Form DHCS3099 "Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (Icf-Ddh/N) Home Office Cost Report" - California

What Is Form DHCS3099?

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.

Download a fillable version of Form DHCS3099 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Department of Health Care Services
State of California—Health and Human Services Agency
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
MEDI-CAL PROGRAM COST REPORT
INTERMEDIATE CARE FACILITY
FOR THE DEVELOPMENTALLY DISABLED
HABILITATIVE/NURSING HOME OFFICE
COST REPORT
Home Office Name:____________________________________________________________________
Reporting Period: From _______________________________
To ___________________________
DHCS 3099 (05/16)
Department of Health Care Services
State of California—Health and Human Services Agency
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
MEDI-CAL PROGRAM COST REPORT
INTERMEDIATE CARE FACILITY
FOR THE DEVELOPMENTALLY DISABLED
HABILITATIVE/NURSING HOME OFFICE
COST REPORT
Home Office Name:____________________________________________________________________
Reporting Period: From _______________________________
To ___________________________
DHCS 3099 (05/16)
Department of Health Care Services
State of California—Health and Human Services Agency
SCHEDULE 1—HOME OFFICE COST REPORT
GENERAL INFORMATION
1.
Home Of
fice Name
3. Phone Number
2. Street Address
City
State
ZIP Code
4. Cost Reporting Period
5. Report Contact Person Name
Phone Number
From:
To:
6. Type of Chain Organization
ԅ
Nonprofit
ԅ
For profit
ԅ
Corporation
ԅ
Corporation
ԅ
Church Affiliated
ԅ
Partnership
ԅ
Other (Specify)
ԅ
Other (Specify)
_____________________________
_____________________________
7. Key Officers
President
___________________________________________________
Vice President(s) ___________________________________________________
___________________________________________________
Secretary
___________________________________________________
Treasurer
___________________________________________________
Controller
___________________________________________________
CERTIFICATION
8.
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.
9. Email a PDF signed copy to: ICFDDHN.Submissions@dhcs.ca.gov. For assistance/questions, contact ARAS at
ICFDDHN.Questions@dhcs.ca.gov or (916) 650-6696.
Is this report being filed as a result of change in ownership?
ԅ Yes
ԅ No
Page 1 of 6
DHCS 3099 (05/16)
Home Office Name
Fiscal Year End
SCHEDULE 2—STATEMENT OF REIMBURSABLE COSTS
(6)
(1)
(2)
(3)
(4)
(5)
Expenses
Adjustments
Allowable
Direct
Pooled
Per Home
Increase
Expenses
Allocations
Costs
Account Description
Office Books
(Column 4 – Column 5)
(Schedule 3, Column 3)
(Column 2 +/– Column 3)
(Schedule 4, Line 11)
1. Salaries—Officers
2. Salaries—Other
3. Payroll Taxes
4. Employee Benefits
5. Travel
6. Entertainment
7. Automobile
8. Depreciation—Building
9. Depreciation—Equipment
10. Other Depreciation & Amortization
11. Leases and Rentals
12. Interest—Mortgages
13. Interest—Other
14. Taxes and Licenses
15. Legal and Accounting
16. Insurance
17. Telephone
18. Utilities
19. Office Supplies
20. Nonprogram
21. Other (Specify)
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
TOTAL
*
* To Schedule 5
Page 2 of 6
DHCS 3099 (05/16)
Home Office Name
Fiscal Year End
SCHEDULE 3—MEDI-CAL ADJUSTMENTS TO EXPENSES
(1)
(2)
(3)
(4)
(5)
Basis
Account to be Adjusted
of
Line
(Schedule 2, Column 1)
Description
Adjustment*
Amount
Number
Account Name
1. Penalties
2. Donations
3. Gain/Loss on Asset Disposal
4. Life Insurance Premium—Corporation Benefits
5. Bad Debts
6. Fund-Raising Expense
7. Rebates/Refunds
8. Interest Income
9. Nonclient Care Related
10. Other (Specify)
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
TOTAL
(To Schedule 2, Column 3)
* The Basis for the Adjustment is either A or B.
A = Cost
B = Revenue (Cost Recovery Items)
Page 3 of 6
DHCS 3099 (05/16)
Home Office Name
Fiscal Year End
SCHEDULE 4—DIRECT ALLOCATION OF EXPENSES TO CHAIN COMPONENTS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Expenses Directly Allocable to Chain Component
(Specify Type of Expense)
Facility
Total**
(Chain Component)
A
B
C
D
E
F
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
TOTAL*
* Transfer amount(s) on Line 11 to Schedule 2, Column 5.
** Transfer Column 7 amount(s) to Schedule 6, Column 3.
Page 4 of 6
DHCS 3099 (05/16)