Page 1
E00 Wkst E Calculation of Reimbursement Settlement
A Part A - Inpatient Hospital Services under PPS
A18 Hospital Medicare
00101 DRG Amounts other than outlier payments for discharges occuring prior to October 1, 2013.
100080 JFK MEDICAL CENTER 00100 Amounts 18,427,257.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 16,695,594.
100176 PALM BEACH GARDENS 00100 Amounts 31,273,000.
100234 WEST PALM HOSPITAL 00100 Amounts 1,939,545.
100258 DELRAY MEDICAL CENTER 00100 Amounts 56,580,228.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 10,856,355.
100269 PALMS WEST HOSPITAL 00100 Amounts 5,485,146.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 13,536,181.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 8,500,571.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 4,862,814.
00200 Outlier Payments for Discharges
100002 BETHESDA HOSPITAL INC 00100 Amounts 998,345.
100080 JFK MEDICAL CENTER 00100 Amounts 1,778,326.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 226,863.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 2,559,359.
100176 PALM BEACH GARDENS 00100 Amounts 3,320,704.
100234 WEST PALM HOSPITAL 00100 Amounts 105,542.
100253 JUPITER MEDICAL CENTER 00100 Amounts 595,708.
100258 DELRAY MEDICAL CENTER 00100 Amounts 3,493,571.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 288,378.
100269 PALMS WEST HOSPITAL 00100 Amounts 503,862.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 493,496.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 839,812.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 305,088.
00300 Managed Care Similated Payments.
100002 BETHESDA HOSPITAL INC 00100 Amounts 25,141,018.
100080 JFK MEDICAL CENTER 00100 Amounts 57,512,904.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 988,418.
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Provider Provider Name Col Column Desc Amount Type
Page 2
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 18,262,777.
100176 PALM BEACH GARDENS 00100 Amounts 17,233,817.
100234 WEST PALM HOSPITAL 00100 Amounts 5,229,352.
100258 DELRAY MEDICAL CENTER 00100 Amounts 28,967,332.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 10,243,915.
100269 PALMS WEST HOSPITAL 00100 Amounts 14,737,472.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 18,938,810.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 10,872,287.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 7,767,272.
00400 Bed days available divided by number of days in the cost reporting period. Beds
100002 BETHESDA HOSPITAL INC 00100 Amounts 381.22 Beds
100080 JFK MEDICAL CENTER 00100 Amounts 441.05 Beds
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 66.22 Beds
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 345.47 Beds
100176 PALM BEACH GARDENS 00100 Amounts 182.64 Beds
100234 WEST PALM HOSPITAL 00100 Amounts 158.37 Beds
100253 JUPITER MEDICAL CENTER 00100 Amounts 193.83 Beds
100258 DELRAY MEDICAL CENTER 00100 Amounts 314.18 Beds
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 186.95 Beds
100269 PALMS WEST HOSPITAL 00100 Amounts 193.61 Beds
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 210.75 Beds
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 316.23 Beds
100288 ST MARYS MEDICAL CENTER 00100 Amounts 383.71 Beds
00500 IME Adj - FTE count for allopathic and osteopathic programs for periods before 12/31/1996.
FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 1.58 FTEs
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 15. FTEs
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 10.50 FTEs
00600 IME Adj - FTE count for allopathic and osteopathic programs which meet the criteria for new programs
FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 39.9000 FTEs
100234 WEST PALM HOSPITAL 00100 Amounts 6.3200 FTEs
100269 PALMS WEST HOSPITAL 00100 Amounts 20.6700 FTEs
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Provider Provider Name Col Column Desc Amount Type
Page 3
00700 IME Adj - MMA Section 422 reduction amount to the IME cap as specified under 42 CRR 412.105(f)(1)(iv
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.11
00701 IME Adj - ACA Section 5503 reduction amount to the IME cap as specified under MMA Section 42 CRR 412
100269 PALMS WEST HOSPITAL 00100 Amounts 6.86
00800 IME Adj - Adjustment to FTE count for allopathic and osteopathic programs for affiliated programs in
FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 45. FTEs
00801 IME Adj - The amount of increase if the hospital was awarded FTE cap slots under section 5503 of the
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 9.
00900 IME Adj - (Sum of Lines 05 Plus 06 Minus Lines 07 and 7.01 Plus/Minus Line 08 plus lines 8.02 and 8.
100002 BETHESDA HOSPITAL INC 00100 Amounts 45.
100080 JFK MEDICAL CENTER 00100 Amounts 41.48
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 15.
100234 WEST PALM HOSPITAL 00100 Amounts 6.32
100269 PALMS WEST HOSPITAL 00100 Amounts 13.81
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 19.39
01000 IME Adj - FTE count for allopathic and ostepathic programs in the current year from your records.
FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 14.07 FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 57.72 FTEs
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 12.67 FTEs
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 37.97 FTEs
100234 WEST PALM HOSPITAL 00100 Amounts 16.31 FTEs
100269 PALMS WEST HOSPITAL 00100 Amounts 20.79 FTEs
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 18. FTEs
01100 IME Adj - FTE counts for residents in dental and podiatric programs. FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 5.90 FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 5.99 FTEs
01200 IME Adj - Current Year Allowable FTEs (See Instructions) FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 19.97 FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 47.47 FTEs
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 12.67 FTEs
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Provider Provider Name Col Column Desc Amount Type
Page 4
100234 WEST PALM HOSPITAL 00100 Amounts 6.32 FTEs
100269 PALMS WEST HOSPITAL 00100 Amounts 13.81 FTEs
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 18. FTEs
01300 IME Adj - Total Allowable FTE Count For Prior Year FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 16.02 FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 45.90 FTEs
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 11.33 FTEs
100234 WEST PALM HOSPITAL 00100 Amounts 6.32 FTEs
100269 PALMS WEST HOSPITAL 00100 Amounts 13.81 FTEs
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 17.63 FTEs
01400 IME Adj - Total allowable FTE count for the penultimate year if year ended before 9-1-1997.
FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 8.18 FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 45.90 FTEs
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 12.58 FTEs
100234 WEST PALM HOSPITAL 00100 Amounts 6.32 FTEs
100269 PALMS WEST HOSPITAL 00100 Amounts 13.81 FTEs
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 19.39 FTEs
01500 IME Adj - Total (Lines 12 to 14 Divided by Line 03) (See Instructions) FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 14.72 FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 46.42 FTEs
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 12.19 FTEs
100234 WEST PALM HOSPITAL 00100 Amounts 6.32 FTEs
100269 PALMS WEST HOSPITAL 00100 Amounts 13.81 FTEs
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 18.34 FTEs
01600 IME Adj - Adjustment for residents in initial years of the program. FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 4.96 FTEs
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 37.97 FTEs
100258 DELRAY MEDICAL CENTER 00100 Amounts 15.83 FTEs
01800 IME Adj - Adjusted Rolling Average FTE Count FTEs
100002 BETHESDA HOSPITAL INC 00100 Amounts 19.68 FTEs
100080 JFK MEDICAL CENTER 00100 Amounts 46.42 FTEs
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 12.19 FTEs
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Provider Provider Name Col Column Desc Amount Type
Page 5
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 37.97 FTEs
100234 WEST PALM HOSPITAL 00100 Amounts 6.32 FTEs
100258 DELRAY MEDICAL CENTER 00100 Amounts 15.83 FTEs
100269 PALMS WEST HOSPITAL 00100 Amounts 13.81 FTEs
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 18.34 FTEs
01900 IME Adj - Current Year Resident to Bed Ratio (Line 18 Divided by Line 04) Ratio
100002 BETHESDA HOSPITAL INC 00100 Amounts 0.051624 Ratio
100080 JFK MEDICAL CENTER 00100 Amounts 0.105249 Ratio
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 0.184083 Ratio
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 0.109908 Ratio
100234 WEST PALM HOSPITAL 00100 Amounts 0.039907 Ratio
100258 DELRAY MEDICAL CENTER 00100 Amounts 0.050385 Ratio
100269 PALMS WEST HOSPITAL 00100 Amounts 0.071329 Ratio
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.087023 Ratio
02000 IME Adj - Prior Year Resident to Bed Ratio (See Instructions) Ratio
100002 BETHESDA HOSPITAL INC 00100 Amounts 0.041564 Ratio
100080 JFK MEDICAL CENTER 00100 Amounts 0.118832 Ratio
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 0.182898 Ratio
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 0.107427 Ratio
100234 WEST PALM HOSPITAL 00100 Amounts 0.039321 Ratio
100258 DELRAY MEDICAL CENTER 00100 Amounts 0.048364 Ratio
100269 PALMS WEST HOSPITAL 00100 Amounts 0.070006 Ratio
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.091842 Ratio
02100 IME Adj - Enter the Lesser of Line 19 or Line 20 (See Instructions) Ratio
100002 BETHESDA HOSPITAL INC 00100 Amounts 0.041564 Ratio
100080 JFK MEDICAL CENTER 00100 Amounts 0.105249 Ratio
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 0.182898 Ratio
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 0.107427 Ratio
100234 WEST PALM HOSPITAL 00100 Amounts 0.039321 Ratio
100258 DELRAY MEDICAL CENTER 00100 Amounts 0.048364 Ratio
100269 PALMS WEST HOSPITAL 00100 Amounts 0.070006 Ratio
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.087023 Ratio
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Provider Provider Name Col Column Desc Amount Type
Page 6
02200 IME Adj -IME Payment Adjustment (See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 1,273,291.
100080 JFK MEDICAL CENTER 00100 Amounts 4,703,204.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 245,342.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 4,677,333.
100234 WEST PALM HOSPITAL 00100 Amounts 126,232.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,926,633.
100269 PALMS WEST HOSPITAL 00100 Amounts 667,960.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 832,717.
02400 IME Adj For Add-on - IME FTE Resident Count Over Cap (See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts -30.93
100080 JFK MEDICAL CENTER 00100 Amounts 16.24
100130 LAKESIDE MEDICAL CENTER 00100 Amounts -2.33
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 37.97
100234 WEST PALM HOSPITAL 00100 Amounts 9.99
100269 PALMS WEST HOSPITAL 00100 Amounts 6.98
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts -1.39
02900 IME Adj For Add-on - Total IME Payment (Sum Lines 22 and 28)
100002 BETHESDA HOSPITAL INC 00100 Amounts 1,273,291.
100080 JFK MEDICAL CENTER 00100 Amounts 4,703,204.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 245,342.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 4,677,333.
100234 WEST PALM HOSPITAL 00100 Amounts 126,232.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,926,633.
100269 PALMS WEST HOSPITAL 00100 Amounts 667,960.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 832,717.
03000 DHS Adj - Percentage of SSI recipient patient days to Medicare part A patient days (see instructions
Percent
100002 BETHESDA HOSPITAL INC 00100 Amounts 0.04 Percent
100080 JFK MEDICAL CENTER 00100 Amounts 0.08 Percent
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 0.27 Percent
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 0.01 Percent
100176 PALM BEACH GARDENS 00100 Amounts 0.04 Percent
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Provider Provider Name Col Column Desc Amount Type
Page 7
100234 WEST PALM HOSPITAL 00100 Amounts 0.11 Percent
100253 JUPITER MEDICAL CENTER 00100 Amounts 0.02 Percent
100258 DELRAY MEDICAL CENTER 00100 Amounts 0.03 Percent
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 0.04 Percent
100269 PALMS WEST HOSPITAL 00100 Amounts 0.10 Percent
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.07 Percent
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 0.08 Percent
100288 ST MARYS MEDICAL CENTER 00100 Amounts 0.13 Percent
03100 DHS Adj - Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part 1.
Percent
100002 BETHESDA HOSPITAL INC 00100 Amounts 0.28 Percent
100080 JFK MEDICAL CENTER 00100 Amounts 0.17 Percent
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 0.42 Percent
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 0.01 Percent
100176 PALM BEACH GARDENS 00100 Amounts 0.08 Percent
100234 WEST PALM HOSPITAL 00100 Amounts 0.32 Percent
100253 JUPITER MEDICAL CENTER 00100 Amounts 0.07 Percent
100258 DELRAY MEDICAL CENTER 00100 Amounts 0.08 Percent
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 0.26 Percent
100269 PALMS WEST HOSPITAL 00100 Amounts 0.32 Percent
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.27 Percent
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 0.22 Percent
100288 ST MARYS MEDICAL CENTER 00100 Amounts 0.55 Percent
03200 DHS Adj - Sum of Lines 04 and 4.01 Percent
100002 BETHESDA HOSPITAL INC 00100 Amounts 0.32 Percent
100080 JFK MEDICAL CENTER 00100 Amounts 0.25 Percent
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 0.69 Percent
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 0.02 Percent
100176 PALM BEACH GARDENS 00100 Amounts 0.12 Percent
100234 WEST PALM HOSPITAL 00100 Amounts 0.42 Percent
100253 JUPITER MEDICAL CENTER 00100 Amounts 0.09 Percent
100258 DELRAY MEDICAL CENTER 00100 Amounts 0.10 Percent
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 0.29 Percent
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Provider Provider Name Col Column Desc Amount Type
Page 8
100269 PALMS WEST HOSPITAL 00100 Amounts 0.42 Percent
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.34 Percent
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 0.30 Percent
100288 ST MARYS MEDICAL CENTER 00100 Amounts 0.68 Percent
03300 DHS Adj - Allowable Disproportionate Share Percentage (see instructions) Percent
100002 BETHESDA HOSPITAL INC 00100 Amounts 0.16 Percent
100080 JFK MEDICAL CENTER 00100 Amounts 0.10 Percent
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 0.12 Percent
100234 WEST PALM HOSPITAL 00100 Amounts 0.24 Percent
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 0.13 Percent
100269 PALMS WEST HOSPITAL 00100 Amounts 0.24 Percent
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 0.17 Percent
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 0.14 Percent
100288 ST MARYS MEDICAL CENTER 00100 Amounts 0.45 Percent
03400 Worksheet E Part A Total DHS Adjustment - Disproportionate Share Adjustment (See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 2,260,061.
100080 JFK MEDICAL CENTER 00100 Amounts 2,061,553.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 77,451.
100234 WEST PALM HOSPITAL 00100 Amounts 359,190.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 481,502.
100269 PALMS WEST HOSPITAL 00100 Amounts 1,062,748.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 780,191.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 961,003.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,757,363.
03500 Total Uncompensated Care Amount (See Instructions)
100002 BETHESDA HOSPITAL INC 00200 Amounts 6,406,145,534.
100080 JFK MEDICAL CENTER 00100 Amounts 7,647,644,885.
100080 JFK MEDICAL CENTER 00200 Amounts 6,406,145,534.
100130 LAKESIDE MEDICAL CENTER 00200 Amounts 6,406,145,534.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 7,647,644,885.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Amounts 6,406,145,534.
100176 PALM BEACH GARDENS 00100 Amounts 6,406,145,534.
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Provider Provider Name Col Column Desc Amount Type
Page 9
100176 PALM BEACH GARDENS 00200 Amounts 5,977,483,147.
100234 WEST PALM HOSPITAL 00100 Amounts 7,647,644,885.
100234 WEST PALM HOSPITAL 00200 Amounts 6,405,785,388.
100253 JUPITER MEDICAL CENTER 00200 Amounts 6,406,145,534.
100258 DELRAY MEDICAL CENTER 00100 Amounts 6,406,145,534.
100258 DELRAY MEDICAL CENTER 00200 Amounts 5,977,483,147.
100269 PALMS WEST HOSPITAL 00100 Amounts 7,647,644,885.
100269 PALMS WEST HOSPITAL 00200 Amounts 6,406,145,534.
03501 Total Uncompensanted Care Amount - Factor 3 (See Instructions)
100002 BETHESDA HOSPITAL INC 00200 Amounts 0.
100080 JFK MEDICAL CENTER 00100 Amounts 0.
100080 JFK MEDICAL CENTER 00200 Amounts 0.
100130 LAKESIDE MEDICAL CENTER 00200 Amounts 0.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 0.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Amounts 0.
100176 PALM BEACH GARDENS 00100 Amounts 0.
100176 PALM BEACH GARDENS 00200 Amounts 0.
100234 WEST PALM HOSPITAL 00100 Amounts 0.
100234 WEST PALM HOSPITAL 00200 Amounts 0.
100253 JUPITER MEDICAL CENTER 00200 Amounts 0.
100258 DELRAY MEDICAL CENTER 00100 Amounts 0.
100258 DELRAY MEDICAL CENTER 00200 Amounts 0.
100269 PALMS WEST HOSPITAL 00100 Amounts 0.
100269 PALMS WEST HOSPITAL 00200 Amounts 0.
03502 Hospital Uncompensanted Care Payment (If Line 34 is Zero, Enter Zero)
100002 BETHESDA HOSPITAL INC 00200 Amounts 5,869,194.
100080 JFK MEDICAL CENTER 00100 Amounts 5,852,391.
100080 JFK MEDICAL CENTER 00200 Amounts 4,878,882.
100130 LAKESIDE MEDICAL CENTER 00200 Amounts 703,611.
100234 WEST PALM HOSPITAL 00100 Amounts 1,572,302.
100234 WEST PALM HOSPITAL 00200 Amounts 1,258,854.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 2,484,495.
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Provider Provider Name Col Column Desc Amount Type
Page 10
100268 WEST BOCA MEDICAL CENTER 00200 Amounts 2,264,437.
100269 PALMS WEST HOSPITAL 00100 Amounts 3,659,002.
100269 PALMS WEST HOSPITAL 00200 Amounts 3,102,351.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 2,640,309.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Amounts 2,329,845.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 2,017,943.
100287 GOOD SAMARITAN HOSPITAL 00200 Amounts 1,635,880.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 12,451,002.
100288 ST MARYS MEDICAL CENTER 00200 Amounts 10,329,781.
03503 Pro Rata Share of the Hospital Uncompensanted Care Payment Amount (See Instructions)
100002 BETHESDA HOSPITAL INC 00200 Amounts 5,869,194.
100080 JFK MEDICAL CENTER 00100 Amounts 1,475,124.
100080 JFK MEDICAL CENTER 00200 Amounts 3,652,497.
100130 LAKESIDE MEDICAL CENTER 00200 Amounts 703,611.
100234 WEST PALM HOSPITAL 00100 Amounts 396,307.
100234 WEST PALM HOSPITAL 00200 Amounts 629,427.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 1,859,977.
100268 WEST BOCA MEDICAL CENTER 00200 Amounts 570,763.
100269 PALMS WEST HOSPITAL 00100 Amounts 1,223,010.
100269 PALMS WEST HOSPITAL 00200 Amounts 2,068,235.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 1,976,625.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Amounts 587,249.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 674,491.
100287 GOOD SAMARITAN HOSPITAL 00200 Amounts 1,090,587.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 4,161,710.
100288 ST MARYS MEDICAL CENTER 00200 Amounts 6,886,524.
03600 Total Uncompensated Care Amount (Sum of Col 01 and 02 on Line 35.03)
100002 BETHESDA HOSPITAL INC 00100 Amounts 5,869,194.
100080 JFK MEDICAL CENTER 00100 Amounts 5,127,621.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 703,611.
100234 WEST PALM HOSPITAL 00100 Amounts 1,025,734.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 2,430,740.
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Provider Provider Name Col Column Desc Amount Type
Page 11
100269 PALMS WEST HOSPITAL 00100 Amounts 3,291,245.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 2,563,874.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 1,765,078.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 11,048,234.
04700 Sub Total (see instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 67,115,103.
100080 JFK MEDICAL CENTER 00100 Amounts 97,901,663.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 3,834,949.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 89,354,231.
100176 PALM BEACH GARDENS 00100 Amounts 44,109,754.
100234 WEST PALM HOSPITAL 00100 Amounts 7,556,175.
100253 JUPITER MEDICAL CENTER 00100 Amounts 38,619,922.
100258 DELRAY MEDICAL CENTER 00100 Amounts 79,314,000.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 17,584,528.
100269 PALMS WEST HOSPITAL 00100 Amounts 23,334,747.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 22,615,997.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 31,583,450.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 28,662,569.
04900 Total Payment for Inpateint Operating Cost SCH and MDH Only
100002 BETHESDA HOSPITAL INC 00100 Amounts 67,679,544.
100080 JFK MEDICAL CENTER 00100 Amounts 101,113,011.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 3,928,880.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 90,394,461.
100176 PALM BEACH GARDENS 00100 Amounts 44,109,754.
100234 WEST PALM HOSPITAL 00100 Amounts 7,667,314.
100253 JUPITER MEDICAL CENTER 00100 Amounts 38,619,922.
100258 DELRAY MEDICAL CENTER 00100 Amounts 80,069,265.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 17,584,528.
100269 PALMS WEST HOSPITAL 00100 Amounts 23,887,505.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 23,494,796.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 31,583,450.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 28,662,569.
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Provider Provider Name Col Column Desc Amount Type
Page 12
05000 Payment for Inpatient Program Captial (From Wkst L Parts 1,2 or 3)
100002 BETHESDA HOSPITAL INC 00100 Amounts 5,104,476.
100080 JFK MEDICAL CENTER 00100 Amounts 7,512,300.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 270,092.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 7,110,743.
100176 PALM BEACH GARDENS 00100 Amounts 3,838,429.
100234 WEST PALM HOSPITAL 00100 Amounts 543,444.
100253 JUPITER MEDICAL CENTER 00100 Amounts 3,183,211.
100258 DELRAY MEDICAL CENTER 00100 Amounts 6,309,657.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 1,244,395.
100269 PALMS WEST HOSPITAL 00100 Amounts 1,646,149.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 1,685,290.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 2,489,694.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,445,221.
05200 Direct Graduate Medical Education Payment (Wkst E-4 Line 49)
100002 BETHESDA HOSPITAL INC 00100 Amounts 645,357.
100080 JFK MEDICAL CENTER 00100 Amounts 1,750,525.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 302,860.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,248,398.
100234 WEST PALM HOSPITAL 00100 Amounts 151,154.
100258 DELRAY MEDICAL CENTER 00100 Amounts 810,404.
100269 PALMS WEST HOSPITAL 00100 Amounts 390,239.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 487,334.
05300 Nursing and Allied Health Managed Care payment
100002 BETHESDA HOSPITAL INC 00100 Amounts 283,900.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 86,543.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 22,180.
05400 Special Addon Payments for New Technologies
100002 BETHESDA HOSPITAL INC 00100 Amounts 3,659.
100080 JFK MEDICAL CENTER 00100 Amounts 112,986.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 24,920.
100176 PALM BEACH GARDENS 00100 Amounts 211,295.
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Provider Provider Name Col Column Desc Amount Type
Page 13
100258 DELRAY MEDICAL CENTER 00100 Amounts 490,622.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 2,071.
05700 Routine Service Other Pass Through Costs
100002 BETHESDA HOSPITAL INC 00100 Amounts 367,832.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 9,489.
05800 Ancillary Service Other Pass Through Costs
100002 BETHESDA HOSPITAL INC 00100 Amounts 121,349.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 67,230.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 11,125.
05900 Total (Sum of Amounts on Lines 49 Through 58)
100002 BETHESDA HOSPITAL INC 00100 Amounts 74,206,117.
100080 JFK MEDICAL CENTER 00100 Amounts 110,488,822.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 4,501,832.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 98,932,295.
100176 PALM BEACH GARDENS 00100 Amounts 48,159,478.
100234 WEST PALM HOSPITAL 00100 Amounts 8,361,912.
100253 JUPITER MEDICAL CENTER 00100 Amounts 41,803,133.
100258 DELRAY MEDICAL CENTER 00100 Amounts 87,679,948.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 18,871,717.
100269 PALMS WEST HOSPITAL 00100 Amounts 25,923,893.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 25,669,491.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 34,073,144.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 30,107,790.
06000 Primary Payer Payments
100002 BETHESDA HOSPITAL INC 00100 Amounts 114,772.
100080 JFK MEDICAL CENTER 00100 Amounts 36,769.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 48,645.
100176 PALM BEACH GARDENS 00100 Amounts 10,633.
100253 JUPITER MEDICAL CENTER 00100 Amounts 8,630.
100258 DELRAY MEDICAL CENTER 00100 Amounts 100,576.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 4,232.
100269 PALMS WEST HOSPITAL 00100 Amounts 62,140.
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Provider Provider Name Col Column Desc Amount Type
Page 14
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 82,536.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 32,149.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 145,930.
06100 Total Amount Payable for Program Beneficiaries (Line 59 Minus 60)
100002 BETHESDA HOSPITAL INC 00100 Amounts 74,091,345.
100080 JFK MEDICAL CENTER 00100 Amounts 110,452,053.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 4,501,832.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 98,883,650.
100176 PALM BEACH GARDENS 00100 Amounts 48,148,845.
100234 WEST PALM HOSPITAL 00100 Amounts 8,361,912.
100253 JUPITER MEDICAL CENTER 00100 Amounts 41,794,503.
100258 DELRAY MEDICAL CENTER 00100 Amounts 87,579,372.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 18,867,485.
100269 PALMS WEST HOSPITAL 00100 Amounts 25,861,753.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 25,586,955.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 34,040,995.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 29,961,860.
06200 Deductibles Billed to Program Beneficiaries
100002 BETHESDA HOSPITAL INC 00100 Amounts 5,939,304.
100080 JFK MEDICAL CENTER 00100 Amounts 7,772,716.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 286,692.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 8,851,836.
100176 PALM BEACH GARDENS 00100 Amounts 3,841,026.
100234 WEST PALM HOSPITAL 00100 Amounts 559,776.
100253 JUPITER MEDICAL CENTER 00100 Amounts 4,073,384.
100258 DELRAY MEDICAL CENTER 00100 Amounts 7,461,020.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 1,980,300.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,056,889.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 2,037,252.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 3,200,020.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,532,081.
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Provider Provider Name Col Column Desc Amount Type
Page 15
06300 Coinsurance Billed to Program Beneficiaries
100002 BETHESDA HOSPITAL INC 00100 Amounts 186,361.
100080 JFK MEDICAL CENTER 00100 Amounts 783,013.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 34,398.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 520,926.
100176 PALM BEACH GARDENS 00100 Amounts 290,766.
100234 WEST PALM HOSPITAL 00100 Amounts 82,320.
100253 JUPITER MEDICAL CENTER 00100 Amounts 75,628.
100258 DELRAY MEDICAL CENTER 00100 Amounts 287,511.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 30,583.
100269 PALMS WEST HOSPITAL 00100 Amounts 270,039.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 137,130.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 262,549.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 119,651.
06400 Reimbursable Bad Debts
100002 BETHESDA HOSPITAL INC 00100 Amounts 738,347.
100080 JFK MEDICAL CENTER 00100 Amounts 1,363,696.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 86,640.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 697,995.
100176 PALM BEACH GARDENS 00100 Amounts 260,409.
100234 WEST PALM HOSPITAL 00100 Amounts 310,795.
100253 JUPITER MEDICAL CENTER 00100 Amounts 91,879.
100258 DELRAY MEDICAL CENTER 00100 Amounts 351,199.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 210,736.
100269 PALMS WEST HOSPITAL 00100 Amounts 498,734.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 266,606.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 508,577.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 364,075.
06500 Adjusted Reimbursable Bad Debts
100002 BETHESDA HOSPITAL INC 00100 Amounts 479,926.
100080 JFK MEDICAL CENTER 00100 Amounts 886,402.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 56,316.
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Provider Provider Name Col Column Desc Amount Type
Page 16
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 453,697.
100176 PALM BEACH GARDENS 00100 Amounts 169,266.
100234 WEST PALM HOSPITAL 00100 Amounts 202,017.
100253 JUPITER MEDICAL CENTER 00100 Amounts 59,721.
100258 DELRAY MEDICAL CENTER 00100 Amounts 228,279.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 136,978.
100269 PALMS WEST HOSPITAL 00100 Amounts 324,177.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 173,294.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 330,575.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 236,649.
06600 Reimbursable Bad Debts for Dual Eligible Beneficiaries
100002 BETHESDA HOSPITAL INC 00100 Amounts 525,695.
100080 JFK MEDICAL CENTER 00100 Amounts 649,226.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 316,728.
100176 PALM BEACH GARDENS 00100 Amounts 187,790.
100234 WEST PALM HOSPITAL 00100 Amounts 93,525.
100258 DELRAY MEDICAL CENTER 00100 Amounts 222,995.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 148,090.
100269 PALMS WEST HOSPITAL 00100 Amounts 188,849.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 55,211.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 370,630.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 245,303.
06700 Sub Total (Lines 61 Plus Line 65 Minus Lines 62 and 63)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68,445,606.
100080 JFK MEDICAL CENTER 00100 Amounts 102,782,726.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 4,237,058.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 89,964,585.
100176 PALM BEACH GARDENS 00100 Amounts 44,186,319.
100234 WEST PALM HOSPITAL 00100 Amounts 7,921,833.
100253 JUPITER MEDICAL CENTER 00100 Amounts 37,705,212.
100258 DELRAY MEDICAL CENTER 00100 Amounts 80,059,120.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 16,993,580.
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Provider Provider Name Col Column Desc Amount Type
Page 17
100269 PALMS WEST HOSPITAL 00100 Amounts 23,859,002.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 23,585,867.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 30,909,001.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 28,546,777.
06800 Credits received from manufactures for replaced devices applicable to MS-DRG.
100080 JFK MEDICAL CENTER 00100 Amounts 9,000.
07000 Other Adjustments (Specify) CC 07093
100002 BETHESDA HOSPITAL INC 00100 Amounts -243,490. CC 07093
100002 BETHESDA HOSPITAL INC 00100 Amounts -62,390. CC 07094
100080 JFK MEDICAL CENTER 00000 Description
100080 JFK MEDICAL CENTER 00000 Description CC 07001
100080 JFK MEDICAL CENTER 00100 Amounts -1.
100080 JFK MEDICAL CENTER 00100 Amounts -1,070,338. CC 07093
100080 JFK MEDICAL CENTER 00100 Amounts -254,795. CC 07094
100080 JFK MEDICAL CENTER 00100 Amounts 822,013. CC 07099
100130 LAKESIDE MEDICAL CENTER 00000 Description CC 07097
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 10,261. CC 07093
100130 LAKESIDE MEDICAL CENTER 00100 Amounts -16,781. CC 07094
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 730,323. CC 07097
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 07001
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts -108,505. CC 07093
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts -553,476. CC 07094
100176 PALM BEACH GARDENS 00100 Amounts 182,027. CC 07093
100176 PALM BEACH GARDENS 00100 Amounts -205,003. CC 07094
100234 WEST PALM HOSPITAL 00100 Amounts -12,414. CC 07093
100234 WEST PALM HOSPITAL 00100 Amounts -4,582. CC 07094
100253 JUPITER MEDICAL CENTER 00100 Amounts 173,530. CC 07093
100253 JUPITER MEDICAL CENTER 00100 Amounts -406,857. CC 07094
100258 DELRAY MEDICAL CENTER 00100 Amounts -246,609. CC 07093
100258 DELRAY MEDICAL CENTER 00100 Amounts -221,488. CC 07094
100268 WEST BOCA MEDICAL CENTER 00100 Amounts -5,589. CC 07093
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Provider Provider Name Col Column Desc Amount Type
Page 18
100268 WEST BOCA MEDICAL CENTER 00100 Amounts -89,910. CC 07094
100269 PALMS WEST HOSPITAL 00000 Description
100269 PALMS WEST HOSPITAL 00100 Amounts 127.
100269 PALMS WEST HOSPITAL 00100 Amounts -16,651. CC 07093
100269 PALMS WEST HOSPITAL 00100 Amounts -56,568. CC 07094
100275 WELLINGTON REGL MEDICAL CENTER 00000 Description
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 74.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts -89,963. CC 07093
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts -237,197. CC 07094
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 57,829. CC 07099
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts -123,405. CC 07093
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts -19,265. CC 07094
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 234,846. CC 07099
100288 ST MARYS MEDICAL CENTER 00100 Amounts -52,758. CC 07093
100288 ST MARYS MEDICAL CENTER 00100 Amounts -65,507. CC 07094
07100 Amount Due Provider (Line 67 Minus Lines 68 Plus/Minus Lines 69 and 70)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68,139,726.
100002 BETHESDA HOSPITAL INC 00100 Amounts 1,362,795. CC 07101
100080 JFK MEDICAL CENTER 00100 Amounts 100,626,579.
100080 JFK MEDICAL CENTER 00100 Amounts 2,012,532. CC 07101
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 4,960,861.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 99,217. CC 07101
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 89,302,604.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,786,052. CC 07101
100176 PALM BEACH GARDENS 00100 Amounts 44,163,343.
100176 PALM BEACH GARDENS 00100 Amounts 883,267. CC 07101
100234 WEST PALM HOSPITAL 00100 Amounts 7,904,837.
100234 WEST PALM HOSPITAL 00100 Amounts 158,097. CC 07101
100253 JUPITER MEDICAL CENTER 00100 Amounts 37,471,885.
100253 JUPITER MEDICAL CENTER 00100 Amounts 749,438. CC 07101
100258 DELRAY MEDICAL CENTER 00100 Amounts 79,591,023.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,591,820. CC 07101
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Provider Provider Name Col Column Desc Amount Type
Page 19
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 16,898,081.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 337,962. CC 07101
100269 PALMS WEST HOSPITAL 00100 Amounts 23,785,910.
100269 PALMS WEST HOSPITAL 00100 Amounts 475,718. CC 07101
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 23,200,952.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 464,019. CC 07101
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 30,531,485.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 610,630. CC 07101
100288 ST MARYS MEDICAL CENTER 00100 Amounts 28,428,512.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 568,570. CC 07101
07200 Interim Payments
100002 BETHESDA HOSPITAL INC 00100 Amounts 65,974,907.
100080 JFK MEDICAL CENTER 00100 Amounts 101,006,809.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 4,444,201.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 87,036,010.
100176 PALM BEACH GARDENS 00100 Amounts 43,515,184.
100234 WEST PALM HOSPITAL 00100 Amounts 7,508,864.
100253 JUPITER MEDICAL CENTER 00100 Amounts 36,695,375.
100258 DELRAY MEDICAL CENTER 00100 Amounts 75,787,834.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 16,747,122.
100269 PALMS WEST HOSPITAL 00100 Amounts 23,309,442.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 22,786,321.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 30,067,607.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 28,806,396.
07400 Balance Due Provider(Program) (Line 71 Minus the Sum of Lines 72 and 73)
100002 BETHESDA HOSPITAL INC 00100 Amounts 802,024.
100080 JFK MEDICAL CENTER 00100 Amounts -2,392,762.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 417,443.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 480,542.
100176 PALM BEACH GARDENS 00100 Amounts -235,108.
100234 WEST PALM HOSPITAL 00100 Amounts 237,876.
100253 JUPITER MEDICAL CENTER 00100 Amounts 27,072.
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Provider Provider Name Col Column Desc Amount Type
Page 20
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,211,369.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts -187,003.
100269 PALMS WEST HOSPITAL 00100 Amounts 750.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts -49,388.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts -146,752.
100288 ST MARYS MEDICAL CENTER 00100 Amounts -946,454.
07500 Protested Amounts (Non Allowable Cost Report Items) in Accordance with CMS Pub. 15-2 Section 115.2
100002 BETHESDA HOSPITAL INC 00100 Amounts 977,862.
100080 JFK MEDICAL CENTER 00100 Amounts 4,838,109.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 49,159.
100176 PALM BEACH GARDENS 00100 Amounts 802,276.
100234 WEST PALM HOSPITAL 00100 Amounts 1,589,667.
100253 JUPITER MEDICAL CENTER 00100 Amounts 360,703.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 417,343.
100269 PALMS WEST HOSPITAL 00100 Amounts 728,730.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 329,395.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 855,663.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 416,151.
09000 Operating Outlier Reconciliation Amount from Wkst E Part A Line 02
100002 BETHESDA HOSPITAL INC 00100 Amounts 998,345.
100080 JFK MEDICAL CENTER 00100 Amounts 1,778,326.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 226,863.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 2,559,359.
100176 PALM BEACH GARDENS 00100 Amounts 3,320,704.
100234 WEST PALM HOSPITAL 00100 Amounts 105,542.
100253 JUPITER MEDICAL CENTER 00100 Amounts 595,708.
100258 DELRAY MEDICAL CENTER 00100 Amounts 3,493,571.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 288,378.
100269 PALMS WEST HOSPITAL 00100 Amounts 503,862.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 493,496.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 839,812.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 305,088.
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Provider Provider Name Col Column Desc Amount Type
Page 21
09100 Capital Outlier From Wkst L Part 1 Line 02
100002 BETHESDA HOSPITAL INC 00100 Amounts 150,600.
100080 JFK MEDICAL CENTER 00100 Amounts 171,053.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 30,067.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 201,835.
100176 PALM BEACH GARDENS 00100 Amounts 483,668.
100234 WEST PALM HOSPITAL 00100 Amounts 12,325.
100253 JUPITER MEDICAL CENTER 00100 Amounts 82,420.
100258 DELRAY MEDICAL CENTER 00100 Amounts 125,322.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 18,985.
100269 PALMS WEST HOSPITAL 00100 Amounts 59,535.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 83,388.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 108,350.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 17,267.
B Part B - Medical and Other Health Services
A18 Hospital Medicare
00100 Medical and Other Services (See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 10,979.
100080 JFK MEDICAL CENTER 00100 Amounts 11,944.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 1,054.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 33,721.
100176 PALM BEACH GARDENS 00100 Amounts 13,158.
100234 WEST PALM HOSPITAL 00100 Amounts 486.
100253 JUPITER MEDICAL CENTER 00100 Amounts 18,081.
100258 DELRAY MEDICAL CENTER 00100 Amounts 4,188.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 11,789.
100269 PALMS WEST HOSPITAL 00100 Amounts 7,656.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,833.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 27,100.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,960.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 94,593.
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Provider Provider Name Col Column Desc Amount Type
Page 22
00200 Medical and other services reimbrused under OPPS (see instructions).
100002 BETHESDA HOSPITAL INC 00100 Amounts 25,788,398.
100080 JFK MEDICAL CENTER 00100 Amounts 22,043,892.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 1,464,990.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 98,032,429.
100176 PALM BEACH GARDENS 00100 Amounts 17,871,774.
100234 WEST PALM HOSPITAL 00100 Amounts 2,757,225.
100253 JUPITER MEDICAL CENTER 00100 Amounts 28,229,027.
100258 DELRAY MEDICAL CENTER 00100 Amounts 23,317,948.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 5,382,789.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,560,434.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 6,377,690.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 21,497,598.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 4,075,481.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 640,751.
00300 PPS Payments Received
100002 BETHESDA HOSPITAL INC 00100 Amounts 26,148,400.
100080 JFK MEDICAL CENTER 00100 Amounts 23,756,129.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 1,077,784.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 92,657,038.
100176 PALM BEACH GARDENS 00100 Amounts 17,354,604.
100234 WEST PALM HOSPITAL 00100 Amounts 2,170,158.
100253 JUPITER MEDICAL CENTER 00100 Amounts 32,280,922.
100258 DELRAY MEDICAL CENTER 00100 Amounts 22,259,985.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 4,416,564.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,529,958.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 6,590,313.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 12,556,993.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,675,063.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 984,105.
00400 Outlir Payments (See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 48,833.
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Provider Provider Name Col Column Desc Amount Type
Page 23
100080 JFK MEDICAL CENTER 00100 Amounts 168,425.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 5,054.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 108,448.
100176 PALM BEACH GARDENS 00100 Amounts 201,904.
100234 WEST PALM HOSPITAL 00100 Amounts 40,905.
100253 JUPITER MEDICAL CENTER 00100 Amounts 26,156.
100258 DELRAY MEDICAL CENTER 00100 Amounts 108,292.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 17,714.
100269 PALMS WEST HOSPITAL 00100 Amounts 8,576.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 10,547.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 39,652.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 87,197.
00900 Ancillary Service Other Pass Through Costs (Wkst D Part 4 Col 13 Line 200
100002 BETHESDA HOSPITAL INC 00100 Amounts 140,688.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 244,796.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 16,168.
01100 Total Cost (Sum of Lines 01 and 10)
100002 BETHESDA HOSPITAL INC 00100 Amounts 10,979.
100080 JFK MEDICAL CENTER 00100 Amounts 11,944.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 1,054.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 33,721.
100176 PALM BEACH GARDENS 00100 Amounts 13,158.
100234 WEST PALM HOSPITAL 00100 Amounts 486.
100253 JUPITER MEDICAL CENTER 00100 Amounts 18,081.
100258 DELRAY MEDICAL CENTER 00100 Amounts 4,188.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 11,789.
100269 PALMS WEST HOSPITAL 00100 Amounts 7,656.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,833.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 27,100.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,960.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 94,593.
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Provider Provider Name Col Column Desc Amount Type
Page 24
01400 Reasonable Charges - Total Reasonable Charges (Sum of Lines 12 and 13)
100002 BETHESDA HOSPITAL INC 00100 Amounts 61,131.
100080 JFK MEDICAL CENTER 00100 Amounts 172,476.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 7,254.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 156,176.
100176 PALM BEACH GARDENS 00100 Amounts 151,501.
100234 WEST PALM HOSPITAL 00100 Amounts 5,205.
100253 JUPITER MEDICAL CENTER 00100 Amounts 113,738.
100258 DELRAY MEDICAL CENTER 00100 Amounts 70,152.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 48,369.
100269 PALMS WEST HOSPITAL 00100 Amounts 57,936.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 54,069.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 254,451.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 56,725.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 618,977.
01800 Customary Charges - Total
100002 BETHESDA HOSPITAL INC 00100 Amounts 61,131.
100080 JFK MEDICAL CENTER 00100 Amounts 172,476.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 7,254.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 156,176.
100176 PALM BEACH GARDENS 00100 Amounts 151,501.
100234 WEST PALM HOSPITAL 00100 Amounts 5,205.
100253 JUPITER MEDICAL CENTER 00100 Amounts 113,738.
100258 DELRAY MEDICAL CENTER 00100 Amounts 70,152.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 48,369.
100269 PALMS WEST HOSPITAL 00100 Amounts 57,936.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 54,069.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 254,451.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 56,725.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 618,977.
01900 Excess of Customary Charges Over Reasonable Cost (Complete Only If Line 14 Exceeds 05)
100002 BETHESDA HOSPITAL INC 00100 Amounts 50,152.
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Provider Provider Name Col Column Desc Amount Type
Page 25
100080 JFK MEDICAL CENTER 00100 Amounts 160,532.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 6,200.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 122,455.
100176 PALM BEACH GARDENS 00100 Amounts 138,343.
100234 WEST PALM HOSPITAL 00100 Amounts 4,719.
100253 JUPITER MEDICAL CENTER 00100 Amounts 95,657.
100258 DELRAY MEDICAL CENTER 00100 Amounts 65,964.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 36,580.
100269 PALMS WEST HOSPITAL 00100 Amounts 50,280.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 48,236.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 227,351.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 50,765.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 524,384.
02100 Lesser of Cost or Charges (Line 11 Minus Line 20) (For CAH, See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 10,979.
100080 JFK MEDICAL CENTER 00100 Amounts 11,944.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 1,054.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 33,721.
100176 PALM BEACH GARDENS 00100 Amounts 13,158.
100234 WEST PALM HOSPITAL 00100 Amounts 486.
100253 JUPITER MEDICAL CENTER 00100 Amounts 18,081.
100258 DELRAY MEDICAL CENTER 00100 Amounts 4,188.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 11,789.
100269 PALMS WEST HOSPITAL 00100 Amounts 7,656.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,833.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 27,100.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,960.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 94,593.
02400 Total Prospective Payment (Sum of Lines 03,04,08,09)
100002 BETHESDA HOSPITAL INC 00100 Amounts 26,337,921.
100080 JFK MEDICAL CENTER 00100 Amounts 23,924,554.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 1,082,838.
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Provider Provider Name Col Column Desc Amount Type
Page 26
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 93,010,282.
100176 PALM BEACH GARDENS 00100 Amounts 17,556,508.
100234 WEST PALM HOSPITAL 00100 Amounts 2,211,063.
100253 JUPITER MEDICAL CENTER 00100 Amounts 32,307,078.
100258 DELRAY MEDICAL CENTER 00100 Amounts 22,368,277.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 4,450,446.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,538,534.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 6,600,860.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 12,596,645.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,762,260.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 984,105.
02500 Reimbursement Settlement - Deductibles and Coinsurance (See Instructions)
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 36.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 3,177.
100176 PALM BEACH GARDENS 00100 Amounts 877.
100253 JUPITER MEDICAL CENTER 00100 Amounts 6,679,345.
100258 DELRAY MEDICAL CENTER 00100 Amounts 259.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 372.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 1,968.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 4,061.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 123,795.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 207,878.
02600 Reimbursement Settlement - Deductibles and Coinsurance relating to amount on line 17.01.
100002 BETHESDA HOSPITAL INC 00100 Amounts 5,019,503.
100080 JFK MEDICAL CENTER 00100 Amounts 4,189,819.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 247,214.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 18,369,294.
100176 PALM BEACH GARDENS 00100 Amounts 2,693,767.
100234 WEST PALM HOSPITAL 00100 Amounts 418,597.
100253 JUPITER MEDICAL CENTER 00100 Amounts 5,299.
100258 DELRAY MEDICAL CENTER 00100 Amounts 4,008,164.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 910,570.
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Provider Provider Name Col Column Desc Amount Type
Page 27
100269 PALMS WEST HOSPITAL 00100 Amounts 517,241.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 1,302,901.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 2,611,862.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 562,439.
02700 Reimbursement Settlement - Sub Total (Line 21 and 24 Minus Lines 25 and 26)
100002 BETHESDA HOSPITAL INC 00100 Amounts 21,329,397.
100080 JFK MEDICAL CENTER 00100 Amounts 19,746,679.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 836,642.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 74,671,532.
100176 PALM BEACH GARDENS 00100 Amounts 14,875,022.
100234 WEST PALM HOSPITAL 00100 Amounts 1,792,952.
100253 JUPITER MEDICAL CENTER 00100 Amounts 25,640,515.
100258 DELRAY MEDICAL CENTER 00100 Amounts 18,364,042.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,551,293.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,028,949.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,301,824.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 10,007,822.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,205,781.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts -29,202.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 776,227.
02800 Reimbursement Settlement - Direct Graduate Medical Education Payments (Wkst E-4 Line 50)
100002 BETHESDA HOSPITAL INC 00100 Amounts 201,572.
100080 JFK MEDICAL CENTER 00100 Amounts 391,484.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 93,075.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,207,150.
100234 WEST PALM HOSPITAL 00100 Amounts 44,580.
100258 DELRAY MEDICAL CENTER 00100 Amounts 161,095.
100269 PALMS WEST HOSPITAL 00100 Amounts 44,838.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 149,528.
03000 Reimbursement Settlement - Sub Total (Sum of Lines 27 Through 29)
100002 BETHESDA HOSPITAL INC 00100 Amounts 21,530,969.
100080 JFK MEDICAL CENTER 00100 Amounts 20,138,163.
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Provider Provider Name Col Column Desc Amount Type
Page 28
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 929,717.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 75,878,682.
100176 PALM BEACH GARDENS 00100 Amounts 14,875,022.
100234 WEST PALM HOSPITAL 00100 Amounts 1,837,532.
100253 JUPITER MEDICAL CENTER 00100 Amounts 25,640,515.
100258 DELRAY MEDICAL CENTER 00100 Amounts 18,525,137.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,551,293.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,073,787.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,451,352.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 10,007,822.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,205,781.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts -29,202.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 776,227.
03100 Reimbursement Settlement - Primary Payer Payments
100002 BETHESDA HOSPITAL INC 00100 Amounts 9,787.
100080 JFK MEDICAL CENTER 00100 Amounts 4,348.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 698.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 10,943.
100176 PALM BEACH GARDENS 00100 Amounts 7,132.
100234 WEST PALM HOSPITAL 00100 Amounts 26.
100253 JUPITER MEDICAL CENTER 00100 Amounts 3,366.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,455.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 303.
100269 PALMS WEST HOSPITAL 00100 Amounts 206.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 2,665.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 2,259.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,452.
03200 Reimbursement Settlement - Sub Total (Line 30 Minus Line 31)
100002 BETHESDA HOSPITAL INC 00100 Amounts 21,521,182.
100080 JFK MEDICAL CENTER 00100 Amounts 20,133,815.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 929,019.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 75,867,739.
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Provider Provider Name Col Column Desc Amount Type
Page 29
100176 PALM BEACH GARDENS 00100 Amounts 14,867,890.
100234 WEST PALM HOSPITAL 00100 Amounts 1,837,506.
100253 JUPITER MEDICAL CENTER 00100 Amounts 25,637,149.
100258 DELRAY MEDICAL CENTER 00100 Amounts 18,523,682.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,550,990.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,073,581.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,448,687.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 10,005,563.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,204,329.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts -29,202.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 776,227.
03300 Bad Debts - Composite reate ESRD (Wkst I-5 Line 11)
100288 ST MARYS MEDICAL CENTER 00100 Amounts 129,882.
03400 Bad Debts - Allowable Bad Debts
100002 BETHESDA HOSPITAL INC 00100 Amounts 862,871.
100080 JFK MEDICAL CENTER 00100 Amounts 444,306.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 62,685.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 810,955.
100176 PALM BEACH GARDENS 00100 Amounts 224,638.
100234 WEST PALM HOSPITAL 00100 Amounts 238,403.
100253 JUPITER MEDICAL CENTER 00100 Amounts 104,161.
100258 DELRAY MEDICAL CENTER 00100 Amounts 202,044.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 109,205.
100269 PALMS WEST HOSPITAL 00100 Amounts 104,760.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 117,727.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 439,392.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 144,995.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 1,265.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 117,190.
03500 Bad Debts - Adjusted Reimbursalbe Bad Debts
100002 BETHESDA HOSPITAL INC 00100 Amounts 560,866.
100080 JFK MEDICAL CENTER 00100 Amounts 288,799.
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Provider Provider Name Col Column Desc Amount Type
Page 30
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 40,745.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 527,121.
100176 PALM BEACH GARDENS 00100 Amounts 146,015.
100234 WEST PALM HOSPITAL 00100 Amounts 154,962.
100253 JUPITER MEDICAL CENTER 00100 Amounts 67,705.
100258 DELRAY MEDICAL CENTER 00100 Amounts 131,329.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 70,983.
100269 PALMS WEST HOSPITAL 00100 Amounts 68,094.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 76,523.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 285,605.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 94,247.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 822.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 76,174.
03600 Bad Debts - Reimbursable Bad Debts for Dual Eligible Beneficiaries
100002 BETHESDA HOSPITAL INC 00100 Amounts 725,478.
100080 JFK MEDICAL CENTER 00100 Amounts 231,027.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 475,474.
100176 PALM BEACH GARDENS 00100 Amounts 158,278.
100234 WEST PALM HOSPITAL 00100 Amounts 111,802.
100258 DELRAY MEDICAL CENTER 00100 Amounts 131,127.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 69,527.
100269 PALMS WEST HOSPITAL 00100 Amounts 55,212.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts -7,475.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 287,126.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 78,299.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 1,265.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 117,190.
03700 Bad Debts - Sub Total (Sum of Lines 32, 33, 34 and 35)(Line 35 Hospital and Subprovider Only))
100002 BETHESDA HOSPITAL INC 00100 Amounts 22,082,048.
100080 JFK MEDICAL CENTER 00100 Amounts 20,422,614.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 969,764.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 76,394,860.
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Provider Provider Name Col Column Desc Amount Type
Page 31
100176 PALM BEACH GARDENS 00100 Amounts 15,013,905.
100234 WEST PALM HOSPITAL 00100 Amounts 1,992,468.
100253 JUPITER MEDICAL CENTER 00100 Amounts 25,704,854.
100258 DELRAY MEDICAL CENTER 00100 Amounts 18,655,011.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,621,973.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,141,675.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,525,210.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 10,291,168.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,428,458.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts -28,380.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 852,401.
03800 MSP-LCC Reconciliation Amount From PS&R
100080 JFK MEDICAL CENTER 00100 Amounts -324.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 44.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts -43.
100176 PALM BEACH GARDENS 00100 Amounts -411.
100253 JUPITER MEDICAL CENTER 00100 Amounts 541.
100258 DELRAY MEDICAL CENTER 00100 Amounts 218.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 429.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 38.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1.
03900 SEQUESTRATION
100080 JFK MEDICAL CENTER 00000 Description
100080 JFK MEDICAL CENTER 00000 Description CC 03901
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 122,914.
100253 JUPITER MEDICAL CENTER 00000 Description
100253 JUPITER MEDICAL CENTER 00100 Amounts 342,250.
04000 Sub Total (Line 37 Plus or Minus Lines 39 Minus Line 38)
100002 BETHESDA HOSPITAL INC 00100 Amounts 22,082,048.
100002 BETHESDA HOSPITAL INC 00100 Amounts 441,641. CC 04001
100080 JFK MEDICAL CENTER 00100 Amounts 20,422,938.
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Provider Provider Name Col Column Desc Amount Type
Page 32
100080 JFK MEDICAL CENTER 00100 Amounts 408,459. CC 04001
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 969,720.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 19,394. CC 04001
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 76,517,817.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,530,356. CC 04001
100176 PALM BEACH GARDENS 00100 Amounts 15,014,316.
100176 PALM BEACH GARDENS 00100 Amounts 300,286. CC 04001
100234 WEST PALM HOSPITAL 00100 Amounts 1,992,468.
100234 WEST PALM HOSPITAL 00100 Amounts 39,849. CC 04001
100253 JUPITER MEDICAL CENTER 00100 Amounts 26,046,563.
100253 JUPITER MEDICAL CENTER 00100 Amounts 520,931. CC 04001
100258 DELRAY MEDICAL CENTER 00100 Amounts 18,654,793.
100258 DELRAY MEDICAL CENTER 00100 Amounts 373,096. CC 04001
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,621,973.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 72,439. CC 04001
100269 PALMS WEST HOSPITAL 00100 Amounts 2,141,675.
100269 PALMS WEST HOSPITAL 00100 Amounts 42,834. CC 04001
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,524,781.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 110,496. CC 04001
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 10,291,130.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 205,823. CC 04001
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,428,457.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 48,569. CC 04001
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts -28,380.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 852,401.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 17,048. CC 04001
04100 Interim Payments
100002 BETHESDA HOSPITAL INC 00100 Amounts 21,305,398.
100080 JFK MEDICAL CENTER 00100 Amounts 19,945,213.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 876,081.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 74,671,711.
100176 PALM BEACH GARDENS 00100 Amounts 14,559,830.
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Provider Provider Name Col Column Desc Amount Type
Page 33
100234 WEST PALM HOSPITAL 00100 Amounts 1,825,055.
100253 JUPITER MEDICAL CENTER 00100 Amounts 25,541,399.
100258 DELRAY MEDICAL CENTER 00100 Amounts 17,991,539.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,456,516.
100269 PALMS WEST HOSPITAL 00100 Amounts 2,072,505.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 5,444,536.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 9,946,212.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,258,991.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 796,593.
04200 Worksheet E Part B Tenative Settlement (For Contractor Use Only)
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts -38,740.
04300 Balance Due Provider/Program (Line 40 Minus the Sum of Lines 41 and 42)
100002 BETHESDA HOSPITAL INC 00100 Amounts 335,009.
100080 JFK MEDICAL CENTER 00100 Amounts 69,266.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 74,245.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 315,750.
100176 PALM BEACH GARDENS 00100 Amounts 154,200.
100234 WEST PALM HOSPITAL 00100 Amounts 127,564.
100253 JUPITER MEDICAL CENTER 00100 Amounts -15,767.
100258 DELRAY MEDICAL CENTER 00100 Amounts 290,158.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 93,018.
100269 PALMS WEST HOSPITAL 00100 Amounts 26,336.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts -30,251.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 139,095.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 120,897.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 10,360.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 38,760.
04400 Worksheet E Part B Protested Amounts (Nonallowable Cost Report Items) in Accordance With CMS 15-2
100002 BETHESDA HOSPITAL INC 00100 Amounts 24,246.
100258 DELRAY MEDICAL CENTER 00100 Amounts 6,505.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,385.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 8,735.
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Provider Provider Name Col Column Desc Amount Type
Page 34
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,620.
09000 Completed by Contractor - Original Outlier Amount
100002 BETHESDA HOSPITAL INC 00100 Amounts 48,833.
100080 JFK MEDICAL CENTER 00100 Amounts 168,425.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 5,054.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 108,448.
100176 PALM BEACH GARDENS 00100 Amounts 201,904.
100234 WEST PALM HOSPITAL 00100 Amounts 40,905.
100253 JUPITER MEDICAL CENTER 00100 Amounts 26,156.
100258 DELRAY MEDICAL CENTER 00100 Amounts 108,292.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 17,714.
100269 PALMS WEST HOSPITAL 00100 Amounts 8,576.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 10,547.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 39,652.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 87,197.
B18 IPF Medicare
00100 Medical and Other Services (See Instructions)
100080 JFK MEDICAL CENTER 00100 Amounts 7.
100234 WEST PALM HOSPITAL 00100 Amounts 76.
100258 DELRAY MEDICAL CENTER 00100 Amounts 199.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 935.
00200 Medical and other services reimbrused under OPPS (see instructions).
100080 JFK MEDICAL CENTER 00100 Amounts 14,028.
100234 WEST PALM HOSPITAL 00100 Amounts 330,302.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,978.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 2,905.
00300 PPS Payments Received
100080 JFK MEDICAL CENTER 00100 Amounts 10,276.
100234 WEST PALM HOSPITAL 00100 Amounts 234,926.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,435.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,058.
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Provider Provider Name Col Column Desc Amount Type
Page 35
01100 Total Cost (Sum of Lines 01 and 10)
100080 JFK MEDICAL CENTER 00100 Amounts 7.
100234 WEST PALM HOSPITAL 00100 Amounts 76.
100258 DELRAY MEDICAL CENTER 00100 Amounts 199.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 935.
01400 Reasonable Charges - Total Reasonable Charges (Sum of Lines 12 and 13)
100080 JFK MEDICAL CENTER 00100 Amounts 95.
100234 WEST PALM HOSPITAL 00100 Amounts 818.
100258 DELRAY MEDICAL CENTER 00100 Amounts 3,472.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 8,899.
01800 Customary Charges - Total
100080 JFK MEDICAL CENTER 00100 Amounts 95.
100234 WEST PALM HOSPITAL 00100 Amounts 818.
100258 DELRAY MEDICAL CENTER 00100 Amounts 3,472.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 8,899.
01900 Excess of Customary Charges Over Reasonable Cost (Complete Only If Line 14 Exceeds 05)
100080 JFK MEDICAL CENTER 00100 Amounts 88.
100234 WEST PALM HOSPITAL 00100 Amounts 742.
100258 DELRAY MEDICAL CENTER 00100 Amounts 3,273.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 7,964.
02100 Lesser of Cost or Charges (Line 11 Minus Line 20) (For CAH, See Instructions)
100080 JFK MEDICAL CENTER 00100 Amounts 7.
100234 WEST PALM HOSPITAL 00100 Amounts 76.
100258 DELRAY MEDICAL CENTER 00100 Amounts 199.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 935.
02400 Total Prospective Payment (Sum of Lines 03,04,08,09)
100080 JFK MEDICAL CENTER 00100 Amounts 10,276.
100234 WEST PALM HOSPITAL 00100 Amounts 234,926.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,435.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,058.
02600 Reimbursement Settlement - Deductibles and Coinsurance relating to amount on line 17.01.
100080 JFK MEDICAL CENTER 00100 Amounts 2,050.
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Provider Provider Name Col Column Desc Amount Type
Page 36
100234 WEST PALM HOSPITAL 00100 Amounts 47,298.
100258 DELRAY MEDICAL CENTER 00100 Amounts 407.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 800.
02700 Reimbursement Settlement - Sub Total (Line 21 and 24 Minus Lines 25 and 26)
100080 JFK MEDICAL CENTER 00100 Amounts 8,233.
100234 WEST PALM HOSPITAL 00100 Amounts 187,704.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,227.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,193.
03000 Reimbursement Settlement - Sub Total (Sum of Lines 27 Through 29)
100080 JFK MEDICAL CENTER 00100 Amounts 8,233.
100234 WEST PALM HOSPITAL 00100 Amounts 187,704.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,227.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,193.
03200 Reimbursement Settlement - Sub Total (Line 30 Minus Line 31)
100080 JFK MEDICAL CENTER 00100 Amounts 8,233.
100234 WEST PALM HOSPITAL 00100 Amounts 187,704.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,227.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,193.
03400 Bad Debts - Allowable Bad Debts
100234 WEST PALM HOSPITAL 00100 Amounts 2,009.
03500 Bad Debts - Adjusted Reimbursalbe Bad Debts
100234 WEST PALM HOSPITAL 00100 Amounts 1,306.
03600 Bad Debts - Reimbursable Bad Debts for Dual Eligible Beneficiaries
100234 WEST PALM HOSPITAL 00100 Amounts 2,009.
03700 Bad Debts - Sub Total (Sum of Lines 32, 33, 34 and 35)(Line 35 Hospital and Subprovider Only))
100080 JFK MEDICAL CENTER 00100 Amounts 8,233.
100234 WEST PALM HOSPITAL 00100 Amounts 189,010.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,227.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,193.
04000 Sub Total (Line 37 Plus or Minus Lines 39 Minus Line 38)
100080 JFK MEDICAL CENTER 00100 Amounts 8,233.
100080 JFK MEDICAL CENTER 00100 Amounts 165. CC 04001
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Provider Provider Name Col Column Desc Amount Type
Page 37
100234 WEST PALM HOSPITAL 00100 Amounts 189,010.
100234 WEST PALM HOSPITAL 00100 Amounts 3,780. CC 04001
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,227.
100258 DELRAY MEDICAL CENTER 00100 Amounts 45. CC 04001
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,193.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 104. CC 04001
04100 Interim Payments
100080 JFK MEDICAL CENTER 00100 Amounts 8,081.
100234 WEST PALM HOSPITAL 00100 Amounts 184,037.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,041.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 5,045.
04300 Balance Due Provider/Program (Line 40 Minus the Sum of Lines 41 and 42)
100080 JFK MEDICAL CENTER 00100 Amounts -13.
100234 WEST PALM HOSPITAL 00100 Amounts 1,193.
100258 DELRAY MEDICAL CENTER 00100 Amounts 141.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 44.
C18 IRF Medicare
00100 Medical and Other Services (See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
100258 DELRAY MEDICAL CENTER 00100 Amounts 290.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 151.
00200 Medical and other services reimbrused under OPPS (see instructions).
100258 DELRAY MEDICAL CENTER 00100 Amounts 770.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 223.
00300 PPS Payments Received
100258 DELRAY MEDICAL CENTER 00100 Amounts 781.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 255.
01100 Total Cost (Sum of Lines 01 and 10)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
100258 DELRAY MEDICAL CENTER 00100 Amounts 290.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 151.
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Provider Provider Name Col Column Desc Amount Type
Page 38
01400 Reasonable Charges - Total Reasonable Charges (Sum of Lines 12 and 13)
100002 BETHESDA HOSPITAL INC 00100 Amounts 691.
100258 DELRAY MEDICAL CENTER 00100 Amounts 5,066.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,440.
01800 Customary Charges - Total
100002 BETHESDA HOSPITAL INC 00100 Amounts 691.
100258 DELRAY MEDICAL CENTER 00100 Amounts 5,066.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,440.
01900 Excess of Customary Charges Over Reasonable Cost (Complete Only If Line 14 Exceeds 05)
100002 BETHESDA HOSPITAL INC 00100 Amounts 623.
100258 DELRAY MEDICAL CENTER 00100 Amounts 4,776.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,289.
02100 Lesser of Cost or Charges (Line 11 Minus Line 20) (For CAH, See Instructions)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
100258 DELRAY MEDICAL CENTER 00100 Amounts 290.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 151.
02400 Total Prospective Payment (Sum of Lines 03,04,08,09)
100258 DELRAY MEDICAL CENTER 00100 Amounts 781.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 255.
02600 Reimbursement Settlement - Deductibles and Coinsurance relating to amount on line 17.01.
100258 DELRAY MEDICAL CENTER 00100 Amounts 71.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 41.
02700 Reimbursement Settlement - Sub Total (Line 21 and 24 Minus Lines 25 and 26)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,000.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 365.
03000 Reimbursement Settlement - Sub Total (Sum of Lines 27 Through 29)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,000.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 365.
03200 Reimbursement Settlement - Sub Total (Line 30 Minus Line 31)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
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Provider Provider Name Col Column Desc Amount Type
Page 39
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,000.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 365.
03700 Bad Debts - Sub Total (Sum of Lines 32, 33, 34 and 35)(Line 35 Hospital and Subprovider Only))
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,000.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 365.
04000 Sub Total (Line 37 Plus or Minus Lines 39 Minus Line 38)
100002 BETHESDA HOSPITAL INC 00100 Amounts 68.
100002 BETHESDA HOSPITAL INC 00100 Amounts 1. CC 04001
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,000.
100258 DELRAY MEDICAL CENTER 00100 Amounts 20. CC 04001
100288 ST MARYS MEDICAL CENTER 00100 Amounts 365.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 7. CC 04001
04100 Interim Payments
100002 BETHESDA HOSPITAL INC 00100 Amounts 269.
100258 DELRAY MEDICAL CENTER 00100 Amounts 969.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 448.
04300 Balance Due Provider/Program (Line 40 Minus the Sum of Lines 41 and 42)
100002 BETHESDA HOSPITAL INC 00100 Amounts -202.
100258 DELRAY MEDICAL CENTER 00100 Amounts 11.
100288 ST MARYS MEDICAL CENTER 00100 Amounts -90.
E10 Wkst E-1 Analysis of Payments to Providers for Services Rendered
1 Part 1 - Analysis of Payment to Providers for Services Rendered
A18 Hospital Medicare
00100 Total interim payments paid to provider
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 65,404,246.
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 21,097,265.
100080 JFK MEDICAL CENTER 00200 Part A Amount 100,929,109.
100080 JFK MEDICAL CENTER 00400 Part B Amount 19,945,213.
100130 LAKESIDE MEDICAL CENTER 00200 Part A Amount 4,444,201.
100130 LAKESIDE MEDICAL CENTER 00400 Part B Amount 876,081.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Part A Amount 85,949,194.
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Provider Provider Name Col Column Desc Amount Type
Page 40
100168 BOCA RATON REGIONAL HOSPITAL 00400 Part B Amount 74,364,804.
100176 PALM BEACH GARDENS 00200 Part A Amount 43,451,007.
100176 PALM BEACH GARDENS 00400 Part B Amount 14,559,830.
100234 WEST PALM HOSPITAL 00200 Part A Amount 7,508,864.
100234 WEST PALM HOSPITAL 00400 Part B Amount 1,825,055.
100253 JUPITER MEDICAL CENTER 00200 Part A Amount 36,653,050.
100253 JUPITER MEDICAL CENTER 00400 Part B Amount 25,471,584.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 75,641,971.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 17,991,539.
100268 WEST BOCA MEDICAL CENTER 00200 Part A Amount 16,698,580.
100268 WEST BOCA MEDICAL CENTER 00400 Part B Amount 3,456,516.
100269 PALMS WEST HOSPITAL 00200 Part A Amount 23,289,537.
100269 PALMS WEST HOSPITAL 00400 Part B Amount 2,076,006.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Part A Amount 22,670,940.
100275 WELLINGTON REGL MEDICAL CENTER 00400 Part B Amount 5,444,536.
100287 GOOD SAMARITAN HOSPITAL 00200 Part A Amount 29,948,164.
100287 GOOD SAMARITAN HOSPITAL 00400 Part B Amount 9,946,212.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 28,909,790.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 2,258,991.
102023 SSH - PALM BEACH LLC 00200 Part A Amount 14,889,321.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 11,909,430.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Part A Amount 848,148.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00400 Part B Amount 796,593.
00300 Retroactive Lump Sum Adjustment - Provider to Program Date
100002 BETHESDA HOSPITAL INC 00100 Part A Info 05/17/2016 Date
100002 BETHESDA HOSPITAL INC 00100 Part A Info 09/01/2016 Date
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 556,056. CC 00301
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 14,605. CC 00302
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 570,661. CC 00399
100002 BETHESDA HOSPITAL INC 00300 Part B Info 05/17/2016 Date
100002 BETHESDA HOSPITAL INC 00300 Part B Info 09/01/2016 Date
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 148,914. CC 00301
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Provider Provider Name Col Column Desc Amount Type
Page 41
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 59,219. CC 00302
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 208,133. CC 00399
100080 JFK MEDICAL CENTER 00100 Part A Info 12/21/2015 Date
100080 JFK MEDICAL CENTER 00200 Part A Amount 77,700. CC 00301
100080 JFK MEDICAL CENTER 00200 Part A Amount 77,700. CC 00399
100168 BOCA RATON REGIONAL HOSPITAL 00100 Part A Info 05/19/2016 Date
100168 BOCA RATON REGIONAL HOSPITAL 00200 Part A Amount 1,086,816. CC 00301
100168 BOCA RATON REGIONAL HOSPITAL 00200 Part A Amount 1,086,816. CC 00399
100168 BOCA RATON REGIONAL HOSPITAL 00300 Part B Info 05/19/2016 Date
100168 BOCA RATON REGIONAL HOSPITAL 00400 Part B Amount 306,907. CC 00301
100168 BOCA RATON REGIONAL HOSPITAL 00400 Part B Amount 306,907. CC 00399
100176 PALM BEACH GARDENS 00100 Part A Info 09/21/2016 Date
100176 PALM BEACH GARDENS 00200 Part A Amount 64,177. CC 00301
100176 PALM BEACH GARDENS 00200 Part A Amount 64,177. CC 00399
100253 JUPITER MEDICAL CENTER 00100 Part A Info 06/06/2016 Date
100253 JUPITER MEDICAL CENTER 00200 Part A Amount 42,325. CC 00301
100253 JUPITER MEDICAL CENTER 00200 Part A Amount 42,325. CC 00399
100253 JUPITER MEDICAL CENTER 00300 Part B Info 06/06/2016 Date
100253 JUPITER MEDICAL CENTER 00400 Part B Amount 69,815. CC 00301
100253 JUPITER MEDICAL CENTER 00400 Part B Amount 69,815. CC 00399
100258 DELRAY MEDICAL CENTER 00100 Part A Info 09/08/2016 Date
100258 DELRAY MEDICAL CENTER 00100 Part A Info 12/27/2016 Date
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 134,810. CC 00301
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 11,053. CC 00302
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 145,863. CC 00399
100268 WEST BOCA MEDICAL CENTER 00100 Part A Info 11/29/2016 Date
100268 WEST BOCA MEDICAL CENTER 00200 Part A Amount 48,542. CC 00301
100268 WEST BOCA MEDICAL CENTER 00200 Part A Amount 48,542. CC 00399
100269 PALMS WEST HOSPITAL 00100 Part A Info 02/12/2016 Date
100269 PALMS WEST HOSPITAL 00200 Part A Amount 19,905. CC 00301
100269 PALMS WEST HOSPITAL 00200 Part A Amount 19,905. CC 00399
100269 PALMS WEST HOSPITAL 00300 Part B Info 02/12/2016 Date
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Provider Provider Name Col Column Desc Amount Type
Page 42
100269 PALMS WEST HOSPITAL 00400 Part B Amount 3,501. CC 00350
100269 PALMS WEST HOSPITAL 00400 Part B Amount -3,501. CC 00399
100275 WELLINGTON REGL MEDICAL CENTER 00100 Part A Info 10/21/2016 Date
100275 WELLINGTON REGL MEDICAL CENTER 00100 Part A Info 12/21/2016 Date
100275 WELLINGTON REGL MEDICAL CENTER 00200 Part A Amount 102,703. CC 00301
100275 WELLINGTON REGL MEDICAL CENTER 00200 Part A Amount 12,678. CC 00302
100275 WELLINGTON REGL MEDICAL CENTER 00200 Part A Amount 115,381. CC 00399
100287 GOOD SAMARITAN HOSPITAL 00100 Part A Info 03/03/2016 Date
100287 GOOD SAMARITAN HOSPITAL 00200 Part A Amount 119,443. CC 00301
100287 GOOD SAMARITAN HOSPITAL 00200 Part A Amount 119,443. CC 00399
100288 ST MARYS MEDICAL CENTER 00100 Part A Info 03/09/2016 Date
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 103,394. CC 00351
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount -103,394. CC 00399
102023 SSH - PALM BEACH LLC 00100 Part A Info 09/01/2016 Date
102023 SSH - PALM BEACH LLC 00100 Part A Info 10/26/2016 Date
102023 SSH - PALM BEACH LLC 00200 Part A Amount 160,300. CC 00301
102023 SSH - PALM BEACH LLC 00200 Part A Amount 457,688. CC 00350
102023 SSH - PALM BEACH LLC 00200 Part A Amount -297,388. CC 00399
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Part A Info 07/12/2016 Date
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Part A Info 02/16/2016 Date
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 1,923,774. CC 00301
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 49,460. CC 00350
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 1,874,314. CC 00399
00400 Total Interim Payments (Sum of Lines 01,02 & 3.99) (Transfer to Wkst E or E-3 As Appropriate)
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 65,974,907.
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 21,305,398.
100080 JFK MEDICAL CENTER 00200 Part A Amount 101,006,809.
100080 JFK MEDICAL CENTER 00400 Part B Amount 19,945,213.
100130 LAKESIDE MEDICAL CENTER 00200 Part A Amount 4,444,201.
100130 LAKESIDE MEDICAL CENTER 00400 Part B Amount 876,081.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Part A Amount 87,036,010.
100168 BOCA RATON REGIONAL HOSPITAL 00400 Part B Amount 74,671,711.
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Provider Provider Name Col Column Desc Amount Type
Page 43
100176 PALM BEACH GARDENS 00200 Part A Amount 43,515,184.
100176 PALM BEACH GARDENS 00400 Part B Amount 14,559,830.
100234 WEST PALM HOSPITAL 00200 Part A Amount 7,508,864.
100234 WEST PALM HOSPITAL 00400 Part B Amount 1,825,055.
100253 JUPITER MEDICAL CENTER 00200 Part A Amount 36,695,375.
100253 JUPITER MEDICAL CENTER 00400 Part B Amount 25,541,399.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 75,787,834.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 17,991,539.
100268 WEST BOCA MEDICAL CENTER 00200 Part A Amount 16,747,122.
100268 WEST BOCA MEDICAL CENTER 00400 Part B Amount 3,456,516.
100269 PALMS WEST HOSPITAL 00200 Part A Amount 23,309,442.
100269 PALMS WEST HOSPITAL 00400 Part B Amount 2,072,505.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Part A Amount 22,786,321.
100275 WELLINGTON REGL MEDICAL CENTER 00400 Part B Amount 5,444,536.
100287 GOOD SAMARITAN HOSPITAL 00200 Part A Amount 30,067,607.
100287 GOOD SAMARITAN HOSPITAL 00400 Part B Amount 9,946,212.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 28,806,396.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 2,258,991.
102023 SSH - PALM BEACH LLC 00200 Part A Amount 14,591,933.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 13,783,744.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Part A Amount 848,148.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00400 Part B Amount 796,593.
00500 Tentative Settlement Payment - Provider to Program Date
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Part A Info 03/06/2017 Date
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 997,297. CC 00501
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 997,297. CC 00599
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Part B Info 03/06/2017 Date
102025 KINDRED HOSPITAL THE PALM BEACHES 00400 Part B Amount 38,740. CC 00550
102025 KINDRED HOSPITAL THE PALM BEACHES 00400 Part B Amount -38,740. CC 00599
00602 Tentative Settlement Payment - Provider to Program
100080 JFK MEDICAL CENTER 00200 Part A Amount 2,392,762.
100176 PALM BEACH GARDENS 00200 Part A Amount 235,108.
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Provider Provider Name Col Column Desc Amount Type
Page 44
100253 JUPITER MEDICAL CENTER 00400 Part B Amount 15,767.
100268 WEST BOCA MEDICAL CENTER 00200 Part A Amount 187,003.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Part A Amount 49,388.
100275 WELLINGTON REGL MEDICAL CENTER 00400 Part B Amount 30,251.
100287 GOOD SAMARITAN HOSPITAL 00200 Part A Amount 146,752.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 946,454.
00700 Worksheet E-1 Total Medicare Program Liability (See Instructions)
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 66,776,931.
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 21,640,407.
100080 JFK MEDICAL CENTER 00200 Part A Amount 98,614,047.
100080 JFK MEDICAL CENTER 00400 Part B Amount 20,014,479.
100130 LAKESIDE MEDICAL CENTER 00200 Part A Amount 4,861,644.
100130 LAKESIDE MEDICAL CENTER 00400 Part B Amount 950,326.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Part A Amount 87,516,552.
100168 BOCA RATON REGIONAL HOSPITAL 00400 Part B Amount 74,987,461.
100176 PALM BEACH GARDENS 00200 Part A Amount 43,280,076.
100176 PALM BEACH GARDENS 00400 Part B Amount 14,714,030.
100234 WEST PALM HOSPITAL 00200 Part A Amount 7,746,740.
100234 WEST PALM HOSPITAL 00400 Part B Amount 1,952,619.
100253 JUPITER MEDICAL CENTER 00200 Part A Amount 36,722,447.
100253 JUPITER MEDICAL CENTER 00400 Part B Amount 25,525,632.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 77,999,203.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 18,281,697.
100268 WEST BOCA MEDICAL CENTER 00200 Part A Amount 16,560,119.
100268 WEST BOCA MEDICAL CENTER 00400 Part B Amount 3,549,534.
100269 PALMS WEST HOSPITAL 00200 Part A Amount 23,310,192.
100269 PALMS WEST HOSPITAL 00400 Part B Amount 2,098,841.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Part A Amount 22,736,933.
100275 WELLINGTON REGL MEDICAL CENTER 00400 Part B Amount 5,414,285.
100287 GOOD SAMARITAN HOSPITAL 00200 Part A Amount 29,920,855.
100287 GOOD SAMARITAN HOSPITAL 00400 Part B Amount 10,085,307.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 27,859,942.
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Provider Provider Name Col Column Desc Amount Type
Page 45
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 2,379,888.
102023 SSH - PALM BEACH LLC 00200 Part A Amount 15,489,754.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 14,857,230.
102025 KINDRED HOSPITAL THE PALM BEACHES 00400 Part B Amount -28,380.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Part A Amount 900,845.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00400 Part B Amount 835,353.
00800 FLORIDA
100002 BETHESDA HOSPITAL INC 00000 Description
100002 BETHESDA HOSPITAL INC 00100 Part A Info 09001 Date
100080 JFK MEDICAL CENTER 00000 Description
100080 JFK MEDICAL CENTER 00100 Part A Info 05901 Date
100130 LAKESIDE MEDICAL CENTER 00000 Description
100130 LAKESIDE MEDICAL CENTER 00100 Part A Info 09001 Date
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description
100168 BOCA RATON REGIONAL HOSPITAL 00100 Part A Info 09001 Date
100176 PALM BEACH GARDENS 00000 Description
100176 PALM BEACH GARDENS 00100 Part A Info 04011 Date
100234 WEST PALM HOSPITAL 00000 Description
100234 WEST PALM HOSPITAL 00100 Part A Info 05901 Date
100253 JUPITER MEDICAL CENTER 00000 Description
100253 JUPITER MEDICAL CENTER 00100 Part A Info 09001 Date
100258 DELRAY MEDICAL CENTER 00000 Description
100258 DELRAY MEDICAL CENTER 00100 Part A Info 04011 Date
100268 WEST BOCA MEDICAL CENTER 00000 Description
100268 WEST BOCA MEDICAL CENTER 00100 Part A Info 04011 Date
100269 PALMS WEST HOSPITAL 00000 Description
100269 PALMS WEST HOSPITAL 00100 Part A Info 09001 Date
100275 WELLINGTON REGL MEDICAL CENTER 00000 Description
100275 WELLINGTON REGL MEDICAL CENTER 00100 Part A Info 12001 Date
100287 GOOD SAMARITAN HOSPITAL 00000 Description
100287 GOOD SAMARITAN HOSPITAL 00100 Part A Info 04011 Date
100288 ST MARYS MEDICAL CENTER 00000 Description
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Provider Provider Name Col Column Desc Amount Type
Page 46
100288 ST MARYS MEDICAL CENTER 00100 Part A Info 04011 Date
102023 SSH - PALM BEACH LLC 00000 Description
102023 SSH - PALM BEACH LLC 00100 Part A Info 09001 Date
102025 KINDRED HOSPITAL THE PALM BEACHES 00000 Description
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Part A Info 09001 Date
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Part A Amount 05/08/2017
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00000 Description
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Part A Info 05901 Date
B18 IPF Medicare
00100 Total interim payments paid to provider
100080 JFK MEDICAL CENTER 00200 Part A Amount 1,786,535.
100080 JFK MEDICAL CENTER 00400 Part B Amount 8,081.
100234 WEST PALM HOSPITAL 00200 Part A Amount 2,388,005.
100234 WEST PALM HOSPITAL 00400 Part B Amount 184,037.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 4,162,588.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 2,041.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 2,863,157.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 5,045.
00300 Retroactive Lump Sum Adjustment - Provider to Program Date
100258 DELRAY MEDICAL CENTER 00100 Part A Info 11/09/2016 Date
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 31,223. CC 00301
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 31,223. CC 00399
100288 ST MARYS MEDICAL CENTER 00100 Part A Info 03/09/2016 Date
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 4,654. CC 00350
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount -4,654. CC 00399
00400 Total Interim Payments (Sum of Lines 01,02 & 3.99) (Transfer to Wkst E or E-3 As Appropriate)
100080 JFK MEDICAL CENTER 00200 Part A Amount 1,786,535.
100080 JFK MEDICAL CENTER 00400 Part B Amount 8,081.
100234 WEST PALM HOSPITAL 00200 Part A Amount 2,388,005.
100234 WEST PALM HOSPITAL 00400 Part B Amount 184,037.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 4,193,811.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 2,041.
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Provider Provider Name Col Column Desc Amount Type
Page 47
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 2,858,503.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 5,045.
00602 Tentative Settlement Payment - Provider to Program
100080 JFK MEDICAL CENTER 00400 Part B Amount 13.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 7,738.
00700 Worksheet E-1 Total Medicare Program Liability (See Instructions)
100080 JFK MEDICAL CENTER 00200 Part A Amount 1,786,651.
100080 JFK MEDICAL CENTER 00400 Part B Amount 8,068.
100234 WEST PALM HOSPITAL 00200 Part A Amount 2,615,673.
100234 WEST PALM HOSPITAL 00400 Part B Amount 185,230.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 4,186,073.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 2,182.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 2,876,648.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 5,089.
00800 WISCONSIN PHYSICIAN SERVICES
100080 JFK MEDICAL CENTER 00000 Description
100080 JFK MEDICAL CENTER 00100 Part A Info 05901 Date
100234 WEST PALM HOSPITAL 00000 Description
100234 WEST PALM HOSPITAL 00100 Part A Info 05901 Date
100258 DELRAY MEDICAL CENTER 00000 Description
100258 DELRAY MEDICAL CENTER 00100 Part A Info 04011 Date
100288 ST MARYS MEDICAL CENTER 00000 Description
100288 ST MARYS MEDICAL CENTER 00100 Part A Info 04011 Date
C18 IRF Medicare
00100 Total interim payments paid to provider
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 13,631,235.
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 269.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 12,580,347.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 969.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 2,265,639.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 448.
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Page 48
00300 Retroactive Lump Sum Adjustment - Provider to Program Date
100002 BETHESDA HOSPITAL INC 00100 Part A Info 09/01/2016 Date
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 58,668. CC 00350
100002 BETHESDA HOSPITAL INC 00200 Part A Amount -58,668. CC 00399
100288 ST MARYS MEDICAL CENTER 00100 Part A Info 03/09/2016 Date
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 4,884. CC 00301
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 4,884. CC 00399
00400 Total Interim Payments (Sum of Lines 01,02 & 3.99) (Transfer to Wkst E or E-3 As Appropriate)
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 13,572,567.
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 269.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 12,580,347.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 969.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 2,270,523.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 448.
00602 Tentative Settlement Payment - Provider to Program
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 161,813.
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 202.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 154,821.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 90.
00700 Worksheet E-1 Total Medicare Program Liability (See Instructions)
100002 BETHESDA HOSPITAL INC 00200 Part A Amount 13,410,754.
100002 BETHESDA HOSPITAL INC 00400 Part B Amount 67.
100258 DELRAY MEDICAL CENTER 00200 Part A Amount 12,425,526.
100258 DELRAY MEDICAL CENTER 00400 Part B Amount 980.
100288 ST MARYS MEDICAL CENTER 00200 Part A Amount 2,298,790.
100288 ST MARYS MEDICAL CENTER 00400 Part B Amount 358.
00800 FLORIDA
100002 BETHESDA HOSPITAL INC 00000 Description
100002 BETHESDA HOSPITAL INC 00100 Part A Info 09001 Date
100258 DELRAY MEDICAL CENTER 00000 Description
100258 DELRAY MEDICAL CENTER 00100 Part A Info 04011 Date
100288 ST MARYS MEDICAL CENTER 00000 Description
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Page 49
100288 ST MARYS MEDICAL CENTER 00100 Part A Info 04011 Date
2 Part 2 - Health Information Technology Data Collection and Calculation
A18 Hospital Medicare
00100 Total Hospital Discharges as Defined in AARA 4102 from Wkst S-3 Part 1 Line 14 Col 15
Discharges
100002 BETHESDA HOSPITAL INC 00100 Amount 22,225. Discharges
100080 JFK MEDICAL CENTER 00100 Amount 28,294. Discharges
100130 LAKESIDE MEDICAL CENTER 00100 Amount 1,993. Discharges
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 18,808. Discharges
100176 PALM BEACH GARDENS 00100 Amount 9,768. Discharges
100253 JUPITER MEDICAL CENTER 00100 Amount 12,038. Discharges
100258 DELRAY MEDICAL CENTER 00100 Amount 15,811. Discharges
100268 WEST BOCA MEDICAL CENTER 00100 Amount 11,282. Discharges
100269 PALMS WEST HOSPITAL 00100 Amount 14,125. Discharges
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amount 11,894. Discharges
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 10,932. Discharges
100288 ST MARYS MEDICAL CENTER 00100 Amount 16,174. Discharges
102023 SSH - PALM BEACH LLC 00100 Amount 611. Discharges
00200 Medicare Days From Wkst S-3 Part 1 Col 6 Sum of Lines 01 and 08 to 12 Days
100002 BETHESDA HOSPITAL INC 00100 Amount 31,854. Days
100080 JFK MEDICAL CENTER 00100 Amount 43,122. Days
100130 LAKESIDE MEDICAL CENTER 00100 Amount 1,857. Days
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 47,789. Days
100176 PALM BEACH GARDENS 00100 Amount 22,205. Days
100253 JUPITER MEDICAL CENTER 00100 Amount 20,491. Days
100258 DELRAY MEDICAL CENTER 00100 Amount 39,979. Days
100268 WEST BOCA MEDICAL CENTER 00100 Amount 8,392. Days
100269 PALMS WEST HOSPITAL 00100 Amount 12,366. Days
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amount 9,665. Days
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Provider Provider Name Col Column Desc Amount Type
Page 50
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 17,640. Days
100288 ST MARYS MEDICAL CENTER 00100 Amount 9,214. Days
102023 SSH - PALM BEACH LLC 00100 Amount 8,965. Days
00300 Medicare HMO Days From Wkst S-3 Part 1 Col 06 Line 2 Days
100002 BETHESDA HOSPITAL INC 00100 Amount 13,669. Days
100080 JFK MEDICAL CENTER 00100 Amount 32,176. Days
100130 LAKESIDE MEDICAL CENTER 00100 Amount 1,294. Days
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 10,601. Days
100176 PALM BEACH GARDENS 00100 Amount 9,120. Days
100253 JUPITER MEDICAL CENTER 00100 Amount 4,861. Days
100258 DELRAY MEDICAL CENTER 00100 Amount 15,552. Days
100268 WEST BOCA MEDICAL CENTER 00100 Amount 6,017. Days
100269 PALMS WEST HOSPITAL 00100 Amount 10,419. Days
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amount 10,487. Days
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 6,538. Days
100288 ST MARYS MEDICAL CENTER 00100 Amount 5,011. Days
102023 SSH - PALM BEACH LLC 00100 Amount 4,344. Days
00400 Total Inpatient Bed Days From S-3 Part 1 Col 08 Sum of Lines 01 and 08 to 12. Days
100002 BETHESDA HOSPITAL INC 00100 Amount 91,300. Days
100080 JFK MEDICAL CENTER 00100 Amount 132,430. Days
100130 LAKESIDE MEDICAL CENTER 00100 Amount 8,312. Days
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 83,774. Days
100176 PALM BEACH GARDENS 00100 Amount 47,411. Days
100253 JUPITER MEDICAL CENTER 00100 Amount 44,930. Days
100258 DELRAY MEDICAL CENTER 00100 Amount 76,550. Days
100268 WEST BOCA MEDICAL CENTER 00100 Amount 40,432. Days
100269 PALMS WEST HOSPITAL 00100 Amount 58,733. Days
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amount 48,114. Days
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 46,471. Days
100288 ST MARYS MEDICAL CENTER 00100 Amount 86,734. Days
102023 SSH - PALM BEACH LLC 00100 Amount 16,900. Days
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Provider Provider Name Col Column Desc Amount Type
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00500 Total Hospital Charges From Wkst C Part 1 Col 08 Line 200
100002 BETHESDA HOSPITAL INC 00100 Amount 1,678,082,690.
100080 JFK MEDICAL CENTER 00100 Amount 3,961,336,000.
100130 LAKESIDE MEDICAL CENTER 00100 Amount 127,349,655.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 1,897,933,156.
100176 PALM BEACH GARDENS 00100 Amount 1,250,442,108.
100253 JUPITER MEDICAL CENTER 00100 Amount 886,306,242.
100258 DELRAY MEDICAL CENTER 00100 Amount 2,515,364,097.
100268 WEST BOCA MEDICAL CENTER 00100 Amount 742,974,675.
100269 PALMS WEST HOSPITAL 00100 Amount 1,357,920,590.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amount 1,133,494,751.
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 1,212,817,810.
100288 ST MARYS MEDICAL CENTER 00100 Amount 1,579,462,305.
102023 SSH - PALM BEACH LLC 00100 Amount 95,109,608.
00600 Total Hospital Charity Care Charges From Wkst S-10 Col 03 Line 20
100002 BETHESDA HOSPITAL INC 00100 Amount 42,480,683.
100080 JFK MEDICAL CENTER 00100 Amount 84,342,893.
100130 LAKESIDE MEDICAL CENTER 00100 Amount 2,108,235.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 33,358,011.
100176 PALM BEACH GARDENS 00100 Amount 9,968,871.
100253 JUPITER MEDICAL CENTER 00100 Amount 10,929,856.
100258 DELRAY MEDICAL CENTER 00100 Amount 4,859,580.
100268 WEST BOCA MEDICAL CENTER 00100 Amount 908,007.
100269 PALMS WEST HOSPITAL 00100 Amount 25,002,645.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amount 34,695,257.
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 5,467,344.
100288 ST MARYS MEDICAL CENTER 00100 Amount 6,913,212.
00800 Calculation of the HIT Iincentive Payment (See Instructions)
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 981,203.
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 516,930.
100288 ST MARYS MEDICAL CENTER 00100 Amount 206,081.
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Provider Provider Name Col Column Desc Amount Type
Page 52
00900 Sequestation Adjustment Amount (See Instructions)
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 19,624.
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 10,339.
100288 ST MARYS MEDICAL CENTER 00100 Amount 4,122.
01000 Calculation of the HIT Incentive Payment After Sequestration (See Instructions)
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 961,579.
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 506,591.
100288 ST MARYS MEDICAL CENTER 00100 Amount 201,959.
03000 Initial/Interim HIT Payments
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount 1,082,084.
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 488,205.
100288 ST MARYS MEDICAL CENTER 00100 Amount 202,071.
03200 Balance Due Provider (Line 08 Minus Line 30 Plus/Minus Line 31)
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amount -120,505.
100287 GOOD SAMARITAN HOSPITAL 00100 Amount 18,386.
100288 ST MARYS MEDICAL CENTER 00100 Amount -112.
G10 Wkst G-1 Statement of Changes in Fund Balances
00100 Fund Balances at Beginning of Period
100002 BETHESDA HOSPITAL INC 00200 General Fund 295,789,488.
100080 JFK MEDICAL CENTER 00200 General Fund 203,951,226.
100130 LAKESIDE MEDICAL CENTER 00200 General Fund 44,045,524.
100168 BOCA RATON REGIONAL HOSPITAL 00200 General Fund 345,369,234.
100176 PALM BEACH GARDENS 00200 General Fund 153,549,196.
100234 WEST PALM HOSPITAL 00200 General Fund -56,347,518.
100253 JUPITER MEDICAL CENTER 00200 General Fund 123,141,721.
100258 DELRAY MEDICAL CENTER 00200 General Fund 145,933,868.
100268 WEST BOCA MEDICAL CENTER 00200 General Fund 83,602,387.
100269 PALMS WEST HOSPITAL 00200 General Fund 244,938,281.
100275 WELLINGTON REGL MEDICAL CENTER 00200 General Fund 42,728,792.
100287 GOOD SAMARITAN HOSPITAL 00200 General Fund 154,853,999.
100288 ST MARYS MEDICAL CENTER 00200 General Fund 182,036,006.
102023 SSH - PALM BEACH LLC 00200 General Fund -17,954,137.
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102025 KINDRED HOSPITAL THE PALM BEACHES 00200 General Fund -2,740,007.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 General Fund 6,501,569.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00400 Specific Purpose Fund
172,789.
00200 Net Income(Loss) (Worksheet G-3 Line 29)
100002 BETHESDA HOSPITAL INC 00200 General Fund -10,312,752.
100080 JFK MEDICAL CENTER 00200 General Fund 36,568,741.
100130 LAKESIDE MEDICAL CENTER 00200 General Fund -44,885.
100168 BOCA RATON REGIONAL HOSPITAL 00200 General Fund 20,631,662.
100176 PALM BEACH GARDENS 00200 General Fund 22,161,402.
100234 WEST PALM HOSPITAL 00200 General Fund -5,182,343.
100253 JUPITER MEDICAL CENTER 00200 General Fund 9,293,451.
100258 DELRAY MEDICAL CENTER 00200 General Fund 41,792,450.
100268 WEST BOCA MEDICAL CENTER 00200 General Fund 25,228,046.
100269 PALMS WEST HOSPITAL 00200 General Fund 28,772,614.
100275 WELLINGTON REGL MEDICAL CENTER 00200 General Fund 11,988,671.
100287 GOOD SAMARITAN HOSPITAL 00200 General Fund 21,529,193.
100288 ST MARYS MEDICAL CENTER 00200 General Fund 45,180,831.
102023 SSH - PALM BEACH LLC 00200 General Fund -655,796.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 General Fund 3,625,285.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 General Fund 1,835,270.
00300 Total (Sum of Lines 01 and 02)
100002 BETHESDA HOSPITAL INC 00200 General Fund 285,476,736.
100080 JFK MEDICAL CENTER 00200 General Fund 240,519,967.
100130 LAKESIDE MEDICAL CENTER 00200 General Fund 44,000,639.
100168 BOCA RATON REGIONAL HOSPITAL 00200 General Fund 366,000,896.
100176 PALM BEACH GARDENS 00200 General Fund 175,710,598.
100234 WEST PALM HOSPITAL 00200 General Fund -61,529,861.
100253 JUPITER MEDICAL CENTER 00200 General Fund 132,435,172.
100258 DELRAY MEDICAL CENTER 00200 General Fund 187,726,318.
100268 WEST BOCA MEDICAL CENTER 00200 General Fund 108,830,433.
100269 PALMS WEST HOSPITAL 00200 General Fund 273,710,895.
100275 WELLINGTON REGL MEDICAL CENTER 00200 General Fund 54,717,463.
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Provider Provider Name Col Column Desc Amount Type
Page 54
100287 GOOD SAMARITAN HOSPITAL 00200 General Fund 176,383,192.
100288 ST MARYS MEDICAL CENTER 00200 General Fund 227,216,837.
102023 SSH - PALM BEACH LLC 00200 General Fund -18,609,933.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 General Fund 885,278.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 General Fund 8,336,839.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00400 Specific Purpose Fund
172,789.
00400 NON-OPERATING GAINS CC 00500
100002 BETHESDA HOSPITAL INC 00000 Description CC 00500
100002 BETHESDA HOSPITAL INC 00000 Description CC 00600
100002 BETHESDA HOSPITAL INC 00100 General Fund - Changes
6,419,640. CC 00500
100002 BETHESDA HOSPITAL INC 00100 General Fund - Changes
1,065,373. CC 00600
100080 JFK MEDICAL CENTER 00000 Description
100080 JFK MEDICAL CENTER 00100 General Fund - Changes
90.
100176 PALM BEACH GARDENS 00000 Description CC 00500
100176 PALM BEACH GARDENS 00000 Description CC 00600
100176 PALM BEACH GARDENS 00000 Description CC 00700
100176 PALM BEACH GARDENS 00000 Description CC 00800
100176 PALM BEACH GARDENS 00000 Description CC 00900
100176 PALM BEACH GARDENS 00100 General Fund - Changes
1. CC 00600
100176 PALM BEACH GARDENS 00100 General Fund - Changes
176,550. CC 00700
100234 WEST PALM HOSPITAL 00000 Description
100234 WEST PALM HOSPITAL 00000 Description CC 00500
100234 WEST PALM HOSPITAL 00100 General Fund - Changes
2,227,788.
100234 WEST PALM HOSPITAL 00100 General Fund - Changes
19. CC 00500
100258 DELRAY MEDICAL CENTER 00000 Description CC 00500
100258 DELRAY MEDICAL CENTER 00000 Description CC 00600
100258 DELRAY MEDICAL CENTER 00000 Description CC 00700
100258 DELRAY MEDICAL CENTER 00000 Description CC 00800
100258 DELRAY MEDICAL CENTER 00000 Description CC 00900
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Page 55
100258 DELRAY MEDICAL CENTER 00100 General Fund - Changes
15,567,503. CC 00500
100258 DELRAY MEDICAL CENTER 00100 General Fund - Changes
45. CC 00600
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 00500
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 00600
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 00700
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 00800
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 00900
100268 WEST BOCA MEDICAL CENTER 00100 General Fund - Changes
54. CC 00600
100287 GOOD SAMARITAN HOSPITAL 00000 Description CC 00600
100287 GOOD SAMARITAN HOSPITAL 00000 Description CC 00700
100287 GOOD SAMARITAN HOSPITAL 00100 General Fund - Changes
123,843. CC 00600
100288 ST MARYS MEDICAL CENTER 00000 Description CC 00500
100288 ST MARYS MEDICAL CENTER 00100 General Fund - Changes
385,797. CC 00500
102023 SSH - PALM BEACH LLC 00000 Description CC 00500
102025 KINDRED HOSPITAL THE PALM BEACHES 00000 Description
102025 KINDRED HOSPITAL THE PALM BEACHES 00000 Description CC 00500
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 General Fund - Changes
3. CC 00500
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00000 Description
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 General Fund - Changes
1,019,181.
01000 Total Additions (Sum of Lines 04 to 09)
100002 BETHESDA HOSPITAL INC 00200 General Fund 7,485,013.
100080 JFK MEDICAL CENTER 00200 General Fund 90.
100176 PALM BEACH GARDENS 00200 General Fund 176,551.
100234 WEST PALM HOSPITAL 00200 General Fund 2,227,807.
100258 DELRAY MEDICAL CENTER 00200 General Fund 15,567,548.
100268 WEST BOCA MEDICAL CENTER 00200 General Fund 54.
100287 GOOD SAMARITAN HOSPITAL 00200 General Fund 123,843.
100288 ST MARYS MEDICAL CENTER 00200 General Fund 385,797.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 General Fund 3.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 General Fund 1,019,181.
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Page 56
01100 Sub Total (Line 03 Plus Line 10)
100002 BETHESDA HOSPITAL INC 00200 General Fund 292,961,749.
100080 JFK MEDICAL CENTER 00200 General Fund 240,520,057.
100130 LAKESIDE MEDICAL CENTER 00200 General Fund 44,000,639.
100168 BOCA RATON REGIONAL HOSPITAL 00200 General Fund 366,000,896.
100176 PALM BEACH GARDENS 00200 General Fund 175,887,149.
100234 WEST PALM HOSPITAL 00200 General Fund -59,302,054.
100253 JUPITER MEDICAL CENTER 00200 General Fund 132,435,172.
100258 DELRAY MEDICAL CENTER 00200 General Fund 203,293,866.
100268 WEST BOCA MEDICAL CENTER 00200 General Fund 108,830,487.
100269 PALMS WEST HOSPITAL 00200 General Fund 273,710,895.
100275 WELLINGTON REGL MEDICAL CENTER 00200 General Fund 54,717,463.
100287 GOOD SAMARITAN HOSPITAL 00200 General Fund 176,507,035.
100288 ST MARYS MEDICAL CENTER 00200 General Fund 227,602,634.
102023 SSH - PALM BEACH LLC 00200 General Fund -18,609,933.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 General Fund 885,281.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 General Fund 9,356,020.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00400 Specific Purpose Fund
172,789.
01200 BAD DEBT CC 01300
100002 BETHESDA HOSPITAL INC 00000 Description CC 01300
100002 BETHESDA HOSPITAL INC 00100 General Fund - Changes
12,781,198. CC 01300
100080 JFK MEDICAL CENTER 00000 Description
100080 JFK MEDICAL CENTER 00000 Description CC 01300
100080 JFK MEDICAL CENTER 00100 General Fund - Changes
21,736,317.
100176 PALM BEACH GARDENS 00000 Description CC 01300
100176 PALM BEACH GARDENS 00000 Description CC 01400
100176 PALM BEACH GARDENS 00000 Description CC 01500
100176 PALM BEACH GARDENS 00000 Description CC 01600
100176 PALM BEACH GARDENS 00000 Description CC 01700
100176 PALM BEACH GARDENS 00100 General Fund - Changes
9,777,002. CC 01300
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100176 PALM BEACH GARDENS 00100 General Fund - Changes
35,737. CC 01700
100258 DELRAY MEDICAL CENTER 00000 Description CC 01300
100258 DELRAY MEDICAL CENTER 00000 Description CC 01400
100258 DELRAY MEDICAL CENTER 00000 Description CC 01500
100258 DELRAY MEDICAL CENTER 00000 Description CC 01600
100258 DELRAY MEDICAL CENTER 00000 Description CC 01700
100258 DELRAY MEDICAL CENTER 00100 General Fund - Changes
1. CC 01400
100258 DELRAY MEDICAL CENTER 00100 General Fund - Changes
48,148. CC 01700
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 01300
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 01400
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 01500
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 01600
100268 WEST BOCA MEDICAL CENTER 00000 Description CC 01700
100268 WEST BOCA MEDICAL CENTER 00100 General Fund - Changes
24,681,547. CC 01300
100268 WEST BOCA MEDICAL CENTER 00100 General Fund - Changes
72,186. CC 01700
100269 PALMS WEST HOSPITAL 00000 Description
100269 PALMS WEST HOSPITAL 00000 Description CC 01300
100269 PALMS WEST HOSPITAL 00100 General Fund - Changes
13,322,472.
100269 PALMS WEST HOSPITAL 00100 General Fund - Changes
1. CC 01300
100287 GOOD SAMARITAN HOSPITAL 00000 Description CC 01300
100287 GOOD SAMARITAN HOSPITAL 00100 General Fund - Changes
16,898,993. CC 01300
100288 ST MARYS MEDICAL CENTER 00000 Description CC 01300
100288 ST MARYS MEDICAL CENTER 00100 General Fund - Changes
32,685,528. CC 01300
102025 KINDRED HOSPITAL THE PALM BEACHES 00000 Description
102025 KINDRED HOSPITAL THE PALM BEACHES 00000 Description CC 01300
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00000 Description
01800 Deductions Line 12 to 17 (Debit Adjustments) (Specify)
100002 BETHESDA HOSPITAL INC 00200 General Fund 12,781,198.
100080 JFK MEDICAL CENTER 00200 General Fund 21,736,317.
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Provider Provider Name Col Column Desc Amount Type
Page 58
100176 PALM BEACH GARDENS 00200 General Fund 9,812,739.
100258 DELRAY MEDICAL CENTER 00200 General Fund 48,149.
100268 WEST BOCA MEDICAL CENTER 00200 General Fund 24,753,733.
100269 PALMS WEST HOSPITAL 00200 General Fund 13,322,473.
100287 GOOD SAMARITAN HOSPITAL 00200 General Fund 16,898,993.
100288 ST MARYS MEDICAL CENTER 00200 General Fund 32,685,528.
01900 Fund Balance at End of Period Per Balance Sheet (Line 11 Minus 18)
100002 BETHESDA HOSPITAL INC 00200 General Fund 280,180,551.
100080 JFK MEDICAL CENTER 00200 General Fund 218,783,740.
100130 LAKESIDE MEDICAL CENTER 00200 General Fund 44,000,639.
100168 BOCA RATON REGIONAL HOSPITAL 00200 General Fund 366,000,896.
100176 PALM BEACH GARDENS 00200 General Fund 166,074,410.
100234 WEST PALM HOSPITAL 00200 General Fund -59,302,054.
100253 JUPITER MEDICAL CENTER 00200 General Fund 132,435,172.
100258 DELRAY MEDICAL CENTER 00200 General Fund 203,245,717.
100268 WEST BOCA MEDICAL CENTER 00200 General Fund 84,076,754.
100269 PALMS WEST HOSPITAL 00200 General Fund 260,388,422.
100275 WELLINGTON REGL MEDICAL CENTER 00200 General Fund 54,717,463.
100287 GOOD SAMARITAN HOSPITAL 00200 General Fund 159,608,042.
100288 ST MARYS MEDICAL CENTER 00200 General Fund 194,917,106.
102023 SSH - PALM BEACH LLC 00200 General Fund -18,609,933.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 General Fund 885,281.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 General Fund 9,356,020.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00400 Specific Purpose Fund
172,789.
G20 Wkst G-2 Statement of Patient Revenues and Operating Expenses
00100 Hospital
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 84,258,132.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 84,258,132.
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 304,926,106.
100080 JFK MEDICAL CENTER 00300 Total Revenue 304,926,106.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 10,641,784.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 10,641,784.
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Provider Provider Name Col Column Desc Amount Type
Page 59
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 103,659,174.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 103,659,174.
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 88,219,093.
100176 PALM BEACH GARDENS 00300 Total Revenue 88,219,093.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 51,923,577.
100234 WEST PALM HOSPITAL 00300 Total Revenue 51,923,577.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 40,082,355.
100253 JUPITER MEDICAL CENTER 00300 Total Revenue 40,082,355.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 189,337,331.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 189,337,331.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 58,436,950.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 58,436,950.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 91,632,777.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 91,632,777.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 108,217,370.
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 108,217,370.
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 98,551,148.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 98,551,148.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 141,835,208.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 141,835,208.
102023 SSH - PALM BEACH LLC 00100 Inpatient Revenue 38,329,213.
102023 SSH - PALM BEACH LLC 00300 Total Revenue 38,329,213.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Inpatient Revenue 30,493,697.
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Total Revenue 30,493,697.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Inpatient Revenue 11,673,185.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00300 Total Revenue 11,673,185.
00200 Subprovider - IPF
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 51,327,407.
100080 JFK MEDICAL CENTER 00300 Total Revenue 51,327,407.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 60,066,765.
100234 WEST PALM HOSPITAL 00300 Total Revenue 60,066,765.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 40,431,257.
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Provider Provider Name Col Column Desc Amount Type
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100258 DELRAY MEDICAL CENTER 00300 Total Revenue 40,431,257.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 46,942,900.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 46,942,900.
00300 Subprovider - IRF
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 12,884,400.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 12,884,400.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 37,649,393.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 37,649,393.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 10,244,350.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 10,244,350.
01000 Worksheet G-2 Total General Inpatient Care Services
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 97,142,532.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 97,142,532.
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 356,253,513.
100080 JFK MEDICAL CENTER 00300 Total Revenue 356,253,513.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 10,641,784.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 10,641,784.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 103,659,174.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 103,659,174.
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 88,219,093.
100176 PALM BEACH GARDENS 00300 Total Revenue 88,219,093.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 111,990,342.
100234 WEST PALM HOSPITAL 00300 Total Revenue 111,990,342.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 40,082,355.
100253 JUPITER MEDICAL CENTER 00300 Total Revenue 40,082,355.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 267,417,981.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 267,417,981.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 58,436,950.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 58,436,950.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 91,632,777.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 91,632,777.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 108,217,370.
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Provider Provider Name Col Column Desc Amount Type
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100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 108,217,370.
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 98,551,148.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 98,551,148.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 199,022,458.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 199,022,458.
102023 SSH - PALM BEACH LLC 00100 Inpatient Revenue 38,329,213.
102023 SSH - PALM BEACH LLC 00300 Total Revenue 38,329,213.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Inpatient Revenue 30,493,697.
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Total Revenue 30,493,697.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Inpatient Revenue 11,673,185.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00300 Total Revenue 11,673,185.
01100 Intensive Care Unit
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 98,889,727.
100080 JFK MEDICAL CENTER 00300 Total Revenue 98,889,727.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 2,109,638.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 2,109,638.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 12,589,094.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 4,095,394. CC 01101
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 12,589,094.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 4,095,394. CC 01101
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 54,325,424.
100176 PALM BEACH GARDENS 00300 Total Revenue 54,325,424.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 8,692,128.
100234 WEST PALM HOSPITAL 00300 Total Revenue 8,692,128.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 11,447,838.
100253 JUPITER MEDICAL CENTER 00300 Total Revenue 11,447,838.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 57,864,956.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 57,864,956.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 20,581,165.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 20,581,165.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 27,665,616.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 27,665,616.
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Provider Provider Name Col Column Desc Amount Type
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100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 30,893,685.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 13,380,900. CC 01101
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 30,893,685.
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 13,380,900. CC 01101
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 17,826,163.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 17,826,163.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 41,245,841.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 41,245,841.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Inpatient Revenue 6,716,264.
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Total Revenue 6,716,264.
01200 Coronary Care Unit
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 24,668,655.
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 1,129,300. CC 01201
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 24,668,655.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 1,129,300. CC 01201
01400 Surgurical Intensive Care Unit
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 9,813,433.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 9,813,433.
01500 Other Special Care
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 14,625,975.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 14,625,975.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 24,469,603.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 2,488,893. CC 01501
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 24,469,603.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 2,488,893. CC 01501
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 533,835.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 533,835.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 53,879,202.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 53,879,202.
01600 Worksheet G-2 Total Intensive Care Type Inpatient Hospital Services
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 40,423,930.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 40,423,930.
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Provider Provider Name Col Column Desc Amount Type
Page 63
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 98,889,727.
100080 JFK MEDICAL CENTER 00300 Total Revenue 98,889,727.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 2,109,638.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 2,109,638.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 26,497,921.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 26,497,921.
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 54,325,424.
100176 PALM BEACH GARDENS 00300 Total Revenue 54,325,424.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 8,692,128.
100234 WEST PALM HOSPITAL 00300 Total Revenue 8,692,128.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 11,447,838.
100253 JUPITER MEDICAL CENTER 00300 Total Revenue 11,447,838.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 57,864,956.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 57,864,956.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 47,539,661.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 47,539,661.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 27,665,616.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 27,665,616.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 44,274,585.
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 44,274,585.
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 18,359,998.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 18,359,998.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 95,125,043.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 95,125,043.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Inpatient Revenue 6,716,264.
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Total Revenue 6,716,264.
01700 Worksheet G-2 Total Inpatient Routine Care Services
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 137,566,462.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 137,566,462.
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 455,143,240.
100080 JFK MEDICAL CENTER 00300 Total Revenue 455,143,240.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 12,751,422.
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100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 12,751,422.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 130,157,095.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 130,157,095.
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 142,544,517.
100176 PALM BEACH GARDENS 00300 Total Revenue 142,544,517.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 120,682,470.
100234 WEST PALM HOSPITAL 00300 Total Revenue 120,682,470.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 51,530,193.
100253 JUPITER MEDICAL CENTER 00300 Total Revenue 51,530,193.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 325,282,937.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 325,282,937.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 105,976,611.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 105,976,611.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 119,298,393.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 119,298,393.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 152,491,955.
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 152,491,955.
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 116,911,146.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 116,911,146.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 294,147,501.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 294,147,501.
102023 SSH - PALM BEACH LLC 00100 Inpatient Revenue 38,329,213.
102023 SSH - PALM BEACH LLC 00300 Total Revenue 38,329,213.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Inpatient Revenue 37,209,961.
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Total Revenue 37,209,961.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Inpatient Revenue 11,673,185.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00300 Total Revenue 11,673,185.
01800 Ancillary Services
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 875,927,725.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 875,927,725.
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 2,095,612,674.
100080 JFK MEDICAL CENTER 00200 Outpatient Revenue
1,130,221,456.
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100080 JFK MEDICAL CENTER 00300 Total Revenue 3,225,834,130.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 46,260,704.
100130 LAKESIDE MEDICAL CENTER 00200 Outpatient Revenue
42,374,993.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 88,635,697.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 636,111,030.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Outpatient Revenue
1,030,359,801.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 1,666,470,831.
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 647,575,253.
100176 PALM BEACH GARDENS 00200 Outpatient Revenue
458,065,742.
100176 PALM BEACH GARDENS 00300 Total Revenue 1,105,640,995.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 184,844,941.
100234 WEST PALM HOSPITAL 00200 Outpatient Revenue
182,334,549.
100234 WEST PALM HOSPITAL 00300 Total Revenue 367,179,490.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 357,169,578.
100253 JUPITER MEDICAL CENTER 00200 Outpatient Revenue
409,270,486.
100253 JUPITER MEDICAL CENTER 00300 Total Revenue 766,440,064.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 1,509,519,194.
100258 DELRAY MEDICAL CENTER 00200 Outpatient Revenue
664,888,217.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 2,174,407,411.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 335,102,447.
100268 WEST BOCA MEDICAL CENTER 00200 Outpatient Revenue
290,853,036.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 625,955,483.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 739,790,912.
100269 PALMS WEST HOSPITAL 00200 Outpatient Revenue
397,816,056.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 1,137,606,968.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 511,442,544.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Outpatient Revenue
349,915,629.
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 861,358,173.
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 515,806,948.
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100287 GOOD SAMARITAN HOSPITAL 00200 Outpatient Revenue
578,414,831.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 1,094,221,779.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 871,948,658.
100288 ST MARYS MEDICAL CENTER 00200 Outpatient Revenue
407,027,635.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 1,278,976,293.
102023 SSH - PALM BEACH LLC 00100 Inpatient Revenue 56,780,395.
102023 SSH - PALM BEACH LLC 00300 Total Revenue 56,780,395.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Inpatient Revenue 75,752,307.
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Total Revenue 75,752,307.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Outpatient Revenue
12,098,925.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00300 Total Revenue 12,098,925.
01900 Outpatient Services
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 109,013.
100002 BETHESDA HOSPITAL INC 00200 Outpatient Revenue
657,669,767.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 657,778,780.
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 97,243,010.
100080 JFK MEDICAL CENTER 00200 Outpatient Revenue
183,115,620.
100080 JFK MEDICAL CENTER 00300 Total Revenue 280,358,630.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 3,493,307.
100130 LAKESIDE MEDICAL CENTER 00200 Outpatient Revenue
22,469,229.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 25,962,536.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 25,374,291.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Outpatient Revenue
71,204,658.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 96,578,949.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 26,091,361.
100234 WEST PALM HOSPITAL 00200 Outpatient Revenue
46,009,188.
100234 WEST PALM HOSPITAL 00300 Total Revenue 72,100,549.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 14,444,645.
100253 JUPITER MEDICAL CENTER 00200 Outpatient Revenue
53,891,330.
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100253 JUPITER MEDICAL CENTER 00300 Total Revenue 68,335,975.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 36,242,019.
100269 PALMS WEST HOSPITAL 00200 Outpatient Revenue
64,773,210.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 101,015,229.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 24,467,850.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Outpatient Revenue
95,176,771.
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 119,644,621.
02200 Home Health Agency
100168 BOCA RATON REGIONAL HOSPITAL 00200 Outpatient Revenue
4,726,276.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 4,726,276.
02700 HOSPICE CHRG FOR NON-PATIENTS
100002 BETHESDA HOSPITAL INC 00000 Text Information
100002 BETHESDA HOSPITAL INC 00000 Text Information CC 02701
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 3,930,164.
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 6,977,861. CC 02701
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 3,930,164.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 6,977,861. CC 02701
100080 JFK MEDICAL CENTER 00000 Text Information
100130 LAKESIDE MEDICAL CENTER 00000 Text Information
100130 LAKESIDE MEDICAL CENTER 00200 Outpatient Revenue
496,856.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 496,856.
100168 BOCA RATON REGIONAL HOSPITAL 00000 Text Information
100168 BOCA RATON REGIONAL HOSPITAL 00000 Text Information CC 02701
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 319,760.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Outpatient Revenue
819,859.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Outpatient Revenue
13,407,600. CC 02701
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 1,139,619.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 13,407,600. CC 02701
100268 WEST BOCA MEDICAL CENTER 00000 Text Information
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 3,585,189.
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100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 3,585,189.
100287 GOOD SAMARITAN HOSPITAL 00000 Text Information
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 2,421,714.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 2,421,714.
100288 ST MARYS MEDICAL CENTER 00000 Text Information
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 3,020,024.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 3,020,024.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00000 Text Information
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Outpatient Revenue
522,282.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00300 Total Revenue 522,282.
02800 Worksheet G-2 Total Patient Revenues (Transfer to G-3 Line 01)
100002 BETHESDA HOSPITAL INC 00100 Inpatient Revenue 1,024,511,225.
100002 BETHESDA HOSPITAL INC 00200 Outpatient Revenue
657,669,767.
100002 BETHESDA HOSPITAL INC 00300 Total Revenue 1,682,180,992.
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 2,647,998,924.
100080 JFK MEDICAL CENTER 00200 Outpatient Revenue
1,313,337,076.
100080 JFK MEDICAL CENTER 00300 Total Revenue 3,961,336,000.
100130 LAKESIDE MEDICAL CENTER 00100 Inpatient Revenue 62,505,433.
100130 LAKESIDE MEDICAL CENTER 00200 Outpatient Revenue
65,341,078.
100130 LAKESIDE MEDICAL CENTER 00300 Total Revenue 127,846,511.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Inpatient Revenue 791,962,176.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Outpatient Revenue
1,120,518,194.
100168 BOCA RATON REGIONAL HOSPITAL 00300 Total Revenue 1,912,480,370.
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 790,119,770.
100176 PALM BEACH GARDENS 00200 Outpatient Revenue
458,065,742.
100176 PALM BEACH GARDENS 00300 Total Revenue 1,248,185,512.
100234 WEST PALM HOSPITAL 00100 Inpatient Revenue 331,618,772.
100234 WEST PALM HOSPITAL 00200 Outpatient Revenue
228,343,737.
100234 WEST PALM HOSPITAL 00300 Total Revenue 559,962,509.
100253 JUPITER MEDICAL CENTER 00100 Inpatient Revenue 423,144,416.
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100253 JUPITER MEDICAL CENTER 00200 Outpatient Revenue
463,161,816.
100253 JUPITER MEDICAL CENTER 00300 Total Revenue 886,306,232.
100258 DELRAY MEDICAL CENTER 00100 Inpatient Revenue 1,834,802,131.
100258 DELRAY MEDICAL CENTER 00200 Outpatient Revenue
664,888,217.
100258 DELRAY MEDICAL CENTER 00300 Total Revenue 2,499,690,348.
100268 WEST BOCA MEDICAL CENTER 00100 Inpatient Revenue 444,664,247.
100268 WEST BOCA MEDICAL CENTER 00200 Outpatient Revenue
290,853,036.
100268 WEST BOCA MEDICAL CENTER 00300 Total Revenue 735,517,283.
100269 PALMS WEST HOSPITAL 00100 Inpatient Revenue 895,331,324.
100269 PALMS WEST HOSPITAL 00200 Outpatient Revenue
462,589,266.
100269 PALMS WEST HOSPITAL 00300 Total Revenue 1,357,920,590.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Inpatient Revenue 688,402,349.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Outpatient Revenue
445,092,400.
100275 WELLINGTON REGL MEDICAL CENTER 00300 Total Revenue 1,133,494,749.
100287 GOOD SAMARITAN HOSPITAL 00100 Inpatient Revenue 635,139,808.
100287 GOOD SAMARITAN HOSPITAL 00200 Outpatient Revenue
578,414,831.
100287 GOOD SAMARITAN HOSPITAL 00300 Total Revenue 1,213,554,639.
100288 ST MARYS MEDICAL CENTER 00100 Inpatient Revenue 1,169,116,183.
100288 ST MARYS MEDICAL CENTER 00200 Outpatient Revenue
407,027,635.
100288 ST MARYS MEDICAL CENTER 00300 Total Revenue 1,576,143,818.
102023 SSH - PALM BEACH LLC 00100 Inpatient Revenue 95,109,608.
102023 SSH - PALM BEACH LLC 00300 Total Revenue 95,109,608.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Inpatient Revenue 112,962,268.
102025 KINDRED HOSPITAL THE PALM BEACHES 00300 Total Revenue 112,962,268.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Inpatient Revenue 11,673,185.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Outpatient Revenue
12,621,207.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00300 Total Revenue 24,294,392.
02900 Operating Expenses (Worksheet A Column 3 Line 200)
100002 BETHESDA HOSPITAL INC 00200 Operating Expense
318,075,144.
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Provider Provider Name Col Column Desc Amount Type
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100080 JFK MEDICAL CENTER 00200 Operating Expense
426,739,778.
100130 LAKESIDE MEDICAL CENTER 00200 Operating Expense
44,466,084.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Operating Expense
419,896,411.
100176 PALM BEACH GARDENS 00200 Operating Expense
186,935,312.
100234 WEST PALM HOSPITAL 00200 Operating Expense
67,151,108.
100253 JUPITER MEDICAL CENTER 00200 Operating Expense
207,843,995.
100258 DELRAY MEDICAL CENTER 00200 Operating Expense
298,646,163.
100268 WEST BOCA MEDICAL CENTER 00200 Operating Expense
145,953,635.
100269 PALMS WEST HOSPITAL 00200 Operating Expense
145,995,921.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Operating Expense
179,780,659.
100287 GOOD SAMARITAN HOSPITAL 00200 Operating Expense
166,357,494.
100288 ST MARYS MEDICAL CENTER 00200 Operating Expense
275,754,069.
102023 SSH - PALM BEACH LLC 00200 Operating Expense
27,908,815.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Operating Expense
24,719,113.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Operating Expense
24,997,530.
03000 REBATES APPLIED TO EXPENSES
100002 BETHESDA HOSPITAL INC 00000 Text Information
100002 BETHESDA HOSPITAL INC 00100 Operating Expense
-2,049,894.
100080 JFK MEDICAL CENTER 00000 Text Information
100176 PALM BEACH GARDENS 00100 Operating Expense
43,210.
100234 WEST PALM HOSPITAL 00000 Text Information
100234 WEST PALM HOSPITAL 00100 Operating Expense
13.
100268 WEST BOCA MEDICAL CENTER 00100 Operating Expense
731,625.
100269 PALMS WEST HOSPITAL 00000 Text Information
100269 PALMS WEST HOSPITAL 00100 Operating Expense
20.
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100287 GOOD SAMARITAN HOSPITAL 00100 Operating Expense
5,461.
03600 Total Additions to Operating Expense (Lines 30 to 35)
100002 BETHESDA HOSPITAL INC 00200 Operating Expense
-2,049,894.
100176 PALM BEACH GARDENS 00200 Operating Expense
43,210.
100234 WEST PALM HOSPITAL 00200 Operating Expense
13.
100268 WEST BOCA MEDICAL CENTER 00200 Operating Expense
731,625.
100269 PALMS WEST HOSPITAL 00200 Operating Expense
20.
100287 GOOD SAMARITAN HOSPITAL 00200 Operating Expense
5,461.
03700 REVENUE IN EXPENSE ACCTS
100080 JFK MEDICAL CENTER 00000 Text Information
100080 JFK MEDICAL CENTER 00000 Text Information CC 03800
100080 JFK MEDICAL CENTER 00100 Operating Expense
302,414.
100080 JFK MEDICAL CENTER 00100 Inpatient Revenue 417. CC 03800
100176 PALM BEACH GARDENS 00000 Text Information CC 03900
100176 PALM BEACH GARDENS 00100 Inpatient Revenue 26. CC 03900
100234 WEST PALM HOSPITAL 00000 Text Information
100234 WEST PALM HOSPITAL 00100 Operating Expense
176,914.
100258 DELRAY MEDICAL CENTER 00000 Text Information
100258 DELRAY MEDICAL CENTER 00100 Operating Expense
2,810,597.
100269 PALMS WEST HOSPITAL 00000 Text Information
100269 PALMS WEST HOSPITAL 00100 Operating Expense
78,253.
100275 WELLINGTON REGL MEDICAL CENTER 00000 Text Information
100275 WELLINGTON REGL MEDICAL CENTER 00100 Operating Expense
641.
100288 ST MARYS MEDICAL CENTER 00100 Operating Expense
8,695.
102023 SSH - PALM BEACH LLC 00000 Text Information
102023 SSH - PALM BEACH LLC 00100 Operating Expense
420,465.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00000 Text Information
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104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Operating Expense
3.
04200 Total Deductions to Operating Expenses (Lines 37 to 41)
100080 JFK MEDICAL CENTER 00200 Operating Expense
302,831.
100176 PALM BEACH GARDENS 00200 Operating Expense
26.
100234 WEST PALM HOSPITAL 00200 Operating Expense
176,914.
100258 DELRAY MEDICAL CENTER 00200 Operating Expense
2,810,597.
100269 PALMS WEST HOSPITAL 00200 Operating Expense
78,253.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Operating Expense
641.
100288 ST MARYS MEDICAL CENTER 00200 Operating Expense
8,695.
102023 SSH - PALM BEACH LLC 00200 Operating Expense
420,465.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Operating Expense
3.
04300 Worksheet G-2 Total Operating Expenses (Lines 29 and 36 Minus 42)
100002 BETHESDA HOSPITAL INC 00200 Operating Expense
316,025,250.
100080 JFK MEDICAL CENTER 00200 Operating Expense
426,436,947.
100130 LAKESIDE MEDICAL CENTER 00200 Operating Expense
44,466,084.
100168 BOCA RATON REGIONAL HOSPITAL 00200 Operating Expense
419,896,411.
100176 PALM BEACH GARDENS 00200 Operating Expense
186,978,496.
100234 WEST PALM HOSPITAL 00200 Operating Expense
66,974,207.
100253 JUPITER MEDICAL CENTER 00200 Operating Expense
207,843,995.
100258 DELRAY MEDICAL CENTER 00200 Operating Expense
295,835,566.
100268 WEST BOCA MEDICAL CENTER 00200 Operating Expense
146,685,260.
100269 PALMS WEST HOSPITAL 00200 Operating Expense
145,917,688.
100275 WELLINGTON REGL MEDICAL CENTER 00200 Operating Expense
179,780,018.
100287 GOOD SAMARITAN HOSPITAL 00200 Operating Expense
166,362,955.
100288 ST MARYS MEDICAL CENTER 00200 Operating Expense
275,745,374.
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102023 SSH - PALM BEACH LLC 00200 Operating Expense
27,488,350.
102025 KINDRED HOSPITAL THE PALM BEACHES 00200 Operating Expense
24,719,113.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00200 Operating Expense
24,997,527.
G30 Wkst G-3 Statement of Revenues and Expenses
00100 Worksheet G-3 Total Patient Revenues (Wkst G-2 Part 1 Col 3 Line 28)
100002 BETHESDA HOSPITAL INC 00100 Amounts 1,682,180,992.
100080 JFK MEDICAL CENTER 00100 Amounts 3,961,336,000.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 127,846,511.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,912,480,370.
100176 PALM BEACH GARDENS 00100 Amounts 1,248,185,512.
100234 WEST PALM HOSPITAL 00100 Amounts 559,962,509.
100253 JUPITER MEDICAL CENTER 00100 Amounts 886,306,232.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,499,690,348.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 735,517,283.
100269 PALMS WEST HOSPITAL 00100 Amounts 1,357,920,590.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 1,133,494,749.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 1,213,554,639.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,576,143,818.
102023 SSH - PALM BEACH LLC 00100 Amounts 95,109,608.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 112,962,268.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 24,294,392.
00200 Worksheet G-3 Contractual Allowances and Discounts on Patient Accounts
100002 BETHESDA HOSPITAL INC 00100 Amounts 1,384,202,437.
100080 JFK MEDICAL CENTER 00100 Amounts 3,504,236,070.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 97,990,803.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,487,838,052.
100176 PALM BEACH GARDENS 00100 Amounts 1,040,417,986.
100234 WEST PALM HOSPITAL 00100 Amounts 500,106,179.
100253 JUPITER MEDICAL CENTER 00100 Amounts 683,204,239.
100258 DELRAY MEDICAL CENTER 00100 Amounts 2,163,413,931.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 564,269,519.
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100269 PALMS WEST HOSPITAL 00100 Amounts 1,187,068,318.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 943,810,874.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 1,030,054,374.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,256,528,092.
102023 SSH - PALM BEACH LLC 00100 Amounts 67,371,444.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 84,774,756.
00300 Worksheet G-3 Net Patient Revenues (Line 01 Minus 02)
100002 BETHESDA HOSPITAL INC 00100 Amounts 297,978,555.
100080 JFK MEDICAL CENTER 00100 Amounts 457,099,930.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 29,855,708.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 424,642,318.
100176 PALM BEACH GARDENS 00100 Amounts 207,767,526.
100234 WEST PALM HOSPITAL 00100 Amounts 59,856,330.
100253 JUPITER MEDICAL CENTER 00100 Amounts 203,101,993.
100258 DELRAY MEDICAL CENTER 00100 Amounts 336,276,417.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 171,247,764.
100269 PALMS WEST HOSPITAL 00100 Amounts 170,852,272.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 189,683,875.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 183,500,265.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 319,615,726.
102023 SSH - PALM BEACH LLC 00100 Amounts 27,738,164.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 28,187,512.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 24,294,392.
00400 Worksheet G-3 Total Operating Expenses (Wkst G-2 Part 2 Line 43)
100002 BETHESDA HOSPITAL INC 00100 Amounts 316,025,250.
100080 JFK MEDICAL CENTER 00100 Amounts 426,436,947.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 44,466,084.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 419,896,411.
100176 PALM BEACH GARDENS 00100 Amounts 186,978,496.
100234 WEST PALM HOSPITAL 00100 Amounts 66,974,207.
100253 JUPITER MEDICAL CENTER 00100 Amounts 207,843,995.
100258 DELRAY MEDICAL CENTER 00100 Amounts 295,835,566.
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100268 WEST BOCA MEDICAL CENTER 00100 Amounts 146,685,260.
100269 PALMS WEST HOSPITAL 00100 Amounts 145,917,688.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 179,780,018.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 166,362,955.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 275,745,374.
102023 SSH - PALM BEACH LLC 00100 Amounts 27,488,350.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 24,719,113.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 24,997,527.
00500 Worksheet G-3 Net Margin from Service to Patients (Line 03 Minus 04)
100002 BETHESDA HOSPITAL INC 00100 Amounts -18,046,695.
100080 JFK MEDICAL CENTER 00100 Amounts 30,662,983.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts -14,610,376.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 4,745,907.
100176 PALM BEACH GARDENS 00100 Amounts 20,789,030.
100234 WEST PALM HOSPITAL 00100 Amounts -7,117,877.
100253 JUPITER MEDICAL CENTER 00100 Amounts -4,742,002.
100258 DELRAY MEDICAL CENTER 00100 Amounts 40,440,851.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 24,562,504.
100269 PALMS WEST HOSPITAL 00100 Amounts 24,934,584.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 9,903,857.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 17,137,310.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 43,870,352.
102023 SSH - PALM BEACH LLC 00100 Amounts 249,814.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 3,468,399.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts -703,135.
00600 Contributions, Donations, Bequests, etc.
100002 BETHESDA HOSPITAL INC 00100 Amounts 64,073.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 13,157,784.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 10,026,842.
100269 PALMS WEST HOSPITAL 00100 Amounts 3,838,030.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,425.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 2,488,578.
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00700 Income from Investments
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 675.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 208,502.
100176 PALM BEACH GARDENS 00100 Amounts -1,719.
100253 JUPITER MEDICAL CENTER 00100 Amounts 563,145.
100258 DELRAY MEDICAL CENTER 00100 Amounts -5,079.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 299.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts -175.
100288 ST MARYS MEDICAL CENTER 00100 Amounts -251.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 41,829.
01000 Purchase Discounts
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 155,317.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 761.
100176 PALM BEACH GARDENS 00100 Amounts 2,183.
100258 DELRAY MEDICAL CENTER 00100 Amounts 8,205.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 3,887.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 4,900.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 22,100.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 1,693.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 913.
01100 Rebates and Refunds from Expenses
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 9,419.
100176 PALM BEACH GARDENS 00100 Amounts 30,708.
100258 DELRAY MEDICAL CENTER 00100 Amounts 93,974.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 25,888.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 19,343.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 37,809.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 7,085.
01400 Revenue from Meals Sold to Employees and Guests
100002 BETHESDA HOSPITAL INC 00100 Amounts 1,668,869.
100080 JFK MEDICAL CENTER 00100 Amounts 830,431.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,568,583.
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100253 JUPITER MEDICAL CENTER 00100 Amounts -15,197.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 527,026.
100288 ST MARYS MEDICAL CENTER 00100 Amounts -89.
102023 SSH - PALM BEACH LLC 00100 Amounts 62,559.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 86,858.
01700 Revenue from Sale of Druges to Other Than Patients
100002 BETHESDA HOSPITAL INC 00100 Amounts 2,405,070.
01800 Revenue from Sale of Medical Records and Abstracts
100002 BETHESDA HOSPITAL INC 00100 Amounts 276,366.
100080 JFK MEDICAL CENTER 00100 Amounts 290.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 15,863.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 182,536.
100176 PALM BEACH GARDENS 00100 Amounts 132,208.
100253 JUPITER MEDICAL CENTER 00100 Amounts 32,435.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 5,988.
102023 SSH - PALM BEACH LLC 00100 Amounts 30,282.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 3,768.
01900 Tuition (Fee, Sales of Textbooks, Uniforms, etc)
100002 BETHESDA HOSPITAL INC 00100 Amounts 173,095.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 29,960.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 256,769.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 2,711.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 24,144.
02100 Rental of Vending Machines
100258 DELRAY MEDICAL CENTER 00100 Amounts 16,985.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 10,354.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts -88.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 198.
02200 Rental of Hospital Space
100080 JFK MEDICAL CENTER 00100 Amounts 195,400.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 862,683.
100176 PALM BEACH GARDENS 00100 Amounts 1,099,380.
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100253 JUPITER MEDICAL CENTER 00100 Amounts 928,166.
100258 DELRAY MEDICAL CENTER 00100 Amounts 870,066.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 44,015.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 2,539,222.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 418,587.
02300 Governmental Appropriations
100080 JFK MEDICAL CENTER 00100 Amounts 4,189,725.
02400 MISCELLANEOUS INCOMES
100002 BETHESDA HOSPITAL INC 00000 Description
100002 BETHESDA HOSPITAL INC 00000 Description CC 02401
100002 BETHESDA HOSPITAL INC 00000 Description CC 02402
100002 BETHESDA HOSPITAL INC 00000 Description CC 02403
100002 BETHESDA HOSPITAL INC 00000 Description CC 02404
100002 BETHESDA HOSPITAL INC 00000 Description CC 02405
100002 BETHESDA HOSPITAL INC 00000 Description CC 02406
100002 BETHESDA HOSPITAL INC 00000 Description CC 02407
100002 BETHESDA HOSPITAL INC 00000 Description CC 02408
100002 BETHESDA HOSPITAL INC 00000 Description CC 02409
100002 BETHESDA HOSPITAL INC 00100 Amounts 185,077.
100002 BETHESDA HOSPITAL INC 00100 Amounts 401,002. CC 02401
100002 BETHESDA HOSPITAL INC 00100 Amounts 706,905. CC 02402
100002 BETHESDA HOSPITAL INC 00100 Amounts 5,310. CC 02403
100002 BETHESDA HOSPITAL INC 00100 Amounts 793,034. CC 02404
100002 BETHESDA HOSPITAL INC 00100 Amounts 726,135. CC 02405
100002 BETHESDA HOSPITAL INC 00100 Amounts 448,193. CC 02406
100002 BETHESDA HOSPITAL INC 00100 Amounts 174,100. CC 02407
100002 BETHESDA HOSPITAL INC 00100 Amounts 94,416. CC 02408
100002 BETHESDA HOSPITAL INC 00100 Amounts 19,549. CC 02409
100080 JFK MEDICAL CENTER 00000 Description
100080 JFK MEDICAL CENTER 00100 Amounts 689,912.
100130 LAKESIDE MEDICAL CENTER 00000 Description
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 1,253,319.
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100168 BOCA RATON REGIONAL HOSPITAL 00000 Description
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02401
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02402
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02403
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02404
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02405
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02406
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02407
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02408
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02409
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 6,535.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 1,304,395. CC 02401
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 5. CC 02402
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 11,297. CC 02403
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 18,603. CC 02404
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 986,863. CC 02405
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 2,091. CC 02406
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 2,296. CC 02407
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 13,848. CC 02408
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 650,536. CC 02409
100176 PALM BEACH GARDENS 00100 Amounts 99,975.
100176 PALM BEACH GARDENS 00100 Amounts 9,637. CC 02401
100234 WEST PALM HOSPITAL 00000 Description
100234 WEST PALM HOSPITAL 00100 Amounts 1,935,534.
100253 JUPITER MEDICAL CENTER 00000 Description
100253 JUPITER MEDICAL CENTER 00000 Description CC 02401
100253 JUPITER MEDICAL CENTER 00000 Description CC 02402
100253 JUPITER MEDICAL CENTER 00000 Description CC 02403
100253 JUPITER MEDICAL CENTER 00000 Description CC 02404
100253 JUPITER MEDICAL CENTER 00000 Description CC 02405
100253 JUPITER MEDICAL CENTER 00000 Description CC 02406
100253 JUPITER MEDICAL CENTER 00000 Description CC 02407
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100253 JUPITER MEDICAL CENTER 00000 Description CC 02408
100253 JUPITER MEDICAL CENTER 00000 Description CC 02409
100253 JUPITER MEDICAL CENTER 00100 Amounts 245,122.
100253 JUPITER MEDICAL CENTER 00100 Amounts 1,400. CC 02401
100253 JUPITER MEDICAL CENTER 00100 Amounts 32,257. CC 02402
100253 JUPITER MEDICAL CENTER 00100 Amounts 183,683. CC 02403
100253 JUPITER MEDICAL CENTER 00100 Amounts 1,959. CC 02404
100253 JUPITER MEDICAL CENTER 00100 Amounts 12,893,734. CC 02405
100253 JUPITER MEDICAL CENTER 00100 Amounts 201,018. CC 02406
100253 JUPITER MEDICAL CENTER 00100 Amounts 490,393. CC 02407
100253 JUPITER MEDICAL CENTER 00100 Amounts 4,652. CC 02408
100253 JUPITER MEDICAL CENTER 00100 Amounts 39,910. CC 02409
100258 DELRAY MEDICAL CENTER 00100 Amounts 251,649.
100258 DELRAY MEDICAL CENTER 00100 Amounts 90,195. CC 02401
100258 DELRAY MEDICAL CENTER 00100 Amounts 25,604. CC 02402
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 329,932.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts -5,602. CC 02401
100275 WELLINGTON REGL MEDICAL CENTER 00000 Description
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 2,084,814.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 709,401.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 583,625. CC 02402
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts -70. CC 02403
100288 ST MARYS MEDICAL CENTER 00100 Amounts 571,342.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 235,412. CC 02402
102023 SSH - PALM BEACH LLC 00000 Description
102023 SSH - PALM BEACH LLC 00000 Description CC 02401
102023 SSH - PALM BEACH LLC 00100 Amounts 2,981.
102023 SSH - PALM BEACH LLC 00100 Amounts 144,107. CC 02401
102025 KINDRED HOSPITAL THE PALM BEACHES 00000 Description
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 64,369.
02500 Worksheet G-3 Total Other Income (Lines 06 to 24)
100002 BETHESDA HOSPITAL INC 00100 Amounts 8,141,194.
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100080 JFK MEDICAL CENTER 00100 Amounts 5,905,758.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 14,582,958.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 15,885,755.
100176 PALM BEACH GARDENS 00100 Amounts 1,372,372.
100234 WEST PALM HOSPITAL 00100 Amounts 1,935,534.
100253 JUPITER MEDICAL CENTER 00100 Amounts 15,602,677.
100258 DELRAY MEDICAL CENTER 00100 Amounts 1,351,599.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 665,542.
100269 PALMS WEST HOSPITAL 00100 Amounts 3,838,030.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 2,084,814.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 4,391,883.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 1,310,479.
102023 SSH - PALM BEACH LLC 00100 Amounts 239,929.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 156,886.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 2,538,405.
02600 Worksheet G-3 Total Revenue(Lines 05 Plus 25)
100002 BETHESDA HOSPITAL INC 00100 Amounts -9,905,501.
100080 JFK MEDICAL CENTER 00100 Amounts 36,568,741.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts -27,418.
100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 20,631,662.
100176 PALM BEACH GARDENS 00100 Amounts 22,161,402.
100234 WEST PALM HOSPITAL 00100 Amounts -5,182,343.
100253 JUPITER MEDICAL CENTER 00100 Amounts 10,860,675.
100258 DELRAY MEDICAL CENTER 00100 Amounts 41,792,450.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 25,228,046.
100269 PALMS WEST HOSPITAL 00100 Amounts 28,772,614.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 11,988,671.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 21,529,193.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 45,180,831.
102023 SSH - PALM BEACH LLC 00100 Amounts 489,743.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 3,625,285.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 1,835,270.
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02700 LOSS ON SALE OF ASSET(S)
100002 BETHESDA HOSPITAL INC 00000 Description
100002 BETHESDA HOSPITAL INC 00100 Amounts 407,251.
100130 LAKESIDE MEDICAL CENTER 00000 Description
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 17,467.
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description
100168 BOCA RATON REGIONAL HOSPITAL 00000 Description CC 02701
100253 JUPITER MEDICAL CENTER 00000 Description
100253 JUPITER MEDICAL CENTER 00000 Description CC 02701
100253 JUPITER MEDICAL CENTER 00000 Description CC 02702
100253 JUPITER MEDICAL CENTER 00000 Description CC 02703
100253 JUPITER MEDICAL CENTER 00100 Amounts 55,674.
100253 JUPITER MEDICAL CENTER 00100 Amounts 49,431. CC 02701
100253 JUPITER MEDICAL CENTER 00100 Amounts 3,742. CC 02702
100253 JUPITER MEDICAL CENTER 00100 Amounts 1,458,377. CC 02703
102023 SSH - PALM BEACH LLC 00000 Description
102023 SSH - PALM BEACH LLC 00000 Description CC 02701
102023 SSH - PALM BEACH LLC 00000 Description CC 02702
102023 SSH - PALM BEACH LLC 00000 Description CC 02703
102023 SSH - PALM BEACH LLC 00100 Amounts 1,452,483.
102023 SSH - PALM BEACH LLC 00100 Amounts -8. CC 02701
102023 SSH - PALM BEACH LLC 00100 Amounts -306,936. CC 02702
102025 KINDRED HOSPITAL THE PALM BEACHES 00000 Description
02800 Worksheet G-3 Total Other Expenses (Lines 27 and subscripts)
100002 BETHESDA HOSPITAL INC 00100 Amounts 407,251.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts 17,467.
100253 JUPITER MEDICAL CENTER 00100 Amounts 1,567,224.
102023 SSH - PALM BEACH LLC 00100 Amounts 1,145,539.
02900 Worksheet G-3 Net Income or Loss From the Period
100002 BETHESDA HOSPITAL INC 00100 Amounts -10,312,752.
100080 JFK MEDICAL CENTER 00100 Amounts 36,568,741.
100130 LAKESIDE MEDICAL CENTER 00100 Amounts -44,885.
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100168 BOCA RATON REGIONAL HOSPITAL 00100 Amounts 20,631,662.
100176 PALM BEACH GARDENS 00100 Amounts 22,161,402.
100234 WEST PALM HOSPITAL 00100 Amounts -5,182,343.
100253 JUPITER MEDICAL CENTER 00100 Amounts 9,293,451.
100258 DELRAY MEDICAL CENTER 00100 Amounts 41,792,450.
100268 WEST BOCA MEDICAL CENTER 00100 Amounts 25,228,046.
100269 PALMS WEST HOSPITAL 00100 Amounts 28,772,614.
100275 WELLINGTON REGL MEDICAL CENTER 00100 Amounts 11,988,671.
100287 GOOD SAMARITAN HOSPITAL 00100 Amounts 21,529,193.
100288 ST MARYS MEDICAL CENTER 00100 Amounts 45,180,831.
102023 SSH - PALM BEACH LLC 00100 Amounts -655,796.
102025 KINDRED HOSPITAL THE PALM BEACHES 00100 Amounts 3,625,285.
104008 THE JEROME GOLDEN CENTER FOR BEHAVOR 00100 Amounts 1,835,270.
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Provider Provider Name Col Column Desc Amount Type