Report Card Number

Provider CCN

Facility Name

Street Address

City

State Code

Zip Code

County

Medicare CBSA Number

Rural versus Urban

Fiscal Year Begin Date

Fiscal Year End Date

Type of Control

Total Maternal and Child Health Days

Total Medicare Days

Total Medicaid Days

Total Days Other

Total Days Total

Number of Beds

Total Bed Days Available

Total Maternal and Child Health Discharges

Total Medicare Discharges

Total Medicaid Discharges

Total Discharges Title Other

Total Discharges Total

SNF Average Maternal and Child Health Stay

SNF Average Medicare Stay

SNF Average Medicaid Stay

SNF Average Length of Stay Total

SNF Maternal and Child Health Admissions

SNF Medicare Admissions

SNF Medicaid Admissions

SNF Admissions Other

SNF Admissions Total

SNF Maternal and Child Health Days

SNF Medicare Days

SNF Medicaid Days

SNF Days Other

SNF Days Total

SNF Number of Beds

SNF Bed Days Available

SNF Maternal and Child Health Discharges

SNF Medicare Discharges

SNF Medicaid Discharges

SNF Discharges Title Other

SNF Discharges Total

NF Number of Beds

NF Bed Days Available

NF Maternal and Child Health Days

NF Medicaid Days

NF Days Other

NF Days Total

NF Maternal and Child Health Discharges

NF Medicaid Discharges

NF Discharges Title Other

NF Discharges Total

NF Average Maternal and Child Health Stay

NF Average Medicaid Stay

NF Average Length of Stay Total

NF Maternal and Child Health Admissions

NF Medicaid Admissions

NF Admissions Other

NF Admissions Total

Total RUG Days

Total Salaries From Worksheet A

Overhead Non-Salary Costs

Total Charges

Total Costs

Wage-related Costs (core)

Total Salaries (adjusted)

Contract Labor

Cash on hand and in banks

Temporary Investments

Notes Receivable

Accounts Receivable

Less: Allowances for uncollectible notes and accounts receivable

Inventory

Prepaid expenses

Other current assets

Total Current Assets

Land

Land improvements

Buildings

Leasehold improvements

Fixed equipment

Major movable equipment

Minor equipment depreciable

Total fixed Assets

Investments

Other Assets

Total other Assets

Total Assets

Accounts payable

Salaries, wages, and fees payable

Payroll taxes payable

Notes and Loans Payable (short term)

Deferred income

Other current liabilities

Total current liabilities

Mortgage payable

Notes Payable

Unsecured Loans

Other long term liabilities

Total long term liabilities

Total liabilities

General fund balance

Total fund balances

Total Liabilities and fund balances

Total General Inpatient Care Services Revenue

Inpatient Revenue

Outpatient Revenue

Gross Revenue

Less Contractual Allowance and discounts on patients’ accounts

Net Patient Revenue

Less Total Operating Expense

Net Income from service to patients

Total Other Income

Total Income

Net Income

Inpatient PPS Amount

Nursing and Allied Health Education Activities

Allowable Bad Debts