(including fringe benefits) b. Contractual Services c. Interest on Current Debt d. Interest on Project Debt e. Current Depreciation f. Project Depreciation g. Current Amortization h. Project Amortization i. Supplies j. Other Expenses (Specify) k. Total Operating Expenses 3. Income a. Income from Operation b. Non-Operating Income c. Subtotal d. Income Taxes e. Net Income (Loss) Revenues and Expenses PCI Two Most Actual Current Projected – Services Ended Recent Year (ending with third full year in which the Years Projected applicant projects provision of npPCI services CY or FY (Circle) 20__ 20__ 20__ 20__ 20__ 20____ 20____ 4. Patient Mix: A. Percent of Total Revenue 1) Medicare 2) Medicaid 3) Blue 4) Commercial Insurance
(including fringe benefits) b. Contractual Services c. Interest on Current Debt d. Interest on Project Debt e. Current Depreciation f. Project Depreciation g. Current Amortization h. Project Amortization i. Supplies j. Other Expenses (Specify) k. Total Operating Expenses 3. Income a. Income from Operation b. Non-Operating Income c. Subtotal d. Income Taxes e. Net Income (Loss) Revenues and Expenses – PCI Services Two Most Actual Ended Recent Years Current Year Projected Projected (ending with third full year in which the applicant projects provision of npPCI services CY or FY (Circle) 20__ 20__ 20__ 20__ 20__ 20____ 20____ 4. Patient Mix: A. Percent of Total Revenue 1) Medicare 2) Medicaid 3) Blue 4) Commercial Insurance
npPCI%20Application%202018.docx