report record number
provider control type code
provider number
national provider identifier
report status code
fiscal year begin date
fiscal year end date
hcris process date
initial report switch
last report switch
transmittal number
fiscal intermediary number
automated desk review vendor code
fiscal intermediary create date
utilization code
notice of program reimbursment date
special indicator
fiscal intermediary receipt date
Hospital Street Address           S200001 00100 00100
(Y/N)                                       S200001 10500 00100
for outpatient service? (Y/N)               S200001 10600 00100
S200001 10700 00100
schedule? (Y/N)                             S200001 10800 00100
provider? (Y/N)                             S200001 11500 00100
center? (Y/N)                               S200001 11600 00100
transplant center? (Y/N)                    S200001 12500 00100
transplant center cert date                 S200001 12600 00100
transplant center cert date                 S200001 12700 00100
transplant center cert date                 S200001 12800 00100
transplant center cert date                 S200001 12900 00100
certification date                          S200001 13100 00100
certification date                          S200001 13200 00100
enter the OPO number                        S200001 13400 00100
Pub. 15-I, chapter 10? (Y/N)                  S200001 14000 00100
Home Office Name                              S200001 14100 00100
Home Office Street                            S200001 14200 00100
City                                          S200001 14300 00100
included in Worksheet A? (Y/N)                S200001 14400 00100
inpatient services only? (Y/N)               S200001 14500 00100
Hospital City                     S200001 00200 00100
accordance with 42 CFR 412.320?(Y/N/P)        S200001 02200 00100
Hospital Name                     S200001 00300 00100
Beginning Date of SCH status                S200001 03600 00100
Beginning Date of SCH status                S200001 03601 00100
MDH status beginning date (MM/DD/YY)         S200001 03800 00100
(Y/N)                                         S200001 04700 00100
costs? (Y/N)                                  S200001 04800 00100
affiliated with a teaching hospital? (Y/N)  S200001 05600 00100
or allied health costs?                      S200001 06000 00100
413.40(f)(1)(I) (TEFRA)? (Y/N)                S200001 08500 00100
413.40(f)(1)(I)?(Y/N)                         S200001 08600 00100
facility for purposes of Title XIX? (Y/N)     S200001 09300 00100
Hospital PO Box                   S200001 00100 00200
NF Provider Number                S200001 01000 00200
S200001 10700 00200
used: (A, B, or E only)                     S200001 11500 00200
HHA 1 Provider Number                 S200001 01200 00200
Medicare Certified Kidney TC term date      S200001 12600 00200
Medicare Certified Heart TC term date       S200001 12700 00200
Medicare Certified Liver TC term date       S200001 12800 00200
Medicare Certified Lung TC term date        S200001 12900 00200
HHA 2 Provider Number                 S200001 01201 00200
HHA 3 Provider Number                 S200001 01202 00200
ASC 1 Provider Number                 S200001 01300 00200
Medicare Certified Pancreas TC term date    S200001 13000 00200
Hospice 1 Provider Number             S200001 01400 00200
FI/Contractor's Name                          S200001 14000 00200
Home Office PO Box                            S200001 14200 00200
State                                         S200001 14300 00200
Hospice 2 Provider Number             S200001 01401 00200
RHC 1 Provider Number               S200001 01500 00200
RHC 2 Provider Number               S200001 01501 00200
RHC 3 Provider Number               S200001 01502 00200
RHC 4 Provider Number               S200001 01503 00200
RHC 5 Provider Number               S200001 01504 00200
RHC 6 Provider Number               S200001 01505 00200
RHC 7 Provider Number               S200001 01506 00200
RHC 8 Provider Number               S200001 01507 00200
RHC 9 Provider Number               S200001 01508 00200
RHC 10 Provider Number              S200001 01509 00200
RHC 11 Provider Number              S200001 01510 00200
RHC 12 Provider Number              S200001 01511 00200
RHC 13 Provider Number              S200001 01512 00200
RHC 14 Provider Number              S200001 01513 00200
RHC 15 Provider Number              S200001 01514 00200
RHC 16 Provider Number              S200001 01515 00200
RHC 17 Provider Number              S200001 01516 00200
RHC 18 Provider Number              S200001 01517 00200
RHC 19 Provider Number              S200001 01518 00200
FQHC 1 Provider Number              S200001 01600 00200
FQHC 2 Provider Number              S200001 01601 00200
FQHC 3 Provider Number              S200001 01602 00200
FQHC 4 Provider Number              S200001 01603 00200
FQHC 5 Provider Number              S200001 01604 00200
FQHC 6 Provider Number              S200001 01605 00200
FQHC 7 Provider Number              S200001 01606 00200
FQHC 8 Provider Number              S200001 01607 00200
FQHC 9 Provider Number              S200001 01608 00200
CMHC 1 Provider Number              S200001 01700 00200
Renal 1 Provider Number                   S200001 01800 00200
Renal 2 Provider Number                   S200001 01801 00200
Renal 3 Provider Number                   S200001 01802 00200
Renal 4 Provider Number                   S200001 01803 00200
Renal 5 Provider Number                   S200001 01804 00200
Renal 6 Provider Number                   S200001 01805 00200
Renal 7 Provider Number                   S200001 01806 00200
Renal 8 Provider Number                   S200001 01807 00200
Renal 9 Provider Number                   S200001 01808 00200
Renal 10 Provider Number                  S200001 01809 00200
Hospital State                    S200001 00200 00200
Ending Date of SCH status                   S200001 03600 00200
Ending Date of SCH status                   S200001 03601 00200
MDH status ending date (MM/DD/YY)            S200001 03800 00200
IPF Provider Number               S200001 00400 00200
Swing Bed SNF Provider Number     S200001 00700 00200
Swing Bed NF Provider Number      S200001 00800 00200
SNF Provider Number               S200001 00900 00200
Zip Code                                      S200001 14300 00300
Hospital Zip Code                 S200001 00200 00300
Provider's actual MSA or CBSA             S200001 00300 00300
Hospital County                   S200001 00200 00400
Hospital Title 18 Payment System (P/T/O)  S200001 00300 00700
MCP Physician Payment Method (Y/N)       S500000 02100 00100
Initial Physician Payment Method (Y/N)   S500000 02100 00200
Land                                 A700001 00100 00100
Land Improvements                    A700001 00200 00100
Buildings and Fixtures               A700001 00300 00100
Fixed Equipment                      A700001 00500 00100
Land                                 A700001 00100 00200
Land Improvements                    A700001 00200 00200
Buildings and Fixtures               A700001 00300 00200
Fixed Equipment                      A700001 00500 00200
Land                                 A700001 00100 00300
Land Improvements                    A700001 00200 00300
Buildings and Fixtures               A700001 00300 00300
Fixed Equipment                      A700001 00500 00300
Land                                 A700001 00100 00500
Land Improvements                    A700001 00200 00500
Buildings and Fixtures               A700001 00300 00500
Fixed Equipment                      A700001 00500 00500
Investment Income-New Movable Equip       A800000 00200 00200
E10A182 00100 00100
E20F180 00100 00100
E30A181 00100 00100
E30A182 00100 00100
E30B182 00100 00100
E30A183 00100 00100
E30C183 00100 00100
E30A184 00100 00100
E30E186 00100 00100
e_A_hos10_c1_1
e_B_hos10_c1_1
e_B_ipf10_c1_1
e_B_irf10_c1_1
e_B_snf10_c1_1
G200000 00100 00100
G300000 00100 00100
H310181 00500 00500
H310181 00600 00500
H310181 00500 00600
H310181 00600 00600
H310181 00700 00600
H310181 00600 00700
H310181 00700 00700
H320181 00500 00500
H320181 00600 00500
H320181 00500 00600
H320181 00600 00600
H320181 00700 00600
H320181 00600 00700
H320181 00700 00700
H330181 00500 00500
H330181 00600 00500
H330181   00500   006 H330181 00500 00600
H330181   00600   006 H330181 00600 00600
H330181   00700   006 H330181 00700 00600
H330181   00600   007 H330181 00600 00700
H330181   00700   007 H330181 00700 00700
S300001   01400   01400 S300001 01400 01400
Total                                 S300001 00700 00200
Total Hospital                        S300001 00700 00300
Total Hospital                        S300001 00700 00400
Total Hospital                          S300001 00700 00500
Total Adults & Peds                     S300001 00700 00600
HMO                                     S300001 00200 00700
S300001 00300 00700
S300001 00400 00700
Hospital Adlts & Ped Swing Bed SNF      S300001 00500 00700
Hospital Adlts & Ped Swing Bed NF       S300001 00600 00700
Total Adults & Peds                     S300001 00700 00700
Non-Physician Anesthetist Part A          S300002 00200 00200
Physician-Part A                          S300002 00400 00200
Physician-Part B                          S300002 00500 00200
Non-Physician Part B                      S300002 00600 00200
Non-Physician Anesthetist Part A          S300002 00200 00400
Physician-Part A                          S300002 00400 00400
Physician-Part B                          S300002 00500 00400
Non-Physician Part B                      S300002 00600 00400
Non-Physician Anesthetist Part A         S300002 00200 00500
Physician-Part A                         S300002 00400 00500
Physician-Part B                         S300002 00500 00500
Non-Physician Part B                     S300002 00600 00500
Non-Physician Anesthetist Part A         S300002 00200 00600
Physician-Part A                         S300002 00400 00600
Physician-Part B                         S300002 00500 00600
Non-Physician Part B                     S300002 00600 00600
Excluded Area Salaries                  S300003 00200 00200
Subtotal Other Wages and Related Csts   S300003 00400 00200
Subtotal Wage Related Csts              S300003 00500 00200
Total                                   S300003 00600 00200
Excluded Area Salaries                  S300003 00200 00400
Subtotal Other Wages and Related Csts   S300003 00400 00400
Subtotal Wage Related Csts              S300003 00500 00400
Total                                   S300003 00600 00400
Excluded Area Salaries                  S300003 00200 00500
Subtotal Other Wages and Related Csts   S300003 00400 00500
Total                                   S300003 00600 00500
Excluded Area Salaries                  S300003 00200 00600
Subtotal Other Wages and Related Csts   S300003 00400 00600
Subtotal Wage Related Csts              S300003 00500 00600
Total                                   S300003 00600 00600
end of cost reporting period               S500000 00100 00100
receives Dialysis                          S500000 00200 00100
including setup                            S500000 00300 00100
furnished                                  S500000 00500 00100
Number of stations                         S500000 00600 00100
end of cost reporting period               S500000 00100 00200
Patient receives Dialysis                  S500000 00200 00200
including setup                            S500000 00300 00200
furnished                                  S500000 00500 00200
Number of stations                      S500000 00600 00200
end of cost reporting period            S500000 00100 00300
Patient receives Dialysis               S500000 00200 00300
including setup                         S500000 00300 00300
CAPD exchanges per day                  S500000 00400 00400
Number of stations                      S500000 00600 00400
end of cost reporting period            S500000 00100 00500
furnished                               S500000 00200 00500
end of cost reporting period            S500000 00100 00600
Patient receives Dialysis               S500000 00200 00600
CAPD exchanges per day                  S500000 00400 00600