Hrsa 99-5 Hrsa 99-5

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 Application Checklist
Name of Applicant:
Medicare Provider Number:
FFY in which Applying for CHGME PP Funding:	FFY
Type of Application (check box to the left):		Initial Application		Reconciliation Application

Application Forms and Supporting Documentation	This Column to be Completed by the Applicant Hospital	This Column to be Completed by the CHGME PP
Is the Listed Item Completed and Attached?
Forms and Supporting Documentation Required to be Submitted by All Participating Hospitals
HRSA-99 (2 pages)	Yes No	Yes No
HRSA 99-1 (4 pages)	Yes No	Yes No
HRSA 99-2 (1 page)	Yes No	Yes No
HRSA 99-3 (6 pages)	Yes No	Yes No
HRSA 99-4 (2 pages) – Required at Reconciliation only	Yes No	Yes No
HRSA 99-5 (1 page)	Yes No	Yes No
Computer Disk Containing Completed HRSA Forms	Yes No	Yes No
One (1) Copy of the Hospital’s Completed Application Package. The copy should include all required forms and supporting documentation s presented in the original package.	Yes No	Yes No
Additional Supporting Documentation The forms and supporting documentation listed below may not applicable to all hospitals. Hospitals should contact their CHGME PP regional manager for assistance and/or clarification.
Cover letter detailing any issues that may impact the processing or approval of the children’s hospital’s application for CHGME PP funding.	Yes No	Yes No
CMS 2552-96 MCR Worksheet E-3, Part IV(s) Required for each cost reporting period identified in the HRSA 99-1 in which the hospital filed a full MCR.	Yes No	Yes No
Affiliation Agreement for an Aggregate Cap Required for each cost reporting period identified in the HRSA 99-1 in which the hospital established a Medicare GME Affiliation Agreement. Please ensure that the most recent version/update is provided (i.e., reflecting any adjustments made to the agreement during the academic year).	Yes No	Yes No
CMS Letter addressing changes to the Hospital’s 1996 Base Year Cap as a result of §422 of the MMA (increases and decreases).	Yes No	Yes No
Payment Information Form Applicable only to (1) hospitals, which have not previously participated in the CHGME PP and (2) hospitals in which financial institution information has changed since submission of its last application.	Yes No	Yes No

HRSA 99-5 Page 2 of 1	Created in MS Word 6.0
(Rev. 06-2006)