04-05 FORM CMS-2552-96 3690 (Cont.)
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA PROVIDER NO.: PERIOD
FROM ______
TO ______
WORKSHEET S-3, PART I
Component No. of Beds Bed Days Available I/P Days / O/P Visits / Trips Interns & Residents FTEs Full Time Equivalent Discharges
Title V Title XVIII Title XIX Total All Patients Obs. Beds Admittec Obs. Beds Mot Adm Total Less I & R Replacing Non-Phys. Anesthetist Net Employees On Payroll Nonpaid Workers Title V Title XVIII Title
XIX
Total All Patients
Total Title
XIX
Obs. Beds Admittec Obs. Beds Not Adm
1 2 3 4 5 5.01 5.02 6 6.01 602 7 8 9 10 11 12 13 14 15  
1 Hospital Adults & Peds. (columns 3, 4, 5 and 6, exclude Swing Bed Observation Bed and Hospice days)                                       1
2 HMO                                       2
3 Hospital Adults & Peds. Swing Bed SNF                                       3
4 Hospital Adults & Peds. Swing Bed NF                                       4
5 Total Adults and Peds. (exclude observation beds) (see instructions)                                       5
6 Intensive Care Unit                                       6
7 Coronary Care Unit                                       7
8 Burn Intensive Care Unit                                       8
9 Surgical Intensive Care Unit                                       9
10 Other Special Care                                       10
11 Nursery                                       11
12 Total (see instructions)                                       12
13 RPCH\CAH visits                                       13
14 Subprovider                                       14
15 Skilled Nursing Facility                                       15
16 Nursing Facility                                       16
17 Other Long Term Care                                       17
18 Home Health Agency                                       18
20 ASC (Distinct Part)                                       20
21 Hospice (Distinct Part)                                       21
23 Outpatient Rehab. Provider (specify)                                       23
24 RHC/FQHC (specify)                                       24
25 Total (sum of lines 12-24)                                       25
26 Observation Bed Days                                       26
27 Ambulance Trips                                       27
28 Employee discount days (see instru.)                                       28

FORM CMS-2552-96 (4-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.1)

Rev. 14



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