Hrsa_chgme_99-3

Department of Health and Human Services
Health Resources and Services Administration

OMB No. 0915-0247
Expiration Date: 06/30/2013

CHILDREN’S HOSPITALS GRADUATE MEDICAL
EDUCATION PAYMENT PROGRAM

APPLICATION FORM HRSA 99-3

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 62.16 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.

Department of Health and Human Services
Health Resources and Services Administration

OMB No. 0915-0247
Expiration Date: 06/30/2013

Children’s Hospitals Graduate Medical Education Payment Program
Certification
Name of Applicant:
City, State:
Medicare Provider Number:
FFY in which Applying for CHGME PP Funding:
Type of Application (check box to the left):

FFY
Initial Application

Reconciliation Application

Certifying Official: A Certifying Official is the individual selected and empowered by the applicant hospital to
certify the legitimacy of the application for funds under the Children’s Hospitals Graduate Medical Education
Payment Program (CHGME PP). This Certification Statement includes the minimum standards to which the
applicant must comply for participation in the CHGME Payment Program. Read these statements carefully. By
signing the Certification Statement, the applicant hospital agrees to adhere to all the conditions listed and is aware
that the applicant hospital may be denied entry to or revoked from the program if any conditions are violated. The
Certification Statement must contain an original signature. Faxed or photocopied signatures will not be accepted.
CERTIFICATION STATEMENT
I certify that I have examined the accompanying electronically or manually filed CHGME Payment Program
application and that, to the best of my knowledge and belief, all information on the Fiscal Year _______ application
(Hospital Name) is true, correct and complete and meets the requirements
provided by
of 42 U.S.C. 256e, and applicable laws, regulations and policies. (1)
If I become aware that any information in this form is not true, accurate, or complete, I agree to notify the CHGME
Payment Program of this fact within 30 days. (Note: Any changes in the information reported in this application
must be reported to the CHGME Payment Program within 30 days of said change.)
I understand that any omission, misrepresentation, or falsification of any information contained in this application or
contained in any communication supplying information to the CHGME Payment Program may be punishable by
criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.
(Hospital Name) in excess of the amount to
I acknowledge that any funds paid to
which the hospital is determined to be entitled under the terms and conditions of the award are subject to recovery or
offset by HHS pursuant to the Federal Claims Collection Act and implementing regulations and 45 CFR Part 30.
(1)

If the institution has not met the specific requirements of the attached laws, attach an explanation on plain white
paper.
Name of Certifying Official:
Title of Certifying Official:
Telephone Number:
Email Address of Certifying Official:
Signature:
Signature Date (MM/DD/YYYY):

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Penalties for Falsifying Information on the CHGME Payment Program Application
Among the penalties for falsifying information on the CHGME PP application are the following:
1. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who in any matter within the
jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals
or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent
statements or representations, or makes any false writing or document knowing the same to contain any
false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to
$250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of
up to $500,000. 18 U.S.C. § 3571. Section 3571(d) also authorizes fines of up to twice the gross gain
derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.
2. The Civil False Claims Act, 31 U.S.C. § 3729 imposes civil liability, in part, on any person who:
a.) knowingly presents, or causes to be presented, to an officer or an employee of the United States
Government a false or fraudulent claim for payment or approval;
b.) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or
fraudulent claim paid or approved by the Government; or
c.) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus 3 times the amount of damages
sustained by the Government.
3. The government may assert common law claims such as "common law fraud," "money paid by
mistake," and "unjust enrichment." Remedies include compensatory and punitive damages, restitution
and recovery of the amount of the unjust profit.

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ASSURANCES, CERTIFICATIONS AND OTHER REQUIREMENTS
A.

Civil Rights: Before an award is made, the applicant organization must have submitted, and had
accepted by the DHHS Office for Civil Rights, an Assurance of Compliance Form HHS 690 in
accordance with Title VI of the Civil Rights Act of 1964, Public Law 88-352. Pertinent DHHS
regulations are found in 45 CFR Part 80. This provides that no person in the United States shall
on the ground of race, color, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination under any program or activity receiving
Federal financial assistance from DHHS.

B.

Individuals with Disabilities: Before an award is made, the applicant organization must have
submitted, and had accepted by the DHHS Office for Civil Rights, an Assurance of Compliance
Form HHS 690, in accordance with Sec. 504 of the Rehabilitation Act of 1973, Public Law 93112, as amended (29 USC 794). This provides that no handicapped individual shall, solely by
reason of the handicap, be excluded from participation in, be denied the benefits of, or be subject
to discrimination under any program or activity receiving Federal financial assistance. Pertinent
DHHS regulations are found in 45 CFR Part 84.

C.

Age Discrimination: In accordance with Title III of the Age Discrimination Act of 1975, as
amended, Public Law 94-135, 45 CFR Part 91, attention is called to the general rule that no
person in the United States shall, on the basis of age, be excluded from participation in, be denied
the benefit of, or be subjected to, discrimination under any program or activity receiving Federal
financial assistance. The required assurance (Form HHS-690) must be on file with the Office for
Civil Rights, Office of the Secretary, HHS, before a grant may be made.

D.

Sex Discrimination: Before an award is made, the applicant educational organization must have
submitted and had accepted by the DHHS Office for Civil Rights an Assurance of Compliance
Form HHS 690 in accordance with Sec. 901 of Title IX of the Education Amendments of 1972,
Public Law 92-318, as amended, which provides that no person shall, on the basis of sex, be
excluded from participation in, be denied the benefits of, or be subjected to discrimination under
any education program or activity receiving Federal financial assistance. Pertinent DHHS
regulations are found in 45 CFR Part 86.
Specific provisions in Titles VII and VIII of the PHS Act (currently numbered Secs. 794 and 810)
prohibit the Secretary, DHHS, from making any grant, contract, loan guarantee, or interest
subsidy payment under Title VII or VIII to an entity which does not furnish assurances
satisfactory to the Secretary that the entity will not discriminate on the basis of sex in the
admission of individuals to its training programs.
In accordance with 45 CFR Part 83 of DHHS regulations, no grant, contract, loan guarantee or
interest subsidy payment under Titles VII and VIII of the PHS Act shall be made to or for the
benefit of any entity unless the entity furnishes assurances satisfactory to the Director, Office for
Civil Rights, that the entity will not discriminate on the basis of sex in the admission of
individuals to its training programs.
Other Discrimination: Attention is called to the requirements of Sec. 401 of the Health
Programs Extension Act of 1973, Public Law 93-45, as amended (42 USC 300a-7), which
provides that no entity which receives any grant, contract, loan, loan guarantee, or interest
subsidy under the PHS Act may deny admission or otherwise discriminate against any applicant

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(including applicants for internships and residencies) for training or study because of the
applicant’s reluctance or willingness to counsel, suggest, recommend, assist, or in any way
participate in the performance of abortions or sterilizations contrary to, or consistent with, the
applicant’s religious beliefs or moral convictions.
E.

Drug Free Workplace Act of 1988, Title V, Subtitle D of Public Law 100-690: The applicant
institution must comply with the requirements of 45 CFR Part 76, Subpart F, which require
certification that grantees will provide and maintain a drug-free workplace.

F.

Certification Regarding Lobbying and Disclosure of Lobbying Activities: Each person shall
file a certification, and a disclosure form, if required, with each submission that initiates agency
consideration of such person for award of a Federal contract, grant, loan, or cooperative
agreement award action exceeding $100,000. Government-wide guidance for restrictions on
lobbying was published by the Office of Management and Budget in the Federal Register, 54 FR
52306, December 20, 1989. Pertinent DHHS regulations are found in 45 CFR Part 93. See also
authority under Sec. 319, Public Law 101-121, as amended (31 USC 1352).

G.

Misconduct in Science: Each institution which applies for or receives assistance under a
research, research-training, or research-related grant or cooperative agreement under the PHS Act
must submit an annual assurance (Form PHS 6349) certifying that the institution has established
administrative policies as required by the Final Rule (42 CFR Part 50, Subpart A), and that it will
comply with those policies and the requirements of the Final Rule as published in the Federal
Register at 54 FR 32449, August 8, 1989.
As of January 1, 1990, Notice of Grant awards for grants and cooperative agreements involving
research may be issued only to institutions that have filed with the Office of Research Integrity
(ORI), acceptable assurances for dealing with and reporting possible misconduct in science. The
respective Grants Management Offices will determine the status of an institution by contacting
ORI.

H.

Debarment and Suspension: The applicant organization must certify, among other things, that
neither it nor its principals are presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by any Federal department or
agency. Subawardees, that is, other corporations, partnerships, or other legal entities (called
“lower tier” participants), must make the same certification to the applicant organization
concerning their covered transactions. Pertinent DHHS regulations are found in 45 CFR Part 76
and refer to Executive Order 12549 which provides that, to the extent permitted by law, executive
departments and agencies shall participate in a government-wide system for nonprocurement
debarment and suspension.

I.

Statement of Non-Delinquency on Federal Debt: The question applies only to the person or
institution requesting financial assistance, and does not apply to the person who signs an
application form as the authorized representative of an institution or on behalf of another person
who actually receives the funds.
Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct
student loans, FHA loans, and other miscellaneous administrative debts. For purposes of this
statement, the following definitions apply:

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For direct loans, a debt more than 31 days past due on a scheduled payment.
For agents, recipients of a “Notice of Grants Cost Disallowance” who have not repaid the
disallowed amount or who have not resolved the disallowance.
For guaranteed and insured loans, recipients of a loan guaranteed by the Federal Government
that the Federal Government has repurchased from a lender because the borrower breached
the loan agreement and is in default.

J.

Drug-Free Schools and Campuses: The Drug-Free Schools and Communities Act
Amendments of 1989, Public Law 101-226, Sec. 22, which added Sec. 1213 to the Higher
Education Act, require that any public or private institution of higher education (including
independent hospitals conducting training programs for health care personnel), State educational
agency, or local educational agency receiving Federal financial assistance must certify to the
Secretary of Education, as a condition for funding, that it has adopted and implemented a drug
prevention program as described in regulations at 34 CFR Part 86, (55 FR 33581), August 16,
1990, as amended at 61 FR 66225, December 17, 1996. The provisions of the regulations also
apply to sub-grantees which received Federal funds from any Federal grantee regardless of
whether or not the primary grantee is an institution of higher education, State educational agency,
or local educational agency.

K.

Smoke-Free Workplace: The Public Health Service strongly encourages all grant and
cooperative agreement recipients to provide a smoke-free workplace and promote the
non-use of all tobacco products. Title X, Part C of Public Law 103-227, the Pro-Children Act of
1994, prohibits smoking in certain facilities that receive Federal funds in which education,
library, day care, health care, and early childhood development services are provided to children.

RELEASE OF INFORMATION
A.

General Public Information: DHHS makes available routinely to interested persons a report
listing grants awarded. Information made available includes the title of the project, grantee
institution, project director, and the amount of the award.
The Freedom of Information Act (5 USC 552) and the associated Freedom of Information
Regulations of DHHS (45 CFR Part 5) require the release of certain information about grants
upon request. Release does not depend upon the intended use of the information.
Generally available for release upon request are all funded grant applications; progress reports of
grantees; and final reports of any review or evaluation of grantee performance
conducted or caused to be conducted by the Department. Release is subject to deletion of
material that would affect patent or other valuable rights.

B.

Information Available to the Project Director: The Privacy Act of 1974 (5 USC 552a) and the
associated Privacy Act Regulations (45 CFR part 5b) give individuals the right of access, upon
request, to information in the records concerning themselves. The Act provides a mechanism for
correction or amendment of such information. It also provides for the protection of information
pertaining to an individual, but it does not prevent disclosure if release of such information is
required under the Freedom of Information Act. If a Privacy Act system of records applies, the
name and number of the system will be identified.

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If applicable, the Privacy Act requires that a Federal agency requesting information from an
individual advise the individual of the agency’s authority to make the request; whether
compliance with the request is voluntary or mandatory; how and why the information will be
used both inside and outside the agency; and what the consequences are for the individual of
failing to provide all or any part of the requested information.
The DHHS requests the information described in these instructions under authority of the PHS
Act as amended (42 USC 289a-1). Although provision of the information requested is entirely
voluntary, it is necessary for making grant award decisions. A lack of sufficient information may
hinder DHHS’s ability to review applications. This information will be used with the DHHS and
may be disclosed outside the Department as permitted by the Privacy Act under the applicable
system of records.
C.

Government Use of Information: In addition to being used in evaluating applications, other
routine uses of information can include disclosures to the public as required by the Freedom of
Information Act; to the Congress; to the National Archives and Records Service; to the Bureau of
the Census; to law enforcement agencies upon their request; to the General Accounting Office;
and under court order. It may also be disclosed outside of the Department if necessary for the
following purposes.
1. To the cognizant audit agency for auditing;
2. To the Department of Justice as required for litigation;
3. To respond to an inquiry from a Congressional office about the record of an individual made
at the request of that individual;
4. To qualified experts not within the definition of Department employees as prescribed in
Department regulations (45 CFR Part 5b.2, Purpose and Scope) for opinion as a part of the
application review process;
5. To a Federal agency, in response to its request, in connection with the letting of a contract, or
the issuance of a license, grant or other benefit by the requesting agency, to the extent that the
record is relevant and necessary to the requesting agency’s decision on the matter;
6. To individuals and organizations deemed qualified by the DHHS to carry out specific
research related to the review and award process of the DHHS;
7. To organizations in the private sector with whom DHHS has contracted for the purpose of
collating, analyzing, aggregating or otherwise refining records in a system. Relevant records
will be disclosed to such a contractor. The contractor shall be required to maintain Privacy
Act safeguards with respect to such records; and
8. To the applicant organization in connection with performance or administration under the
terms and conditions of the award.

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