| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: 03/31/2010 |
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CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM
APPLICATION FORM HRSA 99-1
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Public Burden Statement |
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An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915 0247. Public reporting burden for the applicant for this collection of information is estimated to average 69 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14 33, Rockville, Maryland, 20857.
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| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: 03/31/2010 |
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| Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts |
| Name of Applicant: |
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| City: |
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State: |
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Zip Code: |
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| Medicare Provider Number: |
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| Fiscal Year in which applying for funding: |
FFY |
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| Type of Application (check box to the left) |
_____Initial Application |
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_____Reconciliation Application |
| Are you a new children's hospital that has not completed three full Medicare cost reporting periods? (Please place 'n' for no or 'y' for yes in the cell to the right) |
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| Section 1 |
DETERMINATION OF RESIDENT FTE CAP FOR THE HOSPITAL'S MOST RECENT COST REPORTING PERIOD ENDING ON OR BEFORE DECEMBER 31, 1996 |
To be completed by hospital |
For CHGME FI Use Only |
| HOSPITAL DATA |
MCR DATA |
FI DATA |
| 1.01 |
Inclusive dates of the subject cost reporting period |
(From) |
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| (To) |
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| 1.02 |
Status of MCR |
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| 1.03 |
Unweighted resident FTE count for allopathic and osteopathic programs (from the 1996 cap year) |
0.00 |
0.00 |
0.00 |
| Section 2 |
AVERAGE OF UNWEIGHTED RESIDENT FTE COUNTS |
HOSPITAL DATA |
MCR DATA |
FI DATA |
| 2.01 |
Total unweighted resident FTE count for the hospital's most recently completed cost reporting period |
0.00 |
0.00 |
0.00 |
| 2.02 |
Total unweighted resident FTE count for the hospital's prior cost reporting period |
0.00 |
0.00 |
0.00 |
| 2.03 |
Total unweighted resident FTE count for the hospital's penultimate cost reporting period |
0.00 |
0.00 |
0.00 |
| 2.04 |
Rolling average of unweighted resident FTE count |
0.00 |
0.00 |
0.00 |
| 2.05 |
Add On: Unweighted resident FTE count meeting the criteria for an exception |
0.00 |
0.00 |
0.00 |
| 2.06 |
Adjusted rolling average of unweighted resident FTE count |
0.00 |
0.00 |
0.00 |
| 2.07 |
Add On: Unweighted resident FTE count from MMA §422 |
0.00 |
0.00 |
0.00 |
| 2.08 |
Grand Total: Unweighted resident FTE Count |
0.00 |
0.00 |
0.00 |
| Section 3 |
AVERAGE OF WEIGHTED RESIDENT FTE COUNTS |
HOSPITAL DATA |
MCR DATA |
FI DATA |
| 3.01 |
Total weighted resident FTE count for the hospital's most recently completed cost reporting period |
0.00 |
0.00 |
0.00 |
| 3.02 |
Total weighted resident FTE count for the hospital's prior cost reporting period |
0.00 |
0.00 |
0.00 |
| 3.03 |
Total weighted resident FTE count for the hospital's penultimate cost reporting period |
0.00 |
0.00 |
0.00 |
| 3.04 |
Rolling average of weighted resident FTE count |
0.00 |
0.00 |
0.00 |
| 3.05 |
Add On: Weighted resident FTE count meeting the criteria for an exception |
0.00 |
0.00 |
0.00 |
| 3.06 |
Adjusted rolling average of weighted resident FTE count |
0.00 |
0.00 |
0.00 |
| 3.07 |
Add On: Weighted resident FTE count from MMA §422 |
0.00 |
0.00 |
0.00 |
| 3.08 |
Grand Total: Weighted resident FTE Count |
0.00 |
0.00 |
0.00 |
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| HRSA 99-1 Page 1 of 4 |
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Created in MS Excel 7.0 |
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| (Rev. 03-2007) |
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| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: 03/31/2010 |
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| Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts |
| Name of Applicant: |
0 |
| City: |
0 |
State: |
0 |
Zip Code: |
0 |
| Medicare Provider Number: |
0 |
| Fiscal Year in which applying for funding: |
FFY |
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| Type of Application (check box to the left) |
______Initial Application |
|
_____Reconciliation Application |
| Section 4 |
DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S MOST RECENTLY COMPLETED COST REPORTING PERIOD |
HOSPITAL DATA |
For CHGME FI Use Only |
| 1996 CAP YEAR |
§422 of the MMA |
MCR DATA |
FI DATA |
| 4.01 |
Inclusive dates of the subject cost reporting period |
(From) |
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| (To) |
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| 4.02 |
Status of MCR |
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| 4.03 |
Unweighted resident FTE count for allopathic and osteopathic programs (from the cap year) |
0.00 |
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0.00 |
0.00 |
| 4.04 |
Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) |
0.00 |
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0.00 |
0.00 |
| 4.05 |
Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs |
0.00 |
0.00 |
0.00 |
| 4.05a |
Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to §422 of the MMA |
0.00 |
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0.00 |
0.00 |
| 4.06 |
FTE adjusted cap |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.07 |
Unweighted resident FTE count for allopathic and osteopathic programs. |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.08 |
Enter the lesser of lines 4.06 and 4.07 |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.09 |
Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.10 |
Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.11 |
Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.12 |
Weighted resident FTE count for allopathic osteopathic programs |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.13 |
Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.14 |
Unweighted resident FTE count for dental and podiatric programs |
0.00 |
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0.00 |
0.00 |
| 4.15 |
Unweighted resident FTE count for dental and podiatric residents in their initial residency period |
0.00 |
0.00 |
0.00 |
| 4.16 |
Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 4.17 |
Weighted resident FTE count for dental and podiatric residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 4.18 |
Weighted resident FTE count for dental and podiatric programs |
0.00 |
0.00 |
0.00 |
| 4.19 |
Total unweighted resident FTE count |
0.00 |
0.00 |
0.00 |
0.00 |
| 4.20 |
Total weighted resident FTE count |
0.00 |
0.00 |
0.00 |
0.00 |
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| HRSA 99-1 Page 2 of 4 |
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Created in MS Excel 7.0 |
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| (Rev. 03-2007) |
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| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: 03/31/2010 |
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| Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts |
| Name of Applicant: |
0 |
| City: |
0 |
State: |
0 |
Zip Code: |
0 |
| Medicare Provider Number: |
0 |
| Fiscal Year in which applying for funding: |
FFY |
|
| Type of Application (check box to the left) |
____Initial Application |
|
______Reconciliation Application |
| Section 5 |
DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S PRIOR COST REPORTING PERIOD |
HOSPITAL DATA |
For CHGME FI Use Only |
| 1996 Cap Year |
MCR DATA |
FI DATA |
| 5.01 |
Inclusive dates of the subject cost reporting period |
(From) |
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| (To) |
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| 5.02 |
Status of MCR |
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| 5.03 |
Unweighted resident FTE count for allopathic and osteopathic programs |
0.00 |
0.00 |
0.00 |
| 5.04 |
Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) |
0.00 |
0.00 |
0.00 |
| 5.05 |
Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs |
0.00 |
0.00 |
0.00 |
| 5.05a |
Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to §422 of the MMA |
|
0.00 |
0.00 |
| 5.06 |
FTE adjusted cap |
0.00 |
0.00 |
0.00 |
| 5.07 |
Unweighted resident FTE count for allopathic and osteopathic programs. |
0.00 |
0.00 |
0.00 |
| 5.08 |
Enter the lesser of lines 4.06 and 4.07 |
0.00 |
0.00 |
0.00 |
| 5.09 |
Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period |
0.00 |
0.00 |
0.00 |
| 5.10 |
Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 5.11 |
Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 5.12 |
Weighted resident FTE count for allopathic osteopathic programs |
0.00 |
0.00 |
0.00 |
| 5.13 |
Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap |
0.00 |
0.00 |
0.00 |
| 5.14 |
Unweighted resident FTE count for dental and podiatric programs |
0.00 |
0.00 |
0.00 |
| 5.15 |
Unweighted resident FTE count for dental and podiatric residents in their initial residency period |
0.00 |
0.00 |
0.00 |
| 5.16 |
Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 5.17 |
Weighted resident FTE count for dental and podiatric residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 5.18 |
Weighted resident FTE count for dental and podiatric programs |
0.00 |
0.00 |
0.00 |
| 5.19 |
Total unweighted resident FTE count |
0.00 |
0.00 |
0.00 |
| 5.20 |
Total weighted resident FTE count |
0.00 |
0.00 |
0.00 |
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| HRSA 99-1 Page 3 of 4 |
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Created in MS Excel 7.0 |
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| (Rev. 03-2007) |
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| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: 03/31/2010 |
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| Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts |
| Name of Applicant: |
0 |
| City: |
0 |
State: |
0 |
Zip Code: |
0 |
| Medicare Provider Number: |
0 |
| Fiscal Year in which applying for funding: |
FFY |
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| Type of Application (check box to the left) |
____Initial Application |
|
______Reconciliation Application |
| Section 6 |
DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S PENULTIMATE COST REPORTING PERIOD |
HOSPITAL DATA |
For CHGME FI Use Only |
| 1996 Cap Year |
MCR DATA |
FI DATA |
| 6.01 |
Inclusive dates of the subject cost reporting period |
(From) |
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| (To) |
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| 6.02 |
Status of MCR |
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| 6.03 |
Unweighted resident FTE count for allopathic and osteopathic programs |
0.00 |
0.00 |
0.00 |
| 6.04 |
Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) |
0.00 |
0.00 |
0.00 |
| 6.05 |
Adjustment (to the cap) for the Unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs |
0.00 |
0.00 |
0.00 |
| 6.05a |
Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to §422 of the MMA |
0.00 |
0.00 |
0.00 |
| 6.06 |
FTE adjusted cap |
0.00 |
0.00 |
0.00 |
| 6.07 |
Unweighted resident FTE count for allopathic and osteopathic programs. |
0.00 |
0.00 |
0.00 |
| 6.08 |
Enter the lesser of lines 4.06 and 4.07 |
0.00 |
0.00 |
0.00 |
| 6.09 |
Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period |
0.00 |
0.00 |
0.00 |
| 6.10 |
Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 6.11 |
Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 6.12 |
Weighted resident FTE count for allopathic osteopathic programs |
0.00 |
0.00 |
0.00 |
| 6.13 |
Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap |
0.00 |
0.00 |
0.00 |
| 6.14 |
Unweighted resident FTE count for dental and podiatric programs |
0.00 |
0.00 |
0.00 |
| 6.15 |
Unweighted resident FTE count for dental and podiatric residents in their initial residency period |
0.00 |
0.00 |
0.00 |
| 6.16 |
Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 6.17 |
Weighted resident FTE count for dental and podiatric residents beyond their initial residency period |
0.00 |
0.00 |
0.00 |
| 6.18 |
Weighted resident FTE count for dental and podiatric programs |
0.00 |
0.00 |
0.00 |
| 6.19 |
Total unweighted resident FTE count |
0.00 |
0.00 |
0.00 |
| 6.20 |
Total weighted resident FTE count |
0.00 |
0.00 |
0.00 |
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| HRSA 99-1 Page 4 of 4 |
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Created in MS Excel 7.0 |
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| (Rev. 03-2007) |
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| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: 03/31/2010 |
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CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM
APPLICATION FORM HRSA 99-2
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Public Burden Statement |
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An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915 0247. Public reporting burden for the applicant for this collection of information is estimated to average 69 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14 33, Rockville, Maryland, 20857.
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| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: 03/31/2010 |
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| Children's Hospitals Graduate Medical Education Payment Program Determination of Indirect Medical Education Data Related to the Teaching of Residents |
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| Name of Applicant: |
0 |
| City |
0 |
State |
0 |
Zip Code: |
0 |
| Medicare Provider Number |
0 |
| Fiscal Year in which Applying for Funding: |
FFY |
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| Type of Application (check box to the left) |
____Initial Application |
|
______Reconciliation Application |
| Inpatient Data for the Current Medicare Cost Report (MCR) Period |
| 1.01 |
Inclusive dates of the current MCR period |
From: |
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To: |
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| 1.02 |
Number of Inpatient Days |
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| 1.03 |
Number of Inpatient Discharges |
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| 1.04 |
Case Mix Index (CMI) |
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Hospitals that elect not to submit a CMI are required to initial the box to the left acknowledging their ineligibility for IME payments. The initials to the left must be consistent with the signature on HRSA 99-3. |
| IRB Ratio for the Current MCR Period |
| 1.05 |
3-year adjusted unweighted resident FTE rolling average for the current MCR period |
0.00 |
| 1.06 |
Bed count for the current MCR period |
0 |
| 1.07 |
IRB ratio for the current MCR period |
0.000000 |
| IRB Ratio for the Previous MCR Period |
| 1.08 |
Inclusive dates of the previous MCR period |
From: |
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To: |
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| 1.09 |
Unweighted resident FTE count for the previous MCR period |
0.00 |
| 1.10 |
Bed count for previous MCR period |
0.00 |
| 1.11 |
IRB ratio for the previous MCR period |
0.000000 |
| IRB Cap |
| 1.12 |
IRB Cap (lesser of 1.07 or 1.11) |
0.000000 |
| §422 of the MMA IRB Ratio for the Current MCR Period |
| 1.13 |
§422 of the MMA unweighted resident FTE count for the current MCR period |
0.00 |
| 1.14 |
Bed count for the current MCR period |
0.00 |
| 1.15 |
§422 of the MMA IRB ratio for the current MCR period |
0.000000 |
| Outpatient Data |
| 1.16 |
Number of Ambulatory Surgery Visits |
0.00 |
| 1.17 |
Number of Radiology Visits |
0.00 |
| 1.18 |
Number of Urgent Care Visits |
0.00 |
| 1.19 |
Number of Emergency Department Visits |
0.00 |
| 1.20 |
Number of Clinic Visits |
0.00 |
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| HRSA 99-2 Page 1 of 1 |
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Created in MS Excel 7.0 |
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| (Rev. 03-2007) |
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