Spreadsheet: 2b3345ff-ecad-44ed-8259-e06571606d46
Sheet: Sheet1

FORM A-1, UNIFORM COST REPORT (UCR) | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 |  | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13
AGENCY EXPENSE REPORT |  |  | __________________________________________ Owner's Federal Tax Identification Number
ODADAS-FIS-047 |  |  |  |  |  |  |  |  |  | MACSIS UPI: _________________
AGENCY NAME: ___________________________________________________________________ |  |  | ________ Budget |  | ________ Actual |  |  |  |  | REPORTING PERIOD: ______________________ to _____________________
AGENCY ADDRESS:  _______________________________________________________________ |  |  |  |  |  |  |  |  |  | AGENCY TELEPHONE NO: _________________________________
1. | 2. | 3. Number of FTE Assigned |  | 4.  Personnel Costs |  | 5. | 6. | 7. | 8. | 9. | 10. | 11. | 12.
 | Number | Direct | Support | Direct | Support | Service Non- | Service | Allocation of | Total | Cost | Unallowable | Total | Allowable
Service Taxonomy | of Units | Service | Service | Service | Service | Personnel | Total | Administrative | Costs | Per | Costs | Allowable | Cost
and MACSIS Procedure Codes |  | (a) | (b) | (a) | (b) | Costs | Costs | Overhead |  | Unit |  | Costs | Per Unit
TREATMENT SERVICES
Acute Hospital Detoxification - H0009
Ambulatory Detoxification - H0014
Assessment - H0001
Case Management - H0006
Crisis Intervention - H0007
Family Counseling - T1006
Group Counseling - H0005
Individual Counseling - H0004
Intensive Outpatient - H0015
Laboratory Urinalysis - H0003
Medical Somatic - H0016
Medication Assisted Treatment - 90805, 90907, 90809, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215
Methadone Administration - H0020
Sub Acute Detoxification - H0012
23 Hour Observation Bed - 99236
[NAME]
[NAME] Room & Board costs
Medical Community Residential Treatment - Hospital Setting - A1210
Medical Community Residential Treatment - Non-Hospital Setting - A0230
Non-Medical Community Residential Treatment - A1220
BH COMMUNITY RESIDENTIAL TREATMENT Excludes Room & Board costs
BH Medical Community Residential Treatment - Hospital Setting - H0017
BH Medical Community Residential Treatment - Non-Hospital Setting - H0018
BH Non-Medical Community Residential Treatment - H0019
COMMUNITY SERVICES
Consultation - A0560
Hotline - H0030
Intervention - H0022
Outreach - H0023
Referral and Information - A0510
Training - H0021
PREVENTION SERVICES
Alternatives - A0660
Community-Based Process - A0630
Education - A0620
Environmental - A0640
Information Dissemination - A0610
Problem Identification and Referral - A0650
ADJUNCTIVE ALCOHOL AND DRUG SERVICES
Child Care - T1009
Meals - T1010
Room and Board - A0740
Transportation - A0750
AOD Services Not Otherwise Classified - H0047
[NAME]
Non-Residential DIP
Residential DIP - 48 Hour
Residential DIP - 72 Hour
OTHER
Administrative Overhead
Mental Health Services
Title IV-E Services
Non AOD/MH/Title IV-E Services
TOTALS
TOTALS FOR AOD SERVICES | 0 | 0 | 0 | 0 | 0 | 0 |  | 0 |  |  | 0
TOTALS FOR AGENCY |  | 0 | 0 | 0 | 0 | 0 |  | 0 |  |  | 0
I certify that this UCR and all supporting documentation (including Forms A-2, A-3 and [NAME] or their equivalents) have been completed in accordance with OAC 3793:2-1-09
Name/Title: __________________________________________________________________________________________________________________
Date: _____________________________________________________________________