully complete the Hospitals Statement Of Costs Form online. By following these steps, users can ensure they comply with the necessary requirements and contribute to the County Poor Relief Program.

Follow the steps to fill out the Hospitals Statement Of Costs Form.

1. Press the ‘Get Form’ button to access the Hospitals Statement Of Costs Form and open it in your preferred online editor.
2. Begin by filling in the 'Name of Hospital' and 'Address' fields, providing the complete name and the physical location of the hospital.
3. Indicate the period covered by the statement by entering the start and end dates in the 'From' and 'to' fields, alongside the corresponding years.
4. Complete the departmental listing by inputting the costs and charges for each service category based on your Medicare Cost Report. Fill in 'Column A' for costs and 'Column B' for charges, ensuring accurate data.
5. Calculate the ratio of costs to charges by dividing the amount in 'Column A' by the amount in 'Column B' for each service category.
6. Accurately complete the 'Hospital Schedule of Patient Charges' section by providing room rates for different categories such as private, semi-private, nursery, and special units. Include the amount per day and the effective period of time.
7. If additional space is needed, attach further pages as required to ensure all information is provided.
8. In the certification section, sign and date the form to certify that the information provided is true and correct. Ensure to include the names and titles of the person completing the form and the hospital administrator.
9. Finally, return the completed form to the Department of Social Services at the provided address or through the specified contact methods.
10. Once satisfied with the filled form, save your changes, download, print, or share the document as needed.

Complete your Hospitals Statement Of Costs Form online today to ensure your hospital's compliance and support local healthcare programs.