Hrsa_chgme_99-5

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 99-5

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
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
Yes No
Yes
children’s hospital’s application for CHGME PP funding.
CMS 2552-96 MCR Worksheet E-3, Part IV(s)
Yes No
Yes
Required for each cost reporting period identified in the HRSA 99-1 in which the
hospital filed a full MCR.
Affiliation Agreement for an Aggregate Cap
Yes No
Yes
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).
CMS Letter(s) addressing changes to the Hospital’s 1996 Base Year Cap as a result of
Yes No
Yes
§422 of the MMA and/or §5503 of the ACA (increases and/or decreases).
Payment Information Form
Yes No
Yes
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.
HRSA 99-5 Page 1 of 1
(Rev. 03-2007)

No
No
No

No
No

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