Form B "New Jersey Acute Care Hospitals Cost Reports - Patient Care Volumes" - New Jersey

What Is Form B?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the New Jersey Department of Health;
  • 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 B by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form B "New Jersey Acute Care Hospitals Cost Reports - Patient Care Volumes" - New Jersey

Download PDF

Fill PDF online

Rate (4.6 / 5) 35 votes
B
NEW JERSEY ACUTE CARE HOSPITALS
Hospital: __________________________________________
2020
COST REPORTS
Do not change any preprinted
Hospital Number: |_____|_____|_____|_____|
PATIENT CARE VOLUMES
wording on this form.
A
B
C
D
E
F
G
H
I
J
K
L
Transfer
Inpatient Volumes
PSA
ICU
MSA
PED
OBS
CCU
NNI
NBN
SNF
SAC
Within
TOTAL
(5)
(6)
Hospital
0
1
Admissions (1,2) (Incl. Same Day Medical Admissions)
(
)
2
Same Day Medical Admissions
/ / / / / / / /
3
Patient Days (1,3)
/ / / / / / / /
4
Licensed Beds/Bassinets (4)
/ / / / / / / /
5
Maintained Beds (7)
/ / / / / / / /
6
Occupancy Percentage (1)
/ / / / / / / /
7
Discharges (1)
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
FOOTNOTES:
(1) Must exclude all Same Day Surgery as defined in NJAC 8:31B-3.11. Calculate occupancy percentage using Licensed Beds/Bassinets.
(2) Include patients transferred from other units within the Hospital for all services (including Newborns).
(3) Include patient days of patients transferred from other units (including Newborns) and Same Day Medical Admissions.
(4) Include licensed MSA beds used for Same Day Surgery or Same Day Medical Admissions, but not unlicensed beds.
(5) Report all Psychiatric admissions here. Provide detailed listing in Form “B” format for all inpatient Psychiatric cases utilizing specialty Psychiatric beds.
(6) Report Burn Care in ICU. Provide detailed listing.
(7) Report “Set up and Staffed Beds” on this line.
This report is required by state regulation. Failure to report as provided for within NJAC 8:31B-3.3 Uniform Reporting: Current Costs and NJAC 8:31B-4.6(c) may result in a
daily penalty past the appropriate submission due date. Intentional misrepresentation of falsification of any information contained within this cost report may be punishable by
fine and/or imprisonment under state law.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I hereby certify that I have read the above statement and that I have examined the accompanying cost report and the Balance Sheet and Statement of Revenues and Expenses prepared
by the
________________________________________________________________________________ ________________________
for the cost report period commencing
(Provider Name)
(Provider Number)
(Provider Name)
(Provider Number)
on _____________________ and concluding on ________________________, and that to the best of my knowledge and belief, it is a true, correct and complete statement prepared
from the books and records of the provider in accordance with the applicable instructions, except as noted.
Name and Title of Contact for these Forms
Telephone Number
Name and Title of Responsible Official
Signature
Date
B
NEW JERSEY ACUTE CARE HOSPITALS
Hospital: __________________________________________
2020
COST REPORTS
Do not change any preprinted
Hospital Number: |_____|_____|_____|_____|
PATIENT CARE VOLUMES
wording on this form.
A
B
C
D
E
F
G
H
I
J
K
L
Transfer
Inpatient Volumes
PSA
ICU
MSA
PED
OBS
CCU
NNI
NBN
SNF
SAC
Within
TOTAL
(5)
(6)
Hospital
0
1
Admissions (1,2) (Incl. Same Day Medical Admissions)
(
)
2
Same Day Medical Admissions
/ / / / / / / /
3
Patient Days (1,3)
/ / / / / / / /
4
Licensed Beds/Bassinets (4)
/ / / / / / / /
5
Maintained Beds (7)
/ / / / / / / /
6
Occupancy Percentage (1)
/ / / / / / / /
7
Discharges (1)
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
FOOTNOTES:
(1) Must exclude all Same Day Surgery as defined in NJAC 8:31B-3.11. Calculate occupancy percentage using Licensed Beds/Bassinets.
(2) Include patients transferred from other units within the Hospital for all services (including Newborns).
(3) Include patient days of patients transferred from other units (including Newborns) and Same Day Medical Admissions.
(4) Include licensed MSA beds used for Same Day Surgery or Same Day Medical Admissions, but not unlicensed beds.
(5) Report all Psychiatric admissions here. Provide detailed listing in Form “B” format for all inpatient Psychiatric cases utilizing specialty Psychiatric beds.
(6) Report Burn Care in ICU. Provide detailed listing.
(7) Report “Set up and Staffed Beds” on this line.
This report is required by state regulation. Failure to report as provided for within NJAC 8:31B-3.3 Uniform Reporting: Current Costs and NJAC 8:31B-4.6(c) may result in a
daily penalty past the appropriate submission due date. Intentional misrepresentation of falsification of any information contained within this cost report may be punishable by
fine and/or imprisonment under state law.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I hereby certify that I have read the above statement and that I have examined the accompanying cost report and the Balance Sheet and Statement of Revenues and Expenses prepared
by the
________________________________________________________________________________ ________________________
for the cost report period commencing
(Provider Name)
(Provider Number)
(Provider Name)
(Provider Number)
on _____________________ and concluding on ________________________, and that to the best of my knowledge and belief, it is a true, correct and complete statement prepared
from the books and records of the provider in accordance with the applicable instructions, except as noted.
Name and Title of Contact for these Forms
Telephone Number
Name and Title of Responsible Official
Signature
Date