| 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: XX/XX/20XX |
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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 this collection of information is estimated to average 11.33 hours per response, including the time for reviewing instructions, searching existing data sources, 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 10-29, 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: XX/XX/20XX |
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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 |
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______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. 02-2014) |
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