NEW JERSEY DEPARTMENT OF HUMAN SERVICES Schedule A-4 Center Name: PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DHS License Number: EXPENSES NOT RELATED TO THE DO NOT change any preprinted Molina Number: wording on this schedule. OPERATION OF THE CENTER 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 Personal Expenses 1 Interest 2 Fines, Penalties and Non-Allowable Interest 3 Amortization of Organization Cost 4 5 Prescribed Drugs 6 7 Income Taxes, including N. J. Corporate Business Tax on Net Income and Subsequent 8 Years Liability 9 10 Contributions 11 Collection Costs for Overdue Private Patient Accounts 12 Promotional and Directory Advertising Except for Bold Print Yellow Page Ads 13 Expenses Relating to Future Expansion, to include Architect Fees 14 Fund Raising Expenses 15 Bad Debts 16 Other (Specify): 17 Other (Specify): 18 Other (Specify): 19 Other (Specify): 20 Other (Specify): 21 Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 25 Other (Specify): Other (Specify): 26 Total to Schedule A, Line 37 27
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 EXPENSES NOT RELATED TO THE OPERATION OF THE CENTER Schedule A-4 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 1 Personal Expenses 2 Interest 3 Fines, Penalties and Non-Allowable Interest 4 Amortization of Organization Cost 5 Prescribed Drugs 6 7 8 Income Taxes, including N. J. Corporate Business Tax on Net Income and Subsequent Years Liability 9 10 11 Contributions 12 Collection Costs for Overdue Private Patient Accounts 13 Promotional and Directory Advertising Except for Bold Print Yellow Page Ads 14 Expenses Relating to Future Expansion, to include Architect Fees 15 Fund Raising Expenses 16 Bad Debts 17 Other (Specify): 18 Other (Specify): 19 Other (Specify): 20 Other (Specify): 21 Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 Other (Specify): 25 Other (Specify): 26 Other (Specify): 27 Total to Schedule A, Line 37
(F)%20PRN%202016-209%20(DHS-DAS%2010_166).docx