NFCCR | Cost Center Reporting Form

Cost Center Reporting Form

Instructions:

All required fields are indicated by "*". Please provide two different email addresses to facilitate any follow-up that may be needed. When you have completed all required fields, select "Submit".
NOTE: Providers with initial certification dates on or after January 1, 2020 are NOT required to file this information.

Provider Information

* Medicaid Provider ID

* Provider Name / Business Name

* Submitter Name

* Submitter Title

* Contact Email (Primary)

* Contact Email (Secondary)

Reporting Information

*Reporting Period

* Direct Care Total Cost for Report Period

Report total direct care costs for time period of this NFCCR submission for those cost centers included in Schedule B-2 of the annual cost report.

* Ancillary Total Cost for Report Period

Report total ancillary care costs for time period of this NFCCR submission for those cost centers included in Schedule C of the annual cost report.

*Total Inpatient Days for Report Period

Report total inpatient days for time period of this NFCCR submission

*Total Tax Cost for Report Period

Report total tax cost for time period of this NFCCR submission

Comments

Confirm and Submit

* I here by declare that the details furnished above are true and correct for the best of my knowledge.

* Full Name of Applicant