Schedule A-2 Center Name: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DHS License Number: DO NOT change any preprinted Molina Number: OTHER ADMINISTRATIVE 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 Office Personnel 1 Office Supplies and Expenses 2 Telephone 3 License and Dues 4 5 Data Processing 6 Insurance Not Related to Property or Employees Business Taxes 7 Travel 8 Accounting Fees 9 Legal Fees 10 Other Administrative Fees 11 Seminars 12 Medical Records 13 14 Help Wanted Ads Services and Supplies Sold 15 Purchase Discounts and Rebates 16 Other OADM Recoveries 17 Amortization of Start-up Costs 18 Employee Gifts and Parties 19 Other (Specify): 20 Other (Specify): 21 Other (Specify): 22 23 Other (Specify): Other (Specify): 24 Other (Specify): 25 Other (Specify): 26 Other (Specify): 27 Other (Specify): 28 Other (Specify): 29 Other (Specify): 30 Total to Schedule A, Line 24 A, 24 31
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 ADMINISTRATIVE Schedule A-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 1 Office Personnel 2 Office Supplies and Expenses 3 Telephone 4 License and Dues 5 Data Processing 6 Insurance Not Related to Property or Employees 7 Business Taxes 8 Travel 9 Accounting Fees 10 Legal Fees 11 Other Administrative Fees 12 Seminars 13 Medical Records 14 Help Wanted Ads 15 Services and Supplies Sold 16 Purchase Discounts and Rebates 17 Other OADM Recoveries 18 Amortization of Start-up Costs 19 Employee Gifts and Parties 20 Other (Specify): 21 Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 Other (Specify): 25 Other (Specify): 26 Other (Specify): 27 Other (Specify): 28 Other (Specify): 29 Other (Specify): 30 Other (Specify): 31 Total to Schedule A, Line 24 A, 24
(F)%20PRN%202016-209%20(DHS-DAS%2010_166).docx