HRSA 99 - updated June 2006

Department of Health and Human Services			OMB No. 0915-0247
Health Resources and Services Administration			Expiration Date:
Children’s Hospitals Graduate Medical Education Payment Program Demographic and Contact Information
Name of Applicant:
City, State:
Medicare Provider Number:
FFY in which Applying for CHGME PP Funding:	FFY
Type of Application (check box to the left):		Initial Application			Reconciliation Application

1. Contact and business information for the applicant hospital:
Official Name of the Hospital:
Physical Address of the Hospital:
Tax ID:			County where hospital is physically located:
Medicare Provider Number:			D&B D-U-N-S Number:
Hospital Website:
2. Contact information for the individual to be notified if the application is funded.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
3. Contact information for the individual authorized to sign for the applicant institution. (This individual should be the same person who signs as the authorizing individual on HRSA 99-3.)
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
Signature and Date:
4. Contact information for the Director of Graduate Medical Education.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
Signature and Date:
5. Contact information for the individual who can provide the documentation for the information submitted since, like all Federal programs, this proposal is subject to audit.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
6. Contact information for the individual who prepared and/or completed this application package for the applicant hospital and can answer questions related to the information submitted.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:

HRSA 99 Page 2 of 2	Created in MS Word 6.0
(Rev. 06-2006)