Medicare Cost Application
In order to complete this application, you will need to download all of the following files. The application text (costapp.zip) provides instructions on how to use each file. All files are either Zipped Word(.doc) or Excel(.xls). To view a file, click on the .pdf file.
| Chapter | File Name | Description | File Size |
|---|---|---|---|
| GENERAL INFORMATION |
costapp.zip
costappl.pdf |
Application Form |
25kb
366kb |
| user-id.asp | HCFA Data Center Access Form | N/A | |
|
summary.zip
|
Summary Description | 14kb | |
| ORGANIZATIONAL AND CONTRACTUAL | staff.zip | Key Management Staff | 2kb |
| mgmtsvcs.zip | Management Services Contracts | 2kb | |
| legal#1.zip | Insurance Coverage Table | 4kb | |
| legal#2.zip | Provider Arrangements Table | 8kb | |
| HEALTH SERVICES DELIVERY | hsd1.zip | Health Services Delivery Tables | 8kb |
| hsd1a.zip | 6kb | ||
| hsd2.zip | 6kb | ||
| hsd3.zip | 11kb | ||
| hsd4.zips | 7kb | ||
| MEDICARE | enroll.zip | Enrollment Projections Table | 4kb |
| FINANCIAL | insolv.zip | Uncovered Expenditures | 8kb |
| finrpt_1.zip | Balance Sheet | 6kb | |
| finrpt_2.zip | Revenues and Expenses | 6kb | |
| finrpt_3.zip | Statement of Changes | 6kb |
If you have any question regarding the content of any of the application forms,
please contact Rosanna Johnson at 410-786-1148.
Last Modified on Thursday, September 16, 2004
Centers for Medicare & Medicaid Services