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FORM CMS-2552-96 (5/2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3605.2)

 

36-506.2
06-03
FORM CMS-2552-96 Rev. 14
3690 (Cont.)
HOSPITAL WAGE INDEX INFORMATION PROVIDER NO.:

_______
PERIOD:
FROM ______
TO ______
WORKSHEET S-3, PART III
PART II - WAGE DATA      
  Amount Reported Reclass. of Salaries (from Wkst. A-6) Adjusted Salaries (col. 1 ± col. 2) Paid Hours Related to Salaries in col. 3 Average Hourly Wage (col. 3 + col. 4) Data Source  
1 2 3 4 5 6  
  OVERHEAD COST - DIRECT SALARIES              
21 Employee Benefits             21
22 Administrative & General             22
22.01 Administrative & General under contract (see inst.)           22.01
23 Maintenance & Repairs             23
24 Operation of Plant             24
25 Laundry & Linen Service             25
26 Housekeeping             26
26.01 Housekeeping under contract (see instructions)             26.01
27 Dietary             27
27.01 Dietary under contract (see instructions)             27.01
28 Cafeteria             28
29 Maintenance of Personnel             29
30 Nursing Administration             30
31 Central Services and Supply             31
32 Pharmacy             32
33 Medical Records & Medical Records Library             33
34 Social Service             34
35 Other General Service             35
PART III - HOSPITAL WAGE INDEX SUMMARY
1 Net salaries (see instructions)             1
2 Excluded area salaries (see instructions)             2
3 Subtotal salaries (line 1 minus line 2)             3
4 Subtotal other wages & related costs (see inst.)             4
5 Subtotal wage-related costs (see inst.)             5
6 Total (sum of lines 3 thru 5)             6
7 Net salaries (see instructions)             7
8 Excluded area salaries             8
9 Subtotal salaries (line 7 minus line 8)             9
10 Subtotal other wages & related costs (see inst.)             10
11 Subtotal wage-related costs (see inst.)             11
12 Total (sum of lines 9 thru 11)             12
13 Total overhead costs (see inst.)             13


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