2001-2019 Full Page-Column-Line to Excel Crosswalk  -  Long-Term Care Financial Annual

Long-term Care Facility Integrated Disclosure and Medi-Cal Cost Report Data & Pivot Tables

long-term-care-facility-integrated-disclosure-and-medi-cal-cost-report-data-pivot-tables

Report Contact Person - Mailing Address - Street or P.O. Box

Previous Facility Medi-Cal Provider Number

License Category - Skilled Nursing Facility

License Category - Intermediate Care Facility

License Category - Skilled Nursing/Residential Care Facility

License Category - Intermediate/Residential Care Facility

License Category - Congregate Living Health Facility

Type of Control - Government non-entry field

Describe Any Items Which Management Believes May Have a Significant Effect on the Data in this Report - Line 25

Describe Any Items Which Management Believes May Have a Significant Effect on the Data in this Report - Line 26

Describe Any Items Which Management Believes May Have a Significant Effect on the Data in this Report - Line 27

Describe Any Items Which Management Believes May Have a Significant Effect on the Data in this Report - Line 28

Describe Any Items Which Management Believes May Have a Significant Effect on the Data in this Report - Line 29

Describe Any Items Which Management Believes May Have a Significant Effect on the Data in this Report - Line 30

Third Party Payor Program - Medicare Date Certified

Third Party Payor Program - Medi-Cal SNF Date Certified

Third Party Payor Program - Medi-Cal ICF Date Certified

Third Party Payor Program - Medi-Cal MD Date Certified

Third Party Payor Program - Medi-Cal DD Date Certified

Third Party Payor Program - Short Doyle Date Certified

Third Party Payor Program - OTHER (Describe)

Legal Organization - Division of Corporation

Health Service - Long-term Rehabilitation

Description of Other Health Service on Line 25

Description of Other Health Service on Line 26

Description of Other Health Service on Line 27

Are there any costs or revenues included in the Statement of Income for the current period which are the result of transactions with related persons or organizations as defined in the instructions of this form? (Exclude compensation of owners and their relatives reported in Item G)

2001-2019 Full Page-Column-Line to Excel Crosswalk - Long-Term Care Financial Annual

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