Hrsa_chgme_99

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

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
Demographic and Contact Information
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

1. Contact and business information for the applicant hospital:
Official Name of the
Hospital:
Physical Address of the
Hospital:
Tax ID:

County where hospital is
physically located:

Medicare Provider
Number:

D&B D-U-N-S Number:

Hospital Website:
2. Contact information for the individual to be notified if the application is funded.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
3. Contact information for the individual authorized to sign for the applicant institution. (This individual
should be the same person who signs as the authorizing individual on HRSA 99-3.)
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
Signature and Date:
HRSA 99 Page 1 of 2
(Rev. 03-2007)

Created in MS Word 6.0

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
Demographic and Contact Information
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

4. Contact information for the Director of Graduate Medical Education.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
Signature and Date:
5. Contact information for the individual who can provide the documentation for the information submitted
since, like all Federal programs, this proposal is subject to audit.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
6. Contact information for the individual who prepared and/or completed this application package for the
applicant hospital and can answer questions related to the information submitted.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:

HRSA 99 Page 2 of 2
(Rev. 03-2007)

Created in MS Word 6.0