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Home Care Provider Revenue Worksheet

home care Revenue Worksheet Do not submit this Worksheet to MDH. This is for your records only. This Worksheet is for your convenience and to clarify what is home care Revenue and what is not. home care services are outlined in these documents: Statement of home care Services: Basic home care Provider Statement of home care Services: Comprehensive home care Provider Do not include Revenue earned from these sources: PCA services to PCA-eligible clients (billing codes PCA T1019 or PCA supervision (QP) T1019)* Services provided under a 245D license (Dept. of Human Services, DHS) 245D basic support services provided under an Integrated License - HCBS Designation Rent or room and board home management services provided under a home management registration Services provided under licenses other than this home care license Include Revenue , from providing licensed home care services, received during the calendar year prior to the year you are submitting this application.

Home Care Revenue Worksheet Do not submit this worksheet to MDH. This is for your records only. This worksheet is for your convenience and to clarify what is home care revenue and what

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Transcription of Home Care Provider Revenue Worksheet

1 home care Revenue Worksheet Do not submit this Worksheet to MDH. This is for your records only. This Worksheet is for your convenience and to clarify what is home care Revenue and what is not. home care services are outlined in these documents: Statement of home care Services: Basic home care Provider Statement of home care Services: Comprehensive home care Provider Do not include Revenue earned from these sources: PCA services to PCA-eligible clients (billing codes PCA T1019 or PCA supervision (QP) T1019)* Services provided under a 245D license (Dept. of Human Services, DHS) 245D basic support services provided under an Integrated License - HCBS Designation Rent or room and board home management services provided under a home management registration Services provided under licenses other than this home care license Include Revenue , from providing licensed home care services, received during the calendar year prior to the year you are submitting this application.

2 For example, if you are submitting the application in 2017, enter Revenue received in 2016 from providing home care services. Source of home care Revenue Amount Received Private pay clients $ Private insurance $ Medicare $ Veterans Administration $ Medical Assistance/Medicaid (waiver money) $ Long-term care insurance $ Other sources of home care Revenue $ Total Revenue from providing home care services ** $ home care Provider Revenue Worksheet 2 *Personal care services not provided as a PCA Provider enrolled with DHS and not billed under the above billing codes may fit the definition of home care services and the Revenue received from these services must be counted toward your home care Revenue . ** Your home care license renewal fee will be based on this total. Enter this amount in the renewal application. In lieu of disclosing your Revenue , you may elect to pay the highest fee.

3 For questions, contact the home care and Assisted Living Program at 651-201-5273 or Minnesota Department of Health home care and Assisted Living Program PO Box 3879, St. Paul, MN 55101 651-201-5273 07/27/2017 To obtain this information in a different format, call: 651-201-5273. Printed on recycled paper.


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