Hrsa 99-1 Hrsa 99-1

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Overview

422 HRSA 99-1 1
99-1 Page 2
99-1 Page 3
99-1 Page 4

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Sheet 1: 422 HRSA 99-1 1

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 Weighted and Unweighted Resident FTE Counts
Name of Applicant:
City:		State:					Zip Code:
Medicare Provider Number:
Fiscal Year in which applying for funding:			FFY
Type of Application (check box to the left)			_____Initial Application			_____Reconciliation Application
Are you a new children's hospital that has not completed three full Medicare cost reporting periods? (Please place 'n' for no or 'y' for yes in the cell to the right)
Section 1	DETERMINATION OF RESIDENT FTE CAP FOR THE HOSPITAL'S MOST RECENT COST REPORTING PERIOD ENDING ON OR BEFORE DECEMBER 31, 1996					To be completed by hospital	For CHGME FI Use Only
						HOSPITAL DATA	MCR DATA	FI DATA
1.01	Inclusive dates of the subject cost reporting period			(From)
				(To)
1.02	Status of MCR
1.03	Unweighted resident FTE count for allopathic and osteopathic programs (from the 1996 cap year)					0.00	0.00	0.00
Section 2	AVERAGE OF UNWEIGHTED RESIDENT FTE COUNTS					HOSPITAL DATA	MCR DATA	FI DATA
2.01	Total unweighted resident FTE count for the hospital's most recently completed cost reporting period					0.00	0.00	0.00
2.02	Total unweighted resident FTE count for the hospital's prior cost reporting period					0.00	0.00	0.00
2.03	Total unweighted resident FTE count for the hospital's penultimate cost reporting period					0.00	0.00	0.00
2.04	Rolling average of unweighted resident FTE count					0.00	0.00	0.00
2.05	Add On: Unweighted resident FTE count meeting the criteria for an exception					0.00	0.00	0.00
2.06	Adjusted rolling average of unweighted resident FTE count					0.00	0.00	0.00
2.07	Add On: Unweighted resident FTE count from MMA §422					0.00	0.00	0.00
2.08	Grand Total: Unweighted resident FTE Count					0.00	0.00	0.00
Section 3	AVERAGE OF WEIGHTED RESIDENT FTE COUNTS					HOSPITAL DATA	MCR DATA	FI DATA
3.01	Total weighted resident FTE count for the hospital's most recently completed cost reporting period					0.00	0.00	0.00
3.02	Total weighted resident FTE count for the hospital's prior cost reporting period					0.00	0.00	0.00
3.03	Total weighted resident FTE count for the hospital's penultimate cost reporting period					0.00	0.00	0.00
3.04	Rolling average of weighted resident FTE count					0.00	0.00	0.00
3.05	Add On: Weighted resident FTE count meeting the criteria for an exception					0.00	0.00	0.00
3.06	Adjusted rolling average of weighted resident FTE count					0.00	0.00	0.00
3.07	Add On: Weighted resident FTE count from MMA §422					0.00	0.00	0.00
3.08	Grand Total: Weighted resident FTE Count					0.00	0.00	0.00
HRSA 99-1 PAGE 1 OF 4							Created in MS Excel 7.0
(Rev. 06-2006)

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Sheet 2: 99-1 Page 2

Department of Health and Human Services							OMB N0. 0915-0247
Health Resources and Services Administration						Expiration Date: 01/31/2007
Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts
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)			______Initial Application			_____Reconciliation Application
Section 4	DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S MOST RECENTLY COMPLETED COST REPORTING PERIOD				HOSPITAL DATA		For CHGME FI Use Only
					1996 CAP YEAR	§422 of the MMA	MCR DATA	FI DATA
4.01	Inclusive dates of the subject cost reporting period			(From)
				(To)
4.02	Status of MCR
4.03	Unweighted resident FTE count for allopathic and osteopathic programs (from the cap year)				0.00		0.00	0.00
4.04	Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap)				0.00		0.00	0.00
4.05	Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs				0.00		0.00	0.00
4.06	FTE adjusted cap				0.00	0.00	0.00	0.00
4.07	Unweighted resident FTE count for allopathic and osteopathic programs.				0.00	0.00	0.00	0.00
4.08	Enter the lesser of lines 4.06 and 4.07				0.00	0.00	0.00	0.00
4.09	Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period				0.00	0.00	0.00	0.00
4.10	Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period				0.00	0.00	0.00	0.00
4.11	Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period				0.00	0.00	0.00	0.00
4.12	Weighted resident FTE count for allopathic osteopathic programs				0.00	0.00	0.00	0.00
4.13	Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap				0.00	0.00	0.00	0.00
4.14	Unweighted resident FTE count for dental and podiatric programs				0.00		0.00	0.00
4.15	Unweighted resident FTE count for dental and podiatric residents in their initial residency period				0.00		0.00	0.00
4.16	Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period				0.00		0.00	0.00
4.17	Weighted resident FTE count for dental and podiatric residents beyond their initial residency period				0.00		0.00	0.00
4.18	Weighted resident FTE count for dental and podiatric programs				0.00		0.00	0.00
4.19	Total unweighted resident FTE count				0.00	0.00	0.00	0.00
4.20	Total weighted resident FTE count				0.00	0.00	0.00	0.00
HRSA 99-1 PAGE 2 OF 4							Created in MS Excel 7.0
(Rev. 06-2006)

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Sheet 3: 99-1 Page 3

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 Weighted and Unweighted Resident FTE Counts
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)			____Initial Application			______Reconciliation Application
Section 5	DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S PRIOR COST REPORTING PERIOD					HOSPITAL DATA	For CHGME FI Use Only
						1996 Cap Year	MCR DATA	FI DATA
5.01	Inclusive dates of the subject cost reporting period			(From)
				(To)
5.02	Status of MCR
5.03	Unweighted resident FTE count for allopathic and osteopathic programs					0.00	0.00	0.00
5.04	Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap)					0.00	0.00	0.00
5.05	Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs					0.00	0.00	0.00
5.06	FTE adjusted cap					0.00	0.00	0.00
5.07	Unweighted resident FTE count for allopathic and osteopathic programs.					0.00	0.00	0.00
5.08	Enter the lesser of lines 4.06 and 4.07					0.00	0.00	0.00
5.09	Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period					0.00	0.00	0.00
5.10	Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period					0.00	0.00	0.00
5.11	Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period					0.00	0.00	0.00
5.12	Weighted resident FTE count for allopathic osteopathic programs					0.00	0.00	0.00
5.13	Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap					0.00	0.00	0.00
5.14	Unweighted resident FTE count for dental and podiatric programs					0.00	0.00	0.00
5.15	Unweighted resident FTE count for dental and podiatric residents in their initial residency period					0.00	0.00	0.00
5.16	Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period					0.00	0.00	0.00
5.17	Weighted resident FTE count for dental and podiatric residents beyond their initial residency period					0.00	0.00	0.00
5.18	Weighted resident FTE count for dental and podiatric programs					0.00	0.00	0.00
5.19	Total unweighted resident FTE count					0.00	0.00	0.00
5.20	Total weighted resident FTE count					0.00	0.00	0.00
HRSA 99-1 PAGE 3 OF 4							Created in MS Excel 7.0
(Rev. 06-2006)

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Sheet 4: 99-1 Page 4

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 Weighted and Unweighted Resident FTE Counts
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)			____Initial Application			______Reconciliation Application
Section 6	DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S PENULTIMATE COST REPORTING PERIOD					HOSPITAL DATA	For CHGME FI Use Only
						1996 Cap Year	MCR DATA	FI DATA
6.01	Inclusive dates of the subject cost reporting period			(From)
				(To)
6.02	Status of MCR
6.03	Unweighted resident FTE count for allopathic and osteopathic programs					0.00	0.00	0.00
6.04	Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap)					0.00	0.00	0.00
6.05	Adjustment (to the cap) for the Unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs					0.00	0.00	0.00
6.06	FTE adjusted cap					0.00	0.00	0.00
6.07	Unweighted resident FTE count for allopathic and osteopathic programs.					0.00	0.00	0.00
6.08	Enter the lesser of lines 4.06 and 4.07					0.00	0.00	0.00
6.09	Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period					0.00	0.00	0.00
6.10	Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period					0.00	0.00	0.00
6.11	Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period					0.00	0.00	0.00
6.12	Weighted resident FTE count for allopathic osteopathic programs					0.00	0.00	0.00
6.13	Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap					0.00	0.00	0.00
6.14	Unweighted resident FTE count for dental and podiatric programs					0.00	0.00	0.00
6.15	Unweighted resident FTE count for dental and podiatric residents in their initial residency period					0.00	0.00	0.00
6.16	Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period					0.00	0.00	0.00
6.17	Weighted resident FTE count for dental and podiatric residents beyond their initial residency period					0.00	0.00	0.00
6.18	Weighted resident FTE count for dental and podiatric programs					0.00	0.00	0.00
6.19	Total unweighted resident FTE count					0.00	0.00	0.00
6.20	Total weighted resident FTE count					0.00	0.00	0.00
HRSA 99-1 PAGE 4 OF 4							Created in MS Excel 7.0
(Rev. 06-2006)