NEW JERSEY DEPARTMENT OF HUMAN SERVICES Schedule B PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT Center Name: DHS License Number: DO NOT change any preprinted NUMBER OF SLOTS UTILIZATION/ Molina Number: wording on this schedule. GROSS REVENUE FROM ROUTINE SERVICES Cost Report F.Y.E.: Number of Slots E F A B C D A + B C + D Authorized Occupied Total Amortized Total Occupied AM PM AM PM A NUMBER OF SLOTS UTILIZATION 1 Private Medicaid 2 3 Other (Specify): 4 Other (Specify): 5 Other (Specify): 6 Other (Specify): 7 Other (Specify): 8 9 ANNUAL UTILIZATION B GROSS REVENUES FROM ROUTINE SERVICES Private 10 Medicaid 11 12 ABC Program for Medically Fragile Children 13 14 15 16 17 18 19 Other (Specify): 20 21 Other (Specify): Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 TOTAL REVENUES FROM ROUTINE SERVICES 25
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 NUMBER OF SLOTS UTILIZATION/ GROSS REVENUE FROM ROUTINE SERVICES Schedule B DO NOT change any preprinted wording on this schedule. Number of Slots E F A B C D A + B Total Amortized C + D Total Occupied Authorized Occupied AM PM AM PM A NUMBER OF SLOTS UTILIZATION 1 Private 2 Medicaid 3 4 Other (Specify): 5 Other (Specify): 6 Other (Specify): 7 Other (Specify): 8 Other (Specify): 9 ANNUAL UTILIZATION B GROSS REVENUES FROM ROUTINE SERVICES 10 Private 11 Medicaid 12 ABC Program for Medically Fragile Children 13 14 15 16 17 18 19 20 Other (Specify): 21 Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 Other (Specify): 25 TOTAL REVENUES FROM ROUTINE SERVICES
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