Schedule A-3 NEW JERSEY DEPARTMENT OF HUMAN SERVICES Center Name: Page 2 of 2 PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DHS License Number: Molina Number: DO NOT change any preprinted OTHER COST DETAILS wording on this schedule. Cost Report F.Y.E.: A B C D E F Schedule A, Description Number of Salaries and Fees and Other Recovery and Net Routine Line Number Hours Employees Fringe Benefits Expenses Eliminations Expenses RHBT REHABILITATIVE AND OTHER SERVICES 25 Occupational Therapy Physical Therapy 26 27 Speech Therapy 28 29 Developmental Therapy 30 31 Other (Specify): Social Worker PRN Other (Specify): 32 Total to Schedule A, Line 11 A, 11 33 OGSR OTHER GENERAL SERVICES Disposal Service 34 Exterminating Service 35 Grounds Maintenance 36 Medical Library 37 Motor Pool 38 Plant Security 39 Snow Removal 40 Fire Drill 41 Other (Specify): 42 IT Consultants Other (Specify): 43 Total to Schedule A, Line 25 A, 25 44 UTIL FACILITY EXPENSES Cable Television 45 Electric 46 Fuel Oil 47 Natural Gas 48 Water and Sewage 49 Total to Schedule A, Line 30 A, 30 50
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT OTHER COST DETAILS Schedule A-3 Page 2 of 2 DO NOT change any preprinted wording on this schedule. Description Schedule A, Line Number A B C D E F Number of Employees Hours Salaries and Fringe Benefits Fees and Other Expenses Recovery and Eliminations Net Routine Expenses RHBT REHABILITATIVE AND OTHER SERVICES 25 Occupational Therapy 26 Physical Therapy 27 Speech Therapy 28 29 Developmental Therapy 30 31 Other (Specify): Social Worker PRN 32 Other (Specify): 33 Total to Schedule A, Line 11 A, 11 OGSR OTHER GENERAL SERVICES 34 Disposal Service 35 Exterminating Service 36 Grounds Maintenance 37 Medical Library 38 Motor Pool 39 Plant Security 40 Snow Removal 41 Fire Drill 42 Other (Specify): IT Consultants 43 Other (Specify): 44 Total to Schedule A, Line 25 A, 25 UTIL FACILITY EXPENSES 45 Cable Television 46 Electric 47 Fuel Oil 48 Natural Gas 49 Water and Sewage 50 Total to Schedule A, Line 30 A, 30