| Department of Health and Human Services |
|
|
|
|
|
|
OMB N0. 0915-0247 |
| Health Resources and Services Administration |
|
|
|
|
|
Expiration Date: |
|
|
|
|
|
|
|
|
|
| Children's Hospitals Graduate Medical Education Payment Program Determination of Indirect Medical Education Data Related to the Teaching of Residents |
|
|
|
|
|
|
|
|
|
| Name of Applicant: |
#REF! |
| City |
#REF! |
State |
#REF! |
Zip Code: |
#REF! |
| Medicare Provider Number |
#REF! |
| Fiscal Year in which Applying for Funding: |
FFY |
#REF! |
| 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: |
|
To: |
|
| 1.02 |
Number of Inpatient Days |
|
| 1.03 |
Number of Inpatient Discharges |
|
| 1.04 |
Case Mix Index (CMI) |
|
|
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 |
#REF! |
| 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 date of the Current MCR period |
From: |
|
To: |
|
| 1.09 |
Unweighted resident FTE count for the previous MCR period |
#REF! |
| 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 |
#REF! |
| 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 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| HRSA 99-2 PAGE 1 OF 1 |
|
|
|
|
|
|
Created in MS Excel 7.0 |
|
| (Rev. 06-2006) |
|
|
|
|
|
|
|
|