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Health Financial Systems MEMORIAL HOSPITAL ASSOCIATION In Lieu of Form CMS255210 This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim FORM APPROVED payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g). OMB NO. 09380050 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT CERTIFICATION Provider CCN: 141305 Period: Worksheet S From 07/01/2013 Parts IIII AND SETTLEMENT SUMMARY To 06/30/2014

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