Schedule A-1 Center Name: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DOH License Number: DO NOT change any preprinted Molina Number: ADMINISTRATION wording on this schedule. Cost Report F.Y.E.: A B C D E F Description Number of Salaries and Fees and Other Recovery and Net Routine Hours Employees Fringe Benefits Expenses Eliminations Expenses DETAILS OF ADMINISTRATION Management Fees, Provider Schedule of Explanation 1 2 Home Office Costs, Not in Line 1 Above 3 Fees and Expenses Director’s Related Party Compensation 4 Management Auto Leasing and Depreciation 5 6 7 8 9 10 Management Out of State Travel 11 Administrator Out of State Travel 12 Assistant Administrator Out of State Travel 13 Management Salary 14 Administrator Salary 15 Assistant Administrator Salary 16 Management General Fringe Benefits 17 18 Administrator General Fringe Benefits Assistant Administrator General Fringe Benefits 19 Management Special Fringe Benefits 20 Administrator Special Fringe Benefits 21 Assistant Administrator Special Fringe Benefits 22 Management Dues 23 Administrator Dues 24 Assistant Administrator Dues 25 Management Other (Specify): 26 27 Administrator Other (Specify): Assistant Administrator Other (Specify): 28 Total to Schedule A, Line 23 29
Center Name: DOH License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT ADMINISTRATION Schedule A-1 DO NOT change any preprinted wording on this schedule. Description A B C D E F Number of Employees Hours Salaries and Fringe Benefits Fees and Other Expenses Recovery and Eliminations Net Routine Expenses DETAILS OF ADMINISTRATION 1 Management Fees, Provider Schedule of Explanation 2 Home Office Costs, Not in Line 1 Above 3 Director’s Fees and Expenses 4 Related Party Compensation 5 Management Auto Leasing and Depreciation 6 7 8 9 10 11 Management Out of State Travel 12 Administrator Out of State Travel 13 Assistant Administrator Out of State Travel 14 Management Salary 15 Administrator Salary 16 Assistant Administrator Salary 17 Management General Fringe Benefits 18 Administrator General Fringe Benefits 19 Assistant Administrator General Fringe Benefits 20 Management Special Fringe Benefits 21 Administrator Special Fringe Benefits 22 Assistant Administrator Special Fringe Benefits 23 Management Dues 24 Administrator Dues 25 Assistant Administrator Dues 26 Management Other (Specify): 27 Administrator Other (Specify): 28 Assistant Administrator Other (Specify): 29 Total to Schedule A, Line 23
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