Hrsa_chgme_99-4

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Overview

HRSA 99-4 Cover Page
HRSA 99-4 Page 1 of 2
HRSA 99-4 Page 2 of 2

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Sheet 1: HRSA 99-4 Cover Page

Department of Health and Human Services								OMB N0. 0915-0247
Health Resources and Services Administration							Expiration Date: 03/31/2010
	CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM APPLICATION FORM HRSA 99-4
	Public Burden Statement
	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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Sheet 2: HRSA 99-4 Page 1 of 2

Department of Health and Human Services							OMB N0. 0915-0247
Health Resources and Services Administration						Expiration Date: 03/31/2010
Children's Hospitals Graduate Medical Education Payment Program Government Performance and Results Act (GPRA) Tables
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) For submission with Reconciliation Application only.
Table 1. Number of FTE Residents Enrolled in Approved Residency Programs Supported by or Rotating at the Children's Hospital
Number of FTE Residents Enrolled in Approved Residency Programs				General Pediatric Residents	Subspecialty Pediatric Residents (Fellows)		Non-Pediatric Residents	Total
1.01	Sponsored by the Children's Hospital and Rotating at the Children's Hospital			0.00	0.00		0.00	0.00
1.02	Sponsored by the Children's Hospital and Rotating at Non-Provider sites			0.00	0.00		0.00	0.00
1.03	Sponsored by Other Hospitals and Rotating at the Children's Hospital			0.00	0.00		0.00	0.00
1.04	Sum of Lines 1.01 through 1.03 (above)			0.00	0.00		0.00	0.00
1.05	Sponsored by the Children's Hospital and Rotating at Other Hospitals			0.00	0.00		0.00	0.00
Table 2. Hospital's Total and Operating Margins
Total Margins
Operating Margins
HRSA 99-4 Page 1 of 2							Created in MS Excel 7.0
(Rev. 03-2007)

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Sheet 3: HRSA 99-4 Page 2 of 2

Department of Health and Human Services							OMB N0. 0915-0247
Health Resources and Services Administration						Expiration Date: 03/31/2010
Children's Hospitals Graduate Medical Education Payment Program Government Performance and Results Act (GPRA) Tables
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) For submission with Reconciliation Application only.
Table 3. Hospital's Allowable Operating Expenses
Total Allowable Operating Expenses
Table 4. Hospital's Revenue, Gross Revenue and Expenses Attributed to Patient Care
Revenue and Expense Type					Inpatient		Outpatient
1. Hospital's gross revenue attributed to Medicaid & SCHIP
2. Hospital's gross revenue attributed to Medicare
3. Hospital's gross revenue attributed to self-pay
4. Hospital's gross revenue attributed to other sources
5. Hospital's total gross revenue attributed to patient care					$0.00		$0.00
6. Hospital's total expenses attributed to uncompensated care (bad debt)
7. Hospital's total expenses attributed to charity care
HRSA 99-4 Page 2 of 2							Created in MS Excel 7.0
(Rev. 03-2007)