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Health Financial Systems ST. JOSEPHS REG MED CENTER PLYMOUTH 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 EXPIRES 09302025 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT CERTIFICATION Provider CCN: 150076 Period: Worksheet S From 07/01/2021 Parts IIII AND SETTLEMENT

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