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DATA REPORT PROVIDER CCN: PERIOD : FROM: TO: FORM APPROVED OMB NO. 0938-0758 WORKSHEET S PARTS I & II PART I - COST REPORT STATUS 1 Provider use only Contractor use only: 1 2 3 4 5 6 7 8 9 10 11 12 Electronic filed cost report Manually submitted cost report Number of times cost report has been amended Medicare utilization Cost report status 1 As Submitted 2 Reserved 3 Reserved 4 Reserved 5 Amended Date received Contractor number First cost report for this provider CCN.
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