MPAPA_Exhibit_E-2.xlsx

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Attached to
Medicare Part A Provider Cost Report Appeals (MPAPA)
Solicitation number
HHSM-500-2013-RFP-0030
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Exhibit E-2

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Base Year

MPAPA
Exhibit E.2: Travel Breakdown
Reason for TripEmployee NameTravel To/FromTravel Dates - From/ToAirfareHotel Rate Per Day Per FTRNumber of NightsTotal Hotel (Plus Appl. Tax if Known)Meals & Incidentals Per Diem Per FTR# of Days M/I Per DiemTotal Per Diem (3/4 for 1st & last day)Car RentalMileage To/From Home AirportHome Airport ParkingTrans. To/From Dest. AirportOtherTotalDO NOT PRINT

Total $ - 0

&"Times New Roman,Italic"&10(Company name) &"Times New Roman,Regular"HHSM-500-2013-RFP-0030

Use date of submission Page &P of &N &A

Option Year 1

MPAPA
Exhibit E.2: Travel Breakdown
Reason for TripEmployee NameTravel To/FromTravel Dates - From/ToAirfareHotel Rate Per Day Per FTRNumber of NightsTotal Hotel (Plus Appl. Tax if Known)Meals & Incidentals Per Diem Per FTR# of Days M/I Per DiemTotal Per Diem (3/4 for 1st & last day)Car RentalMileage To/From Home AirportHome Airport ParkingTrans. To/From Dest. AirportOtherTotalDO NOT PRINT

e

Total $ - 0

&"Times New Roman,Regular"HHSM-500-2013-RFP-0030

Use date of submission Page &P of &N &A

Option Year 2

MPAPA
Exhibit E.2: Travel Breakdown
Reason for TripEmployee NameTravel To/FromTravel Dates - From/ToAirfareHotel Rate Per Day Per FTRNumber of NightsTotal Hotel (Plus Appl. Tax if Known)Meals & Incidentals Per Diem Per FTR# of Days M/I Per DiemTotal Per Diem (3/4 for 1st & last day)Car RentalMileage To/From Home AirportHome Airport ParkingTrans. To/From Dest. AirportOtherTotalDO NOT PRINT

Total $ - 0

&"Times New Roman,Regular"HHSM-500-2013-RFP-0030

Use date of submission Page &P of &N &A

Option Year 3

MPAPA
Exhibit E.2: Travel Breakdown
Reason for TripEmployee NameTravel To/FromTravel Dates - From/ToAirfareHotel Rate Per Day Per FTRNumber of NightsTotal Hotel (Plus Appl. Tax if Known)Meals & Incidentals Per Diem Per FTR# of Days M/I Per DiemTotal Per Diem (3/4 for 1st & last day)Car RentalMileage To/From Home AirportHome Airport ParkingTrans. To/From Dest. AirportOtherTotalDO NOT PRINT

Total $ - 0

&"Times New Roman,Regular"HHSM-500-2013-RFP-0030

Use date of submission Page &P of &N &A

Option Year 4

MPAPA
Exhibit E.2: Travel Breakdown
Reason for TripEmployee NameTravel To/FromTravel Dates - From/ToAirfareHotel Rate Per Day Per FTRNumber of NightsTotal Hotel (Plus Appl. Tax if Known)Meals & Incidentals Per Diem Per FTR# of Days M/I Per DiemTotal Per Diem (3/4 for 1st & last day)Car RentalMileage To/From Home AirportHome Airport ParkingTrans. To/From Dest. AirportOtherTotalDO NOT PRINT

Total $ - 0

&"Times New Roman,Regular"HHSM-500-2013-RFP-0030

Use date of submission Page &P of &N &A

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