STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost - Building 2 1.02 Old Cap Rel Cost - Building 3 1.03 Old Cap Rel Cost - Building 5 1.05 Old Cap Rel Cost - Building 10 1.06 Old Cap Rel Cost - Building 20 1.07 Old Cap Rel Cost - Building 30 1.09 Old Cap Rel Cost - MRI Building 1.10 Old Cap Rel Cost - Building 80 1.11 Old Cap Rel Cost - Building 90 1.13 Old Cap Rel Cost - Land Improvements 2.00 Old Cap Rel Cost - Moveable Equipment 3.00 New Cap Rel Cost - Buildings and Fixtures 3.01 New Cap Rel Cost - Building 2 3.02 New Cap Rel Cost - Building 3 3.03 New Cap Rel Cost - Building 5 3.04 New Cap Rel Cost - Building 9 3.05 New Cap Rel Cost - Building 10 3.06 New Cap Rel Cost - Building 20 3.07 New Cap Rel Cost - Building 30 3.08 New Cap Rel Cost - Building 40 3.09 New Cap Rel Cost - MRI Building 3.10 New Cap Rel Cost - Building 80 3.11 New Cap Rel Cost - Building 90 3.12 New Cap Rel Cost - Building 100 3.13 New Cap Rel Costs - Land Imp 3.14 New Cap Rel Costs - MHRF 4.00 New Cap Rel Costs - Moveable Equipment 4.01 New Cap Rel Costs - Moveable Equipment 5.00 Employee Benefits 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 10.01 Housekeeping 11.00 Dietary 12.00 Cafeteria 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 22.00 Intern and Res Services - Salary and Fringes INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Subprovider I 29.00 Subprovider II 30.00 NICU 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 36.01 Subacute Care Unit 36.02 Transitional Care Unit COMPUTATION OF COST ALLOCATION (W/S B) SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2009 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP ADMINIS- OPERATIONS LAUNDRY & COSTS COSTS COSTS COSTS COSTS COSTS EMPLOYEE ACCUM- TRATIVE & MAINT & OF LINEN BLDG 90 BLDG 100 LAND IM MHRF LA MVBLE EQUIP MVBLE EQUIP BENEFITS COST GENERAL REPAIRS PLANT SERVICE 3.11 3.12 3.13 3.14 4.00 4.01 5.00 6.00 7.00 8.00 9.00 0 0 0 0 0 0 0000 0 0 0 0 0 0 0 71 0 3,306 0 532 26,713 3,794 50,143 849,603 0 1,118,220 87,842,015 0 0 15 1,446 57,307 0 85,824 17,457,626 3,163,245 2,471 6,834 1,062 31,164 59,898 0 94,858 13,232,390 2,397,651 1,599,073 0 0 300 0 0 0 16,248 2,265,833 410,559 450,973 408,471 977 0 212 13,456 0 0 297,427 13,326,530 2,414,709 318,887 288,834 3,173 000000000000 0 0 264 0 75,348 0 109,853 5,359,334 971,088 397,632 360,157 0 0 0 99 0 22,233 0 32,414 1,011,548 183,288 149,610 135,511 0 0 0 87 0 34,811 0 320,354 13,300,020 2,409,905 130,415 118,125 0 0 0 125 0 8,478 0 56,955 3,079,531 557,998 187,784 170,087 0 0 0 57 0 62,013 0 337,916 16,898,181 3,061,876 86,289 78,157 0 0 0 347 0 10,472 0 147,012 7,079,899 1,282,847 521,544 472,392 0 0 0 34 0 0 0 98,250 4,857,905 880,231 50,925 46,125 0 0 0 131 0 14,635 0 389,617 24,099,976 4,366,810 196,940 178,379 0 0 0 1,751 0 125,255 0 1,979,361 79,723,366 14,445,524 2,635,226 2,386,872 1,875,800 0 0 108 0 101,885 0 292,592 13,572,302 2,459,242 162,970 147,611 186,930 0 0 64 0 12,093 0 240,638 10,316,616 1,869,326 96,269 87,197 65,388 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 84 0 35,613 0 32,828 1,380,211 250,088 126,034 114,156 11,300 0 0 6 0 125,071 0 115,290 4,911,624 889,965 8,782 7,954 39,685 0 0 616 415,512 0 0 297,213 12,146,368 2,200,869 926,406 839,098 153,614 000000000000 000000000000 000000000000 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 43.00 Radioisotope 44.00 Laboratory 44.01 Laboratory Pathology 46.00 Whole Blood 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implantable Devices 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Other Ancillary Services 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 61.00 Emergency 61.01 Psych Emergency 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 63.61 Women's Health Center FQHC II 63.62 Family Health Center FQHC III 63.63 Children's Health Center FQHC IV 63.64 Urgent Care FQHC V 64.00 Home Program Dialysis NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 96.01 Other Than Hospital 98.00 99.00 99.01 99.02 99.03 99.04 99.05 99.06 99.07 99.08 99.09 99.10 TOTAL COMPUTATION OF COST ALLOCATION (W/S B) SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2009 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP ADMINIS- OPERATIONS LAUNDRY & COSTS COSTS COSTS COSTS COSTS COSTS EMPLOYEE ACCUM- TRATIVE & MAINT & OF LINEN BLDG 90 BLDG 100 LAND IM MHRF LA MVBLE EQUIP MVBLE EQUIP BENEFITS COST GENERAL REPAIRS PLANT SERVICE 3.11 3.12 3.13 3.14 4.00 4.01 5.00 6.00 7.00 8.00 9.00 0 0 305 0 558,242 0 384,265 27,603,446 5,001,623 459,755 416,426 457,630 0 0 71 0 13,980 0 121,946 5,027,221 910,910 106,682 96,628 28,446 0 0 74 0 116,390 0 90,042 5,292,035 958,893 110,651 100,223 0 0 0 422 0 310,735 0 321,297 22,726,875 4,118,010 634,572 574,768 112,267 0 0 0 0 0 0 0 0 0 0 0 0 104 11,293 346 0 112,293 0 0 22,207,609 4,023,921 520,935 471,840 0 0 0 318 0 8,839 0 4,371 1,532,572 277,695 478,360 433,278 7,857 0 0 0 0 0 0 0 3,118,600 565,077 0 0 0 0 0 25 0 113,211 0 0 4,662,876 844,893 37,506 33,971 0 0 0 90 0 0 0 119,916 5,553,013 1,006,182 135,170 122,431 20,946 0 0 9 0 0 0 19,159 809,950 146,759 14,106 12,777 0 0 0 98 0 127,951 0 14,487 3,476,348 629,899 147,410 133,518 2,665 0 0 3 0 0 0 4,104 161,217 29,212 3,831 3,470 0 0 0 3 0 0 0 0 2,532,040 458,794 4,224 3,826 0 0 0 0 0 0 0 0 4,306,295 780,282 0 0 0 681 0 47 3,517 944 0 0 16,018,681 2,902,515 70,060 63,458 0 0 4,544 43 0 20,045 0 0 2,755,528 499,290 64,992 58,867 3,330 0 0 105 0 9,292 0 26,176 2,082,908 377,414 157,744 142,878 0 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 000000000000 0 0 529 0 38,502 0 160,368 8,319,330 1,507,426 796,422 721,365 81,224 0 0 148 0 59,412 0 532,033 22,244,362 4,030,581 223,031 202,011 357,623 0 0 25 0 0 0 128,396 6,581,701 1,192,575 37,074 33,580 79,476 000000000000 4,048 0 432 0 0 0 198,035 19,660,146 3,562,332 508,950 460,985 0 0 0 108 0 2,369 0 135,804 7,342,337 1,330,399 162,459 147,149 0 1,380 0 376 0 0 0 110,332 7,066,493 1,280,418 565,749 512,431 0 0 0 182 0 0 0 79,542 4,531,045 821,006 274,446 248,581 0 0 0 0 0 0 0 73,844 2,571,088 465,870 141,300 127,983 0 0 0 0 0 0 0 0 463,760 84,031 0 0 0 000000000000 15,483 79,647 4,597 567,925 28,822 0 385,952 32,124,328 5,820,787 6,919,682 6,267,546 48,482 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 25,675 129,031 17,581 1,083,165 3,119,047 0 8,972,940 572,633,077 87,842,015 20,620,872 17,229,114 3,535,836 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost - Building 2 1.02 Old Cap Rel Cost - Building 3 1.03 Old Cap Rel Cost - Building 5 1.05 Old Cap Rel Cost - Building 10 1.06 Old Cap Rel Cost - Building 20 1.07 Old Cap Rel Cost - Building 30 1.09 Old Cap Rel Cost - MRI Building 1.10 Old Cap Rel Cost - Building 80 1.11 Old Cap Rel Cost - Building 90 1.13 Old Cap Rel Cost - Land Improvements 2.00 Old Cap Rel Cost - Moveable Equipment 3.00 New Cap Rel Cost - Buildings and Fixtures 3.01 New Cap Rel Cost - Building 2 3.02 New Cap Rel Cost - Building 3 3.03 New Cap Rel Cost - Building 5 3.04 New Cap Rel Cost - Building 9 3.05 New Cap Rel Cost - Building 10 3.06 New Cap Rel Cost - Building 20 3.07 New Cap Rel Cost - Building 30 3.08 New Cap Rel Cost - Building 40 3.09 New Cap Rel Cost - MRI Building 3.10 New Cap Rel Cost - Building 80 3.11 New Cap Rel Cost - Building 90 3.12 New Cap Rel Cost - Building 100 3.13 New Cap Rel Costs - Land Imp 3.14 New Cap Rel Costs - MHRF 4.00 New Cap Rel Costs - Moveable Equipment 4.01 New Cap Rel Costs - Moveable Equipment 5.00 Employee Benefits 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 10.01 Housekeeping 11.00 Dietary 12.00 Cafeteria 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 22.00 Intern and Res Services - Salary and Fringes INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Subprovider I 29.00 Subprovider II 30.00 NICU 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 36.01 Subacute Care Unit 36.02 Transitional Care Unit COMPUTATION OF COST ALLOCATION (W/S B) SCHEDULE 8.3 Fiscal Period Ended: JUNE 30, 2009 POST CENTRAL MED REC I&R SERV I&R SERV STEP-DOWN TOTAL NURSING SERVICES & & SOCIAL SALARY & OTHER ADJUSTMENT COST HOUSEKEEP DIETARY CAFETERIA ADMIN SUPPLY PHARMACY LIBRARY SERVICES BENEFITS PROGRAM 10.00 10.01 11.00 12.00 14.00 15.00 16.00 17.00 18.00 22.00 26.00 27.00 0 356,243 0 134,038 0 0 116,841 0 0 73,533 168,238 0 0 13,896 0 77,307 0 0 53,862 0 1,754 467,258 0 0 44,567 0 9,324 0 45,624 0 0 21,262 0 26,521 0 0 176,441 0 0 137,167 0 1,523000 2,360,931 0 3,870,166 386,201 6,722,342 98,005 30,231 2,575,026 1,545,510 5,742,041 124,397,241 146,007 0 37,080 40,688 954,129 50,658 24,178 269,687 161,864 0 18,213,346 86,249 0 23,356 32,062 753,767 11,408 10,666 191,045 114,664 0 13,658,014 0000000000 0 0000000000 0 112,916 0 0 4,270 99,773 3,583 360 29,498 17,704 0 2,149,895 7,868 0 0 14,984 350,430 6,293 1,266 103,595 62,177 0 6,404,622 829,978 0 1,475,411 59,457 1,184,375 9,775 1,977 254,963 153,027 0 20,235,317 0000000000 0 0000000000 0 0000000000 0 0000000000 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 43.00 Radioisotope 44.00 Laboratory 44.01 Laboratory Pathology 46.00 Whole Blood 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implantable Devices 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Other Ancillary Services 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 61.00 Emergency 61.01 Psych Emergency 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 63.61 Women's Health Center FQHC II 63.62 Family Health Center FQHC III 63.63 Children's Health Center FQHC IV 63.64 Urgent Care FQHC V 64.00 Home Program Dialysis NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 96.01 Other Than Hospital 98.00 99.00 99.01 99.02 99.03 99.04 99.05 99.06 99.07 99.08 99.09 99.10 TOTAL COMPUTATION OF COST ALLOCATION (W/S B) SCHEDULE 8.3 Fiscal Period Ended: JUNE 30, 2009 POST CENTRAL MED REC I&R SERV I&R SERV STEP-DOWN TOTAL NURSING SERVICES & & SOCIAL SALARY & OTHER ADJUSTMENT COST HOUSEKEEP DIETARY CAFETERIA ADMIN SUPPLY PHARMACY LIBRARY SERVICES BENEFITS PROGRAM 10.00 10.01 11.00 12.00 14.00 15.00 16.00 17.00 18.00 22.00 26.00 27.00 411,900 0 0 70,191 1,127,058 1,768,905 33,231 537,939 322,866 1,953,310 40,164,281 95,578 0 0 17,258 391,907 18,073 9,163 32,087 19,258 0 6,753,212 99,133 0 0 21,335 0 60,623 396,107 386,775 232,139 1,245,473 8,903,388 568,521 0 0 63,323 39,517 217,722 5,657 734,324 440,735 1,108,311 31,344,601 0 0 0 0 0 0 0 0 0 0 0 466,712 0 0 102,148 0 13,540 137 860,976 516,751 0 29,184,568 428,569 0 0 11,967 0 9,727 0 80,627 48,391 1,062,757 4,371,801 0 0 0 0 0 0 0 34,685 20,818 0 3,739,180 33,602 0 0 28,270 0 32,621 0 150,546 90,357 0 5,914,642 121,100 0 0 22,290 0 8,272 6 59,278 35,578 0 7,084,268 12,638 0 0 3,355 0 8,925 0 24,875 14,930 0 1,048,315 132,066 0 0 9,401 29,066 143,574 110,508 88,031 52,836 0 4,955,322 3,432 0 0 2,486 0 53 212 597 358 0 204,869 3,784 0 0 0 0 504,651 0 402,684 241,687 0 4,151,690 0 0 0 0 0 858,525 0 57,975 34,796 0 6,037,873 62,768 0 0 0 0 72,579 14,952,467 1,352,051 811,490 0 36,306,068 58,227 0 0 19,797 0 53,523 134 68,298 40,992 0 3,622,976 141,325 0 0 6,922 90,628 19,316 1,596 36,378 21,834 0 3,078,942 0000000000 0 0000000000 0 0000000000 0 0000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 0 0000000000 0 0000000000 0 0000000000 0 713,524 0 0 51,210 387,334 30,993 73,985 132,240 79,369 11,641,769 24,536,192 199,816 0 290,216 87,946 1,485,489 67,882 19,504 688,870 413,454 739,374 31,050,160 33,215 0 370,543 20,215 325,609 997 5,748 115,959 69,598 0 8,866,289 0000000000 0 455,975 0 0 63,236 453,632 20,509 3,227,087 294,817 176,947 1,509,535 30,394,153 145,549 0 0 22,456 378,027 12,792 418,221 90,638 54,400 1,176,642 11,281,068 506,862 0 0 34,774 194,157 8,675 84,346 96,326 57,814 1,381,384 11,789,429 245,880 0 0 12,226 218,651 2,987 75,441 68,640 41,197 1,000,934 7,541,033 126,592 0 0 10,966 199,056 2,965 671 47,735 28,650 595,705 4,318,580 0 0 0 0 0 0 0 10,667 6,403 0 564,861 0000000000 0 6,199,427 0 1,377,680 50,275 763,891 20,258 774,525 0 0 0 60,366,883 0000000000 0 0000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 0 0000000000 0 0000000000 0 0000000000 0 0000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 0 16,352,133 0 7,444,454 1,613,995 16,148,839 4,177,534 20,257,425 9,877,830 5,928,593 29,157,236 0 572,633,077 This is trial version www.adultpdf.com STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9 Provider Name: SAN FRANCISCO GENERAL HOSPITAL OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP BLDG & FIX BLDG 2 BLDG 3 BLDG 5 BLDG 10 BLDG 20 BLDG 30 MRI BLDG BLDG 80 BLDG 90 LAND IMP MVBLE EQP (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 1.01 1.02 1.03 1.05 1.06 1.07 1.09 1.10 1.11 1.13 2.00 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost - Building 2 1.02 Old Cap Rel Cost - Building 3 1.03 Old Cap Rel Cost - Building 5 1.05 Old Cap Rel Cost - Building 10 1.06 Old Cap Rel Cost - Building 20 1.07 Old Cap Rel Cost - Building 30 1.09 Old Cap Rel Cost - MRI Building 1.10 Old Cap Rel Cost - Building 80 1.11 Old Cap Rel Cost - Building 90 1.13 Old Cap Rel Cost - Land Improvements 2.00 Old Cap Rel Cost - Moveable Equipment 3.00 New Cap Rel Cost - Buildings and Fixtures 3.01 New Cap Rel Cost - Building 2 3.02 New Cap Rel Cost - Building 3 3.03 New Cap Rel Cost - Building 5 3.04 New Cap Rel Cost - Building 9 3.05 New Cap Rel Cost - Building 10 3.06 New Cap Rel Cost - Building 20 3.07 New Cap Rel Cost - Building 30 3.08 New Cap Rel Cost - Building 40 3.09 New Cap Rel Cost - MRI Building 3.10 New Cap Rel Cost - Building 80 3.11 New Cap Rel Cost - Building 90 3.12 New Cap Rel Cost - Building 100 3.13 New Cap Rel Costs - Land Imp 3.14 New Cap Rel Costs - MHRF 4.00 New Cap Rel Costs - Moveable Equipment 4.01 New Cap Rel Costs - Moveable Equipment 5.00 Employee Benefits 5,453 6.00 Administrative and General 4,209 2,345 2,291 185,100 20,912 812 290,645 7.00 Maintenance and Repairs 1,039 1,171 8.00 Operation of Plant 4,362 14,038 2,366 15,725 15,074 3,768 81,391 9.00 Laundry and Linen Service 22,295 659 320 22,954 10.00 Housekeeping 492 10,579 1,490 16,231 10.01 Housekeeping 11.00 Dietary 20,239 20,239 12.00 Cafeteria 7,615 7,615 14.00 Nursing Administration 6,368 6,638 15.00 Central Services and Supply 9,558 9,558 16.00 Pharmacy 4,392 4,392 17.00 Medical Records and Library 10,306 26,546 18.00 Social Service 2,592 2,592 22.00 Intern and Res Services - Salary and Fringes 10,024 10,024 INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics 8,974 125,156 134,130 26.00 Intensive Care Unit 8,295 8,295 27.00 Coronary Care Unit 4,900 4,900 28.00 Subprovider I 29.00 Subprovider II 30.00 NICU 6,415 6,415 33.00 Nursery 447 447 34.00 Medicare Certified Nursing Facility 9,234 47,153 35.00 Distinct Part Nursing Facility 36.00 36.01 Subacute Care Unit 36.02 Transitional Care Unit This is trial version www.adultpdf.com STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9 Provider Name: SAN FRANCISCO GENERAL HOSPITAL OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP OLD CAP BLDG & FIX BLDG 2 BLDG 3 BLDG 5 BLDG 10 BLDG 20 BLDG 30 MRI BLDG BLDG 80 BLDG 90 LAND IMP MVBLE EQP (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 1.01 1.02 1.03 1.05 1.06 1.07 1.09 1.10 1.11 1.13 2.00 ANCILLARY COST CENTERS 37.00 Operating Room 23,401 23,401 39.00 Delivery Room and Labor Room 5,430 5,430 40.00 Anesthesiology 5,632 5,632 41.00 Radiology - Diagnostic 32,299 32,299 43.00 Radioisotope 44.00 Laboratory 1,408 17,145 159 26,515 44.01 Laboratory Pathology 24,192 156 24,348 46.00 Whole Blood 49.00 Respiratory Therapy 1,909 1,909 50.00 Physical Therapy 6,453 6,880 51.00 Occupational Therapy 718 718 53.00 Electrocardiology 7,503 7,503 54.00 Electroencephalography 195 195 55.00 Medical Supplies Charged to Patients 215 215 55.01 Implantable Devices 56.00 Drugs Charged to Patients 2,207 1,038 3,566 57.00 Renal Dialysis 168 3,308 59.00 Other Ancillary Services 8,029 8,029 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 15,387 213 40,537 61.00 Emergency 11,352 11,352 61.01 Psych Emergency 1,887 1,887 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 5,693 6,174 33,097 63.61 Women's Health Center FQHC II 8,269 8,269 63.62 Family Health Center FQHC III 612 2,104 28,796 63.63 Children's Health Center FQHC IV 9,193 13,969 63.64 Urgent Care FQHC V 1,580 64.00 Home Program Dialysis NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 96.01 Other Than Hospital 51,435 63,391 13,328 19,609 23,613 352,204 98.00 99.00 99.01 99.02 99.03 99.04 99.05 99.06 99.07 99.08 99.09 99.10 TOTAL 70,388 39,170 92,240 617,404 56,128000039,1581,346,848 0 COST TO BE ALLOCATED 0 56,715 0 287,858 448 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 0.000000 1.447919 0.000000 0.466239 0.007982 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost - Building 2 1.02 Old Cap Rel Cost - Building 3 1.03 Old Cap Rel Cost - Building 5 1.05 Old Cap Rel Cost - Building 10 1.06 Old Cap Rel Cost - Building 20 1.07 Old Cap Rel Cost - Building 30 1.09 Old Cap Rel Cost - MRI Building 1.10 Old Cap Rel Cost - Building 80 1.11 Old Cap Rel Cost - Building 90 1.13 Old Cap Rel Cost - Land Improvements 2.00 Old Cap Rel Cost - Moveable Equipment 3.00 New Cap Rel Cost - Buildings and Fixtures 3.01 New Cap Rel Cost - Building 2 3.02 New Cap Rel Cost - Building 3 3.03 New Cap Rel Cost - Building 5 3.04 New Cap Rel Cost - Building 9 3.05 New Cap Rel Cost - Building 10 3.06 New Cap Rel Cost - Building 20 3.07 New Cap Rel Cost - Building 30 3.08 New Cap Rel Cost - Building 40 3.09 New Cap Rel Cost - MRI Building 3.10 New Cap Rel Cost - Building 80 3.11 New Cap Rel Cost - Building 90 3.12 New Cap Rel Cost - Building 100 3.13 New Cap Rel Costs - Land Imp 3.14 New Cap Rel Costs - MHRF 4.00 New Cap Rel Costs - Moveable Equipment 4.01 New Cap Rel Costs - Moveable Equipment 5.00 Employee Benefits 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 10.01 Housekeeping 11.00 Dietary 12.00 Cafeteria 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 22.00 Intern and Res Services - Salary and Fringes INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Subprovider I 29.00 Subprovider II 30.00 NICU 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 36.01 Subacute Care Unit 36.02 Transitional Care Unit STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9.1 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP BLDG FIXT BLDG 2 BLDG 3 BLDG 5 BLDG 9 BLDG 10 BLDG 20 BLDG 30 BLDG 40 BLDG MRI BLDG 80 BLDG 90 (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 5,453 4,209 2,345 2,291 185,100 3,418 20,912 28,100 10,813 3,124 6,487 812 1,039 4,362 14,038 2,366 15,725 6,812 15,074 7,459 3,166 243 812 3,768 22,295 659 320 492 10,579 19 31 1,779 195 98 1,490 20,239 7,615 6,368 270 9,558 4,392 10,306 16,240 2,592 10,024 8,974 125,156 8,295 4,900 6,415 447 9,234 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 43.00 Radioisotope 44.00 Laboratory 44.01 Laboratory Pathology 46.00 Whole Blood 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implantable Devices 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Other Ancillary Services 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 61.00 Emergency 61.01 Psych Emergency 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 63.61 Women's Health Center FQHC II 63.62 Family Health Center FQHC III 63.63 Children's Health Center FQHC IV 63.64 Urgent Care FQHC V 64.00 Home Program Dialysis NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 96.01 Other Than Hospital 98.00 99.00 99.01 99.02 99.03 99.04 99.05 99.06 99.07 99.08 99.09 99.10 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9.1 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP BLDG FIXT BLDG 2 BLDG 3 BLDG 5 BLDG 9 BLDG 10 BLDG 20 BLDG 30 BLDG 40 BLDG MRI BLDG 80 BLDG 90 (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 23,401 5,430 5,632 32,299 1,408 17,145 159 24,192 156 1,909 6,453 427 718 7,503 195 215 2,207 1,038 168 8,029 15,387 7,183 213 17,482 11,352 1,887 5,693 19,650 6,174 8,269 272 612 17,526 2,104 9,193 8,554 4,776 1,580 51,435 63,391 13,328 12,248 19,609 21,148 40,570 23,613 70,388 39,170 92,240 617,404 35,560 56,128 44,416 53,416 44,132 0 66,831 39,158 6,319 21,223 15,587 1,862,470 7,617 21,950 61,016 12,374 390 0 13,692 25,675 0.089774 0.541818 0.168983 3.016615 0.214201 0.391070 1.373739 0.231653 0.008837 0.000000 0.204875 0.655677 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost - Building 2 1.02 Old Cap Rel Cost - Building 3 1.03 Old Cap Rel Cost - Building 5 1.05 Old Cap Rel Cost - Building 10 1.06 Old Cap Rel Cost - Building 20 1.07 Old Cap Rel Cost - Building 30 1.09 Old Cap Rel Cost - MRI Building 1.10 Old Cap Rel Cost - Building 80 1.11 Old Cap Rel Cost - Building 90 1.13 Old Cap Rel Cost - Land Improvements 2.00 Old Cap Rel Cost - Moveable Equipment 3.00 New Cap Rel Cost - Buildings and Fixtures 3.01 New Cap Rel Cost - Building 2 3.02 New Cap Rel Cost - Building 3 3.03 New Cap Rel Cost - Building 5 3.04 New Cap Rel Cost - Building 9 3.05 New Cap Rel Cost - Building 10 3.06 New Cap Rel Cost - Building 20 3.07 New Cap Rel Cost - Building 30 3.08 New Cap Rel Cost - Building 40 3.09 New Cap Rel Cost - MRI Building 3.10 New Cap Rel Cost - Building 80 3.11 New Cap Rel Cost - Building 90 3.12 New Cap Rel Cost - Building 100 3.13 New Cap Rel Costs - Land Imp 3.14 New Cap Rel Costs - MHRF 4.00 New Cap Rel Costs - Moveable Equipment 4.01 New Cap Rel Costs - Moveable Equipment 5.00 Employee Benefits 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 10.01 Housekeeping 11.00 Dietary 12.00 Cafeteria 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 22.00 Intern and Res Services - Salary and Fringes INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Subprovider I 29.00 Subprovider II 30.00 NICU 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 36.01 Subacute Care Unit 36.02 Transitional Care Unit STATISTICS FOR COST ALLOCATION (W/S/ B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9.2 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP EMP BENEFIT ADM & GEN MAINT & OPER LAUNDRY HOUSEKEEP BLDG 100 LAND IMPRO MHRF MVBLE EQP MVBLE EQP (GROSS (ACCUM REPAIRS PLANT & LINEN (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) SALARIES) COST) (SQ FT) (SQ FT) (LB LNDRY) (SQ FT) 3.12 3.13 3.14 4.00 4.01 5.00 7.00 8.00 9.00 10.00 (Adj 12 ) 5,453 3,021 18,458 290,645 4,576 776,475 32,208,664 87,842,015 1,171 132 52,374 2,472,039 17,457,626 4,722 81,391 2,844 54,742 2,732,253 13,232,390 81,391 22,954 467,997 2,265,833 22,954 22,954 16,231 1,228 8,566,943 13,326,530 16,231 16,231 4,354 0 20,239 68,863 3,164,140 5,359,334 20,239 20,239 20,239 7,615 20,319 933,644 1,011,548 7,615 7,615 7,615 6,638 31,815 9,227,320 13,300,020 6,638 6,638 6,638 9,558 7,748 1,640,518 3,079,531 9,558 9,558 9,558 4,392 56,675 9,733,165 16,898,181 4,392 4,392 4,392 26,546 9,571 4,234,474 7,079,899 26,546 26,546 26,546 2,592 2,829,951 4,857,905 2,592 2,592 2,592 10,024 13,375 11,222,330 24,099,976 10,024 10,024 10,024 134,130 114,474 57,012,532 79,723,366 134,130 134,130 2,574,293 134,130 8,295 93,115 8,427,670 13,572,302 8,295 8,295 256,537 8,295 4,900 11,052 6,931,208 10,316,616 4,900 4,900 89,736 4,900 0 0 6,415 32,548 945,558 1,380,211 6,415 6,415 15,508 6,415 447 114,306 3,320,750 4,911,624 447 447 54,463 447 47,153 37,919 8,560,771 12,146,368 47,153 47,153 210,815 47,153 0 0 0 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 43.00 Radioisotope 44.00 Laboratory 44.01 Laboratory Pathology 46.00 Whole Blood 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implantable Devices 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Other Ancillary Services 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 61.00 Emergency 61.01 Psych Emergency 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 63.61 Women's Health Center FQHC II 63.62 Family Health Center FQHC III 63.63 Children's Health Center FQHC IV 63.64 Urgent Care FQHC V 64.00 Home Program Dialysis NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 96.01 Other Than Hospital 98.00 99.00 99.01 99.02 99.03 99.04 99.05 99.06 99.07 99.08 99.09 99.10 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 STATISTICS FOR COST ALLOCATION (W/S/ B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9.2 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP EMP BENEFIT ADM & GEN MAINT & OPER LAUNDRY HOUSEKEEP BLDG 100 LAND IMPRO MHRF MVBLE EQP MVBLE EQP (GROSS (ACCUM REPAIRS PLANT & LINEN (SQ FT) (SQ FT) (SQ FT) (SQ FT) (SQ FT) SALARIES) COST) (SQ FT) (SQ FT) (LB LNDRY) (SQ FT) 3.12 3.13 3.14 4.00 4.01 5.00 7.00 8.00 9.00 10.00 (Adj 12 ) 23,401 510,192 11,068,178 27,603,446 23,401 23,401 628,038 23,401 5,430 12,777 3,512,462 5,027,221 5,430 5,430 39,039 5,430 5,632 106,372 2,593,514 5,292,035 5,632 5,632 5,632 32,299 283,989 9,254,471 22,726,875 32,299 32,299 154,072 32,299 0 7,803 26,515 102,628 22,207,609 26,515 26,515 26,515 24,348 8,078 125,914 1,532,572 24,348 24,348 10,783 24,348 3,118,600 1,909 103,467 4,662,876 1,909 1,909 1,909 6,880 3,454,001 5,553,013 6,880 6,880 28,746 6,880 718 551,845 809,950 718 718 718 7,503 116,938 417,287 3,476,348 7,503 7,503 3,657 7,503 195 118,221 161,217 195 195 195 215 2,532,040 215 215 215 4,306,295 3,566 321 863 16,018,681 3,566 3,566 3,566 3,140 3,308 18,320 2,755,528 3,308 3,308 4,570 3,308 8,029 8,492 753,970 2,082,908 8,029 8,029 8,029 0 0 0 0 0 0 0 0 0 0 40,537 35,188 4,619,164 8,319,330 40,537 40,537 111,469 40,537 11,352 54,298 15,324,409 22,244,362 11,352 11,352 490,792 11,352 1,887 3,698,256 6,581,701 1,887 1,887 109,071 1,887 0 33,097 5,704,114 19,660,146 25,905 25,905 25,905 8,269 2,165 3,911,643 7,342,337 8,269 8,269 8,269 28,796 3,177,945 7,066,493 28,796 28,796 28,796 13,969 2,291,101 4,531,045 13,969 13,969 13,969 2,126,958 2,571,088 7,192 7,192 7,192 463,760 0 0 55,034 352,204 51,828 26,341 11,116,783 32,124,328 352,204 352,204 66,535 352,204 0 0 0 0 0 0 0 0 0 0 0 0 89,157 1,346,848 98,848 2,850,581 0 258,452,163 484,791,062 1,049,579 968,188 4,852,478 929,003 129,031 17,581 1,083,165 3,119,047 0 8,972,940 87,842,015 20,620,872 17,229,114 3,535,836 16,352,133 1.447234 0.013053 10.957885 1.094179 0.000000 0.034718 0.181196 19.646803 17.795216 0.728666 17.601808 This is trial version www.adultpdf.com [...]... GENERAL SERVICE COST CENTERS Old Cap Rel Cost - Buildings and Fixtures Old Cap Rel Cost - Building 2 Old Cap Rel Cost - Building 3 Old Cap Rel Cost - Building 5 Old Cap Rel Cost - Building 10 Old Cap Rel Cost - Building 20 Old Cap Rel Cost - Building 30 Old Cap Rel Cost - MRI Building Old Cap Rel Cost - Building 80 Old Cap Rel Cost - Building 90 Old Cap Rel Cost - Land Improvements Old Cap Rel Cost -... New Cap Rel Cost - Buildings and Fixtures New Cap Rel Cost - Building 2 New Cap Rel Cost - Building 3 New Cap Rel Cost - Building 5 New Cap Rel Cost - Building 9 New Cap Rel Cost - Building 10 New Cap Rel Cost - Building 20 New Cap Rel Cost - Building 30 New Cap Rel Cost - Building 40 New Cap Rel Cost - MRI Building New Cap Rel Cost - Building 80 New Cap Rel Cost - Building 90 New Cap Rel Cost - Building... Rel Costs - Land Imp New Cap Rel Costs - MHRF New Cap Rel Costs - Moveable Equipment New Cap Rel Costs - Moveable Equipment Employee Benefits Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Housekeeping Dietary Cafeteria Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Social Service Intern and Res Services... Records and Library Social Service Intern and Res Services - Salary and Fringes INPATIENT ROUTINE COST CENTER Adults and Pediatrics Intensive Care Unit Coronary Care Unit Subprovider I Subprovider II NICU Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility SAN FRANCISCO GENERAL HOSPITAL Provider Name: STATE OF CALIFORNIA This is trial version www.adultpdf.com DIETARY 96,649 134,130... NURSING ADM 20,239 7,615 6,638 9,558 4,392 26,546 2,592 10,024 (MEALS SERVED) 11.00 HOUSEKEEP STATISTICS FOR COST ALLOCATION (W/S B-1) 17,973 31,565 49,033 491,586 254,096 57,223 8,796 46,769 133,029 7,640 SUPPLIES (COST REQ) 15.00 (Adjs 15, 16) CTRL SERV 401 1,408 2,199 33,632 26,898 11,866 (COSTS REQUIS) 16.00 (Adj 17) PHARMACY MED REC 4,267,520 14,987,302 36,885,977 372,533,933 39,016,135 27,638,860... (Adj 18) Fiscal Period Ended: JUNE 30, 2009 4,267,520 14,987,302 36,885,977 372,533,933 39,016,135 27,638,860 (GROSS CHARGES) 18.00 (Adj 18) SOC SERV 22,941 & FRINGES (ASG TIME) 22.00 (Adj 19) I&R-SAL SCHEDULE 9.3 . Unit COMPUTATION OF COST ALLOCATION (W/S B) SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2009 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP ADMINIS- OPERATIONS LAUNDRY & COSTS COSTS COSTS COSTS. OF COST ALLOCATION (W/S B) SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2009 NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP ADMINIS- OPERATIONS LAUNDRY & COSTS COSTS COSTS COSTS COSTS COSTS. STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost