Schedule A-3 NEW JERSEY DEPARTMENT OF HUMAN SERVICES Center Name: Page 1 of 2 PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DHS License Number: DO NOT change any preprinted Molina Number: 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 GFRB GENERAL FRINGE BENEFITS FICA - OASDI 1 FICA - Medicare 2 Compensation 3 Workers’ Unemployment Insurance 4 Disability Insurance 5 6 Medical Insurance Life and Other Insurance 7 Uniform Allowance 8 Employee Physicians and Inoculations 9 Dental Other (Specify): 10 401(k) 11 Other (Specify): CPR 12 Other (Specify): Other (Specify): 13 Other (Specify): 14 General Fringe Benefit Recovery 15 Total to Schedule A, Line 1 A, 1 16 DS DEVELOPMENTAL SERVICES Daily Classroom Supplies Other Therapy: 17 Crafts Other Therapy: 18 Other Therapy: 19 Other Therapy: 20 Other Therapy: 21 Other Therapy: 22 Other Therapy: 23 Total to Schedule A, Line 10 A, 10 24
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 1 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 GFRB GENERAL FRINGE BENEFITS 1 FICA - OASDI 2 FICA - Medicare 3 Workers’ Compensation 4 Unemployment Insurance 5 Disability Insurance 6 Medical Insurance 7 Life and Other Insurance 8 Uniform Allowance 9 Employee Physicians and Inoculations 10 Other (Specify): Dental 11 Other (Specify): 401(k) 12 Other (Specify): CPR 13 Other (Specify): 14 Other (Specify): 15 General Fringe Benefit Recovery 16 Total to Schedule A, Line 1 A, 1 DS DEVELOPMENTAL SERVICES 17 Other Therapy: Daily Classroom Supplies 18 Other Therapy: Crafts 19 Other Therapy: 20 Other Therapy: 21 Other Therapy: 22 Other Therapy: 23 Other Therapy: 24 Total to Schedule A, Line 10 A, 10
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