Worksheet formats are based on information supplied by the Centers for Medicare and Medicaid Services (CMS).  Forms and instructions can be downloaded from the CMS website and are presented here as a convenient reference.

* Worksheets which are not yet available on CostReportData.com have been marked with an asterisk. Please contact us if there is a specific sheet to be requested, as an addition, to those already available.

[-] 2010 Format

S001	Worksheet S Parts I, II & III Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary	form	instructions
S100	Worksheet S-10 Hospital Uncompensated and Indigent Care Data Worksheet S-10 is used for cost reports with begin date before October 1, 2022.	form	instructions
S101	Worksheet S-10 Part I Hospital Uncompensated and Indigent Care Data Worksheets S-10 Part I and S-10 Part II are used for cost reports with begin date on or after October 1, 2022.	form	instructions
S102	Worksheet S-10 Part II Hospital Uncompensated and Indigent Care Data - Hospital Data Worksheets S-10 Part I and S-10 Part II are used for cost reports with begin date on or after October 1, 2022.	form	instructions
S201	Worksheet S-2 Part I Hospital and Hospital Health Care Complex Identification Data	form	instructions
S202	Worksheet S-2 Part II Hospital and Hospital Health Care Complex Reimbursement Questionnaire	form	instructions
S301	Worksheet S-3 Part I Hospital and Hospital Health Care Complex Statistical Data	form	instructions
S302	Worksheet S-3 Parts II & III Hospital Wage Index Information	form	instructions
S304	Worksheet S-3 Part IV Hospital Wage Related Costs	form	instructions
S305	Worksheet S-3 Part V Hospital Contract Labor and Benefit Cost	form	instructions
S400	Worksheet S-4 Hospital-based Home Health Agency Statistical Data	form	instructions
S500	Worksheet S-5 Hospital Renal Dialysis Department Statistical Data	form	instructions
S600	Worksheet S-6 * Hospital-based Community Mental Health Center and Other Outpatient Rehabilitation Provider Statistical Data	form	instructions
S700	Worksheet S-7 Prospective Payment for SNF Statistical Data	form	instructions
S800	Worksheet S-8 * Hospital-based Rural Health Clinic / Federally Qualified Health Center Statistical Data	form	instructions
S900	Worksheet S-9 Parts I-IV * Hospice Identification Data	form	instructions
S111	Worksheet S-11 Part I * Hospital-based FQHC Identification Data	form	instructions
S112	Worksheet S-11 Part II * Hospital-based FQHC Consolidated Cost Report Participant Identification Data	form	instructions
S113	Worksheet S-11 Part III * Hospital-based FQHC Statistical Data	form	instructions
A000	Worksheet A Reclassification and Adjustment of Trial Balance of Expenses	form	instructions
A600	Worksheet A-6 Reclassifications	form	instructions
A701	Worksheet A-7 Parts I, II & III Reconciliation of Capital Costs Centers	form	instructions
A800	Worksheet A-8 Adjustments to Expenses	form	instructions
A81A	Worksheet A-8-1 Part A Statement of Costs of Services from Related Organizations and Home Office Costs	form	instructions
A81B	Worksheet A-8-1 Part B Interrelationship to Related Organization(s) and/or Home Office	form	instructions
A820	Worksheet A-8-2 Provider-based Physicians Adjustments	form	instructions
A830	Worksheet A-8-3 Parts I - VI Reasonable Cost Determination for Therapy Services Furnished by Outside Suppliers	form	instructions
B001	Worksheet B Part I Cost Allocation - General Service Costs	form	instructions
B002	Worksheet B Part II Allocation of Capital-related Costs	form	instructions
B100	Worksheet B-1 Cost Allocation - Statistical Basis	form	instructions
B200	Worksheet B-2 Post Stepdown Adjustments	form	instructions
C001	Worksheet C Part I Computation of Ratio of Costs to Charges	form	instructions
C002	Worksheet C Part II * Calculation of Outpatient Service Cost to Charge Ratios Net of Reductions for Medicaid Only	form	instructions
D001	Worksheet D Part I Apportionment of Inpatient Routine Service Capital Costs	form	instructions
D002	Worksheet D Part II Apportionment of Inpatient Ancillary Service Capital Costs	form	instructions
D003	Worksheet D Part III Apportionment of Inpatient Routine Service Other Pass Through Costs	form	instructions
D004	Worksheet D Part IV Apportionment of Inpatient/Outpatient Ancillary Service Other Pass Through Costs	form	instructions
D005	Worksheet D Part V Apportionment of Medical and Other Health Services Costs	form	instructions
D101	Worksheet D-1 Part I Computation of Inpatient Operating Cost - All Provider Components	form	instructions
D102	Worksheet D-1 Part II Computation of Inpatient Operating Cost - Hospital and Subproviders Only	form	instructions
D103	Worksheet D-1 Parts III & IV Computation of Inpatient Operating Cost - SNF, NF and ICF/IID Only	form	instructions
D200	Worksheet D-2 Parts 1 - III * Apportionment of Cost of Services Rendered by Interns and Residents	form	instructions
D300	Worksheet D-3 Inpatient Ancillary Service Cost Apportionment	form	instructions
D401	Worksheet D-4 Part I Computation of Organ Acquisition Costs and Charges for a Transplant Hospital with a Medicare-certified Transplant Program - Routine and Acillary Costs	form	instructions
D402	Worksheet D-4 Part II Computation of Organ Acquisition Costs and Charges for a Transplant Hospital with a Medicare-certified Transplant Program - Other Costs	form	instructions
D403	Worksheet D-4 Parts III & IV Computation of Organ Acquisition Costs and Charges for a Transplant Hospital with a Medicare-certified Transplant Program - Summary and Statistics	form	instructions
D501	Worksheet D-5 Part I * Apportionment of Cost for Physicians' Services in a Teaching Hospital - Reasonable Compensation Computation PE Before June 30,2014	form	instructions
D502	Worksheet D-5 Part II * Apportionment of Cost for Physicians' Services in a Teaching Hospital - Apportionment of Costs PE Before June 30,2014	form	instructions
D503	Worksheet D-5 Part III * Apportionment of Cost for Physicians' Services in a Teaching Hospital - Reasonable Compensation Computation PE On or after June 30,2014	form	instructions
D504	Worksheet D-5 Part IV * Apportionment of Cost for Physicians' Services in a Teaching Hospital - Apportionment of Costs PE On or after June 30,2014	form	instructions
D601	Worksheet D-6 Parts I & II Computation of Cellular Therapy Acquisition Costs	form	instructions
D603	Worksheet D-6 Part III Computation of Cellular Therapy Acquisition Costs Summary	form	instructions
E00A	Worksheet E Part A Calculation of Reimbursement Settlement - Inpatient PPS	form	instructions
E00B	Worksheet E Part B Calculation of Reimbursement Settlement - Medical and Other Health Services	form	instructions
E101	Worksheet E-1 Part I * Analysis of Payments to Providers for Services Rendered	form	instructions
E102	Worksheet E-1 Part II Calculation of Reimbursement Settlement for HIT	form	instructions
E200	Worksheet E-2 Calculation of Reimbursement Settlement - Swing Beds	form	instructions
E301	Worksheet E-3 Part I Calculation of Medicare Reimbursement Settlement Under TEFRA	form	instructions
E302	Worksheet E-3 Part II Calculation of Medicare Reimbursement Settlement Under IPF PPS	form	instructions
E303	Worksheet E-3 Part III Calculation of Medicare Reimbursement Settlement Under IRF PPS	form	instructions
E304	Worksheet E-3 Part IV Calculation of Medicare Reimbursement Settlement Under LTCH PPS	form	instructions
E305	Worksheet E-3 Part V Calculation of Medicare Reimbursement Settlement for Medicare Part A Services - Cost Reimbursement (CAHs)	form	instructions
E306	Worksheet E-3 Part VI Calculation of Medicare Reimbursement Settlement - Title XVIII Part A PPS SNF Services	form	instructions
E307	Worksheet E-3 Part VII * Calculation of Medicare Reimbursement Settlement - All Other Health Services for Titles V or Title XIX Services	form	instructions
E400	Worksheet E-4 Direct Graduate Medical Education (GME) & ESRD Outpatient Direct Medical Education Costs	form	instructions
E500	Worksheet E-5 * Outlier Reconciliation at Tentative Settlement	form	instructions
E950	Worksheet E-95 * Payment Adjustments for Domestic NIOSH-Approved Surgical N95 Respirators	form	instructions
G000	Worksheet G Balance Sheet	form	instructions
G100	Worksheet G-1 Statement of Changes in Fund Balances	form	instructions
G200	Worksheet G-2 Parts I & II Statement of Patient Revenues and Operating Expenses	form	instructions
G300	Worksheet G-3 Statement of Revenues and Expenses	form	instructions
H000	Worksheet H Analysis of Hosptial-based Home Health Agency Costs	form	instructions
H101	Worksheet H-1 Part I * Cost Allocation - HHA General Service Cost	form	instructions
H102	Worksheet H-1 Part II * Cost Allocation - HHA Statistical Basis	form	instructions
H201	Worksheet H-2 Part I * Allocation of General Service Costs to HHA Cost Centers	form	instructions
H202	Worksheet H-2 Part II * Allocation of General Service Costs to HHA Cost Centers Statistical Basis	form	instructions
H300	Worksheet H-3 Parts I & II * Apportionment of Patient Service Costs	form	instructions
H400	Worksheet H-4 Parts I & II * Calculation of HHA Reimbursement Settlement	form	instructions
H500	Worksheet H-5 * Analysis of Payments to Hospital-based HHAs for Services Rendered to Program Beneficiaries	form	instructions
I100	Worksheet I-1 * Analysis of Renal Dialysis Department Costs	form	instructions
I200	Worksheet I-2 * Allocation of Renal Department Costs to Treatment Modalities	form	instructions
I300	Worksheet I-3 * Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis	form	instructions
I400	Worksheet I-4 * Computation of Average Cost per Treatment for Outpatient Renal Dialysis	form	instructions
I500	Worksheet I-5 * Calculation of Reimbursable Bad Debts - Title XVIII - Part B	form	instructions
J101	Worksheet J-1 Part I * Allocation of General Service Costs to Community Mental Health Centers	form	instructions
J102	Worksheet J-1 Part II * Allocation of General Service Costs to Community Mental Health Centers - Statistical Basis	form	instructions
J201	Worksheet J-2 Part I * Computation of Community Mental Health Center Provider Costs - Apportionment of CMHC Cost Centers	form	instructions
J202	Worksheet J-2 Part II * Computation of Community Mental Health Center Provider Costs - Apportionment of Costs Furnished by Shared ospital Departments	form	instructions
J300	Worksheet J-3 * Calculation of Reimbursement Settlement Community Mental Health Center Provider Services	form	instructions
J400	Worksheet J-4 * Analysis of Payments to Hospital-based Community Mental Health Center for Services Rendered to Program Beneficiaries	form	instructions
K000	Worksheet K Analysis of Hospital-based Hospice Costs	form	instructions
K100	Worksheet K-1 Hospice Compensation Analysis Salaries and Wages	form	instructions
K200	Worksheet K-2 Hospice Compensation Analysis Employee Benefits (Payroll Related)	form	instructions
K300	Worksheet K-3 Hospice Compensation Analysis Contracted Services/Purchased Services	form	instructions
K401	Worksheet K-4 Part I Cost Allocation - Hospice General Service Cost	form	instructions
K402	Worksheet K-4 Part II Cost Allocation - Hospice Statistical Basis	form	instructions
K501	Worksheet K-5 Part I Allocation of General Service Costs to Hospice Cost Centers	form	instructions
K502	Worksheet K-5 Part II Allocation of General Service Costs to Hospice Cost Centers - Statistical Basis	form	instructions
K503	Worksheet K-5 Part III Apportionment of Hospice Shared Services	form	instructions
K600	Worksheet K-6 Calculation of Hospice per Diem Cost	form	instructions
L000	Worksheet L Parts I, II & III Calculation of Capital Payment	form	instructions
L101	Worksheet L-1 Part I * Allocation of Allowable Costs for Extraordinary Circumstances	form	instructions
L102	Worksheet L-1 Part II * Computation of Program Inpatient Routine Service Capital Costs for Extraordinary Circumstances	form	instructions
L103	Worksheet L-1 Part III * Computation of Program Inpatient Ancillary Service Capital Costs for Extraordinary Circumstances	form	instructions
M100	Worksheet M-1 Analysis of Hospital-based Rural Health Clinic / Federally Qualified Health Center Costs	form	instructions
M200	Worksheet M-2 Allocation of Overhead to Hospital-based RHC/FQHC Services	form	instructions
M300	Worksheet M-3 Calculation of Reimbursement Settlement for Hospiital-based RHC/FQHC Services	form	instructions
M400	Worksheet M-4 Computation of Hospital-based RHC/FQHC Vaccine Cost	form	instructions
M500	Worksheet M-5 Analysis of Payments to Hospital-based RHC/FQHC Provider for Services Rendered to Program Beneficiaries	form	instructions
N100	Worksheet N-1 * Reclassification and Adjustment of Trial Balance of Expenses for Hospital-based FQHC	form	instructions
N200	Worksheet N-2 * Calculation of Hospital-based FQHC Cost per Visit	form	instructions
N300	Worksheet N-3 * Computation of Hospital-based FQHC Vaccine Cost	form	instructions
N400	Worksheet N-4 * Calculation of Hospital-based FQHC Reimbursement Settlement	form	instructions
N500	Worksheet N-5 * Analysis of Payments to Hospital-based FQHC for Services Rendered	form	instructions
O000	Worksheet O * Analysis of Hospital-based Hospice Costs	form	instructions
O100	Worksheet O-1 * Hospice Continuous Home Care Costs	form	instructions
O200	Worksheet O-2 * Hospice Routine Home Care Costs	form	instructions
O300	Worksheet O-3 * Hospice Inpatient Respite Care Costs	form	instructions
O400	Worksheet O-4 * Hospice General Inpatient Care Costs	form	instructions
O500	Worksheet O-5 * Cost Allocation - Determination of Hospital-based Hospice Net Expenses for Allocation	form	instructions
O601	Worksheet O-6 Part I * Cost Allocation - Hospital-based Hospice General Service Costs	form	instructions
O602	Worksheet O-6 Part II * Cost Allocation - Hospital-based Hospice General Service Costs Statistical Basis	form	instructions
O700	Worksheet O-7 * Apportionment of Hospital-based Hospice Shared Service Costs By Level of Care	form	instructions
O800	Worksheet O-8 * Calculation of Hospital-based Hospice Per Diem Cost	form	instructions

[+] 1996 Format

S20	Worksheet S-2 Hospital and Hospital Health Care Complex Identification Data	form	instructions
S31	Worksheet S-3, Part I Hospital and Hospital Health Care Complex Statistical Data	form	instructions
S32	Worksheet S-3, Part II Hospital Wage Index Information - Wage Data	form	instructions
S33	Worksheet S-3, Part III Hospital Wage Index Information - Wage Index Summary	form	instructions
S10	Worksheet S-10 Hospital Uncompensated Care Data	form	instructions
A00	Worksheet A Reclassification and Adjustment of Trial Balance of Expenses	form	instructions
A71	Worksheet A-7, Parts I & II Analysis of Changes During Cost Reporting Period in Capital Asset Balance	form	instructions
A73	Worksheet A-7, Parts III & IV Reconciliation of Capital Cost Centers	form	instructions
A80	Worksheet A-8 Adjustments to Expenses	form	instructions
81A	Worksheet A-8-1, Part A Statement of Costs of Services from Related Organizations and Home Office Costs - Costs and Adjustments	form	instructions
81B	Worksheet A-8-1, Part B Statement of Costs of Services from Related Organizations and Home Office Costs - Interrelationships	form	instructions
B01	Worksheet B, Part I Cost Allocation - General Service Costs	form	instructions
B10	Worksheet B-1 Cost Allocation - Statistical Basis	form	instructions
C01	Worksheet C, Part I Computation of Ratio of Costs to Charges	form	instructions
C02	Worksheet C, Part II Calculation of Outpatient Service Cost to Charge Ratios Net of Reductions	form	instructions
D01	Worksheet D, Part I Apportionment of Inpatient Routine Service Capital Costs	form	instructions
D02	Worksheet D, Part II Apportionment of Inpatient Ancillary Service Capital Costs	form	instructions
D03	Worksheet D, Part III Apportionment of Inpatient Routine Service Other Pass Through Costs	form	instructions
D04	Worksheet D, Part IV Apportionment of Inpatient/Outpatient Ancillary Service Other Pass Through Costs	form	instructions
D05	Worksheet D, Parts V & VI Apportionment of Medical, Other Health Services Costs and Vaccine Cost	form	instructions
D11	Worksheet D-1, Part I Computation of Inpatient Operating Cost - All Provider Components	form	instructions
D12	Worksheet D-1, Part II Computation of Inpatient Operating Cost - Hospital and Subproviders Only	form	instructions
D13	Worksheet D-1, Parts III & IV Computation of Inpatient Operating Cost - SNF, NF, ICF/MR, and Observation Beds	form	instructions
D40	Worksheet D-4 Inpatient Ancillary Service Cost Apportionment	form	instructions
D60	Worksheet D-6, Parts III & IV Computation of Organ Acquisition Costs and Charges	form	instructions
E0A	Worksheet E, Part A Calculation of Reimbursement Settlement - Inpatient Hospital Services Under PPS	form	instructions
E0B	Worksheet E, Part B Calculation of Reimbursement Settlement - Medical and Other Health Services	form	instructions
E0C	Worksheet E, Part C Calculation of Reimbursement Settlement - Outpatient Ambulatory Surgical Center	form	instructions
E0D	Worksheet E, Part D Calculation of Reimbursement Settlement - Outpatient Radiology Services	form	instructions
E0E	Worksheet E, Part E Calculation of Reimbursement Settlement - Other Outpatient Diagnostic Procedures	form	instructions
E20	Worksheet E-2 Calculation of Reimbursement Settlement - Swing Beds	form	instructions
E31	Worksheet E-3, Part I Calculation of Medicare Reimbursement Settlement under TEFRA, IRF PPS, LTAC PPS, and IPF PPS	form	instructions
E32	Worksheet E-3, Part II Calculation of Reimbursement Settlement - Medicare Part A Services - Cost Reimbursement	form	instructions
E33	Worksheet E-3, Part III Calculation of Reimbursement Settlement - Title V or Title XIX Services or Title XVIII SNF PPS Only	form	instructions
E34	Worksheet E-3, Part IV Direct Graduate Medical Education (GME) & ESRD Outpatient Direct Medical Education Costs	form	instructions
E35	Worksheet E-3, Part V Calculation of NHCMQ Demonstration Reimbursement Settlement	form	instructions
E36	Worksheet E-3, Part VI Calculation of GME & IME Payments for Redistribution of Unused Residency Slots	form	instructions
G00	Worksheet G Balance Sheet	form	instructions
G20	Worksheet G-2, Parts I & II Statement of Patient Revenues and Operating Revenues	form	instructions
G30	Worksheet G-3 Statement of Revenues and Expenses	form	instructions
H60	Worksheet H-6 Apportionment of Patient Service Costs [HHA]	form	instructions
H70	Worksheet H-7 Calculation of HHA Reimbursement Settlement	form	instructions
L00	Worksheet L Calculation of Capital Payment	form	instructions
M10	Worksheet M-1 Analysis of Provider-Based Rural Health Clinic / Federally Qualified Health Center Costs	form	instructions
M20	Worksheet M-2 Allocation of Overhead to RHC/FQHC Services	form	instructions
M30	Worksheet M-3 Calculation of Reimbursement Settlement for RHC/FQHC Services	form	instructions
M40	Worksheet M-4 Computation of Pneumococcal and Influenza Vaccine Cost	form	instructions
M50	Worksheet M-5 Analysis of Payments to Hospital-Based RHC/FQHC Provider for Services Rendered to Program Beneficiaries	form	instructions