Form DHCS3076 "Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (Icf-Ddh/N) Cost Report" - California

What Is Form DHCS3076?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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Download Form DHCS3076 "Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (Icf-Ddh/N) Cost Report" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH CARE SERVICES
MEDI-CAL PROGRAM COST REPORT
INTERMEDIATE CARE FACILITY
FOR THE DEVELOPMENTALLY DISABLED
Facility Name:
☐ Habilitative
☐ Nursing
Service Level:
NPI Number:
Reporting Period:
From
To
DHCS 3076 (05/16)
State of California—Health and Human Services Agency
Department of Health Care Services
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH CARE SERVICES
MEDI-CAL PROGRAM COST REPORT
INTERMEDIATE CARE FACILITY
FOR THE DEVELOPMENTALLY DISABLED
Facility Name:
☐ Habilitative
☐ Nursing
Service Level:
NPI Number:
Reporting Period:
From
To
DHCS 3076 (05/16)
State of California—Health and Human Services Agency
Department of Health Care Services
INTERMEDIATE CARE FACILITY COST REPORT
FOR THE DEVELOPMENTALLY DISABLED
(HABILITATIVE OR NURSING)
GENERAL INFORMATION AND CERTIFICATION
3. NPI Number
1. Name of Facility
2. State License Number
4. Street Address
5. City
6. ZIP Code
7. Mailing Address
8. City
9. ZIP Code
10. Administrator
11. Report Contact Person
12. E-mail Address
13. Phone Number
14. Mailing Address: Street or P.O. Box
15. City
16. ZIP Code
17. Reporting Period Began
18. Reporting Period End
19. Name of Home Office (If Applicable)
20. Home Office Phone Number
21.
CERTIFICATION
I, ________________________________________________________________, certify under penalty of perjury as
follows:
That I am an official of
and am duly authorized to sign this certification and
that to the best of my knowledge and information, I believe each statement and amount in the accompanying report to be
true, correct, and in compliance with Section 14161 of the California Welfare and Institutions Code.
Signature
Date
Title
Address
Please be advised that continued submission of claims or cost reports for items or services which were not provided as
claimed, are not reimbursable under the Medi-Cal program, or claimed in violation of an agreement with the State, may
subject you (your organization) to civil money penalty assessment in accordance with the Welfare and Institutions Code,
Section 14123.2.
Email a PDF signed copy to: ICFDDHN.Submissions@dhcs.ca.gov. For assistance/questions, contact ARAS at
22.
ICFDDHN.Questions@dhcs.ca.gov or (916) 650-6696.
.
☐ Yes
☐ No
Is this report being filed as a result of change in ownership?
NOTE: A COMPLETED REPORT IS REQUIRED FOR EACH LICENSED FACILITY
Page 1 of 6
DHCS 3076 (05/16) Schedules
Facility Name
Fiscal Year End
SECTION A—REQUEST FOR INFORMATION
1. Are financial statements (income statement, balance sheet, etc.) available for the cost reporting period? ☐ Yes
☐ No
☐ Yes
☐ No
2. Were any assets disposed of during the reporting period?
☐ Yes
☐ No
3. Does your facility maintain patient trust accounts?
If yes:
a. Balance of trust account at the beginning of period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
b. Total deposits during reporting period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
c. Total expenditures from trust account. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
d. Balance at the end of reporting period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
SECTION B—LICENSEE DESCRIPTION
Type of Control
X
Legal Organization
X
01
Church Related Not-For-Profit
Corporation
07
02
Other Not-For-Profit
Division of a Corporation
08
03
Investor Owned For-Profit
Partnership
09
04
Owner/Operator For-Profit
Proprietorship
10
05
Other (Specify)
11
SECTION C—FACILITY CENSUS
Line
Total Statistics
Medi-Cal Fee for Service
Medi-Cal Managed Care
Other
Total
1
Licensed Beds—Beginning of Period
2
Licensed Beds—End of Period
0
3
Client Days
0
4
Discharges Including Deaths
0
5
Admissions
Page 2 of 6
DHCS 3076 (05/16) Schedules
Facility Name
Fiscal Year End
SECTION D—STATEMENT OF RELATED ORGANIZATIONS
Is the facility part of a chain organization? (For definition, see Section E instructions.)
☐ Yes
☐ No
If yes, please complete the following:
Percent of
Home Office or Related Organization
Ownership
SECTION E—STATEMENT OF HOME OFFICE COSTS
Are any costs included during this reporting period a result of transactions with the home office (parent
company)? If yes, you are required to file a home office cost report (See instructions). Please provide the
☐ Yes
☐ No
information which is the result of transactions with a related organization.
Account
Item
Amount
$
SECTION F—STATEMENT OF COMPENSATION TO OWNERS
Average
Compensation
If Employed by Facility:
Owners
Hours
Investment
Worked
Current
Prior
Name of Owners
Percentage
Per Week
Title and Function
Fiscal Year
Fiscal Year
0.00%
$
$
0.00%
0.00%
0.00%
SECTION G—STATEMENT OF COMPENSATION PAID TO ADMINISTRATOR (OTHER THAN OWNERS OR QMRP)
Compensation
Weekly Average
Hours Devoted
Current
Prior
Name
Title
To Facility
Fiscal Year
Fiscal Year
$
$
Page 3 of 6
DHCS 3076 (05/16) Schedules
Facility Name
Fiscal Year End
SECTION H—STATEMENT OF INCOME AND EXPENSE WITH RECLASSIFICATION AND ADJUSTMENTS
(1)
(2)
(3)*
(4) Total
Reclassification
Amount
Line
Account
and
(Col. 2 & 3)
Number
Description
Number
Amount
Adjustments
Revenues: Client Services:
0
005
Medi-Cal Per Diem
4010
$
$
$
0
006
Adult Day Services & Related Transportation
0
010
Private
4020
0
015
Other
4030
0
0
0
020
Subtotal (Lines 005 to 015)
Deductions From Revenue:
0
025
Contractual and Other Deductions
4040
0
0
0
030
Net Client Service Revenue (Line 020 – 025)
0
035
Other Operating Revenue
4050
0
0
0
040
Net Operating Revenue (Line 030 + 035)
Expenses: Client Services
Basic Facility Cost
Property Expenses:
0
045
Depreciation and Amortization
5010
0
050
Leases and Rentals
5020
0
055
Real Property Taxes
5030
0
060
Personal Property Taxes
5040
0
065
Mortgage Interest
5050
0
070
Property Insurance
5060
0
0
0
075
Total Property Expenses (Lines 045 to 070)
General Home Expenses:
0
080
Home Operations and Maintenance
5070
0
085
Utilities
5080
0
090
Client Transportation
5090
(excluding Adult Day Services)
0
095
Dietary
6000
0
100
Personal Care and Laundry
6010
0
0
0
105
Total General Home Expenses (Lines 080 to 100)
0
0
0
110
Total Basic Facility Cost (Line 075 + 105)
$
$
$
* F r o m Page 5, Column 1.
Page 4 of 6
DHCS 3076 (05/16) Schedules