"Census Cover Sheet" - Kentucky

Census Cover Sheet is a legal document that was released by the Kentucky Department of Medicaid Services - a government authority operating within Kentucky.

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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Department of Medicaid Services.

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CENSUS COVER SHEET
DATES OF QUARTERLY CENSUS:
_----...;1 _ _ 1 _ _
thru _ _
, 1 _ _ 1 _ _
*FACILITY NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*(This information must also be on the census)
MEDICAID PROVIDER NUMBER: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
NATIONAL PROVIDER NUMBER: _ _ _ _ _ _ _ _ _ _ _ _ _ _
Instructions - When computing total bed days used and available, include all NF beds,
including bed reserve, regardless of payer source, (Do not include personal care beds,)
(1) Total bed days used (month 1)
=
(2) Total bed days used (month 2)
=
(3) Total bed days used (month 3)
=
(4) Total bed days used for quarter
=
(Add lines 1, 2 and 3 to compute this total)
(5) Total available bed days for NF
= _ _ _ _ _ _ _
(# of beds multiplied by days in the quarter)
(6) Percentage occupancy used for quarter
= ____ ' ____
(2 decimal places)
(Line 4 divided by Line 5)
(7) Is the % in line 6 equal to 95% or higher? (Yes/No) _ _ _ _
Yes:
Number of beds = _ _ _ _
Have the number of beds changed since last quarter? (Yes/No) _ _ _
If yes, effective date of change =
_1_1_
No: Do nothing. You will automatically be paid 50% of your per diem rate for
bed reserve,
COMMENTS: ________________________________________ ___
Signature/Title of Facility Staff
Contact Phone Number
_ _ I
I _ _
Printed Name of Facility Staff
Date
Attach this form to the Quarterly Census
CENSUS COVER SHEET
DATES OF QUARTERLY CENSUS:
_----...;1 _ _ 1 _ _
thru _ _
, 1 _ _ 1 _ _
*FACILITY NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*(This information must also be on the census)
MEDICAID PROVIDER NUMBER: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
NATIONAL PROVIDER NUMBER: _ _ _ _ _ _ _ _ _ _ _ _ _ _
Instructions - When computing total bed days used and available, include all NF beds,
including bed reserve, regardless of payer source, (Do not include personal care beds,)
(1) Total bed days used (month 1)
=
(2) Total bed days used (month 2)
=
(3) Total bed days used (month 3)
=
(4) Total bed days used for quarter
=
(Add lines 1, 2 and 3 to compute this total)
(5) Total available bed days for NF
= _ _ _ _ _ _ _
(# of beds multiplied by days in the quarter)
(6) Percentage occupancy used for quarter
= ____ ' ____
(2 decimal places)
(Line 4 divided by Line 5)
(7) Is the % in line 6 equal to 95% or higher? (Yes/No) _ _ _ _
Yes:
Number of beds = _ _ _ _
Have the number of beds changed since last quarter? (Yes/No) _ _ _
If yes, effective date of change =
_1_1_
No: Do nothing. You will automatically be paid 50% of your per diem rate for
bed reserve,
COMMENTS: ________________________________________ ___
Signature/Title of Facility Staff
Contact Phone Number
_ _ I
I _ _
Printed Name of Facility Staff
Date
Attach this form to the Quarterly Census