Form 99 HRSA 99

Children's Hospital Graduate Medical Eduction Program

CHGME_HRSA_99_FY2014

HRSA 99

OMB: 0915-0247

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Department of Health and Human Services

OMB No. 0915-0247

Health Resources and Services Administration

Expiration Date: XX/XX/20XX



CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM


APPLICATION FORM HRSA 99












Shape1 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 this collection of information is estimated to average 0.33 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.

Type of Application (check box to the left): Initial Application Reconciliation Application




  1. Contact and business information for the applicant hospital:



Shape2 Official Name of the Hospital:

Shape3 Physical Address of the Hospital:

Tax ID: County where hospital is

physically located:

Shape11 Medicare Provider Number:

Hospital Website:

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


  1. Contact information for the individual to be notified if the application is funded.


Shape13 Shape14 Name: Title:

Mailing Address:


Telephone Number:


Email Address:


  1. 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.)


Shape18 Shape19 Name: Title:

Shape20 Mailing Address:


Shape21 Telephone Number:


Shape22 Email Address:


Signature and Date:

Shape24 Shape25 Type of Application (check box to the left): Initial Application Reconciliation Application




  1. Contact information for the Director of Graduate Medical Education.


Shape26 Shape27 Name: Title:

Shape28 Mailing Address:


Shape29 Telephone Number:


Shape30 Email Address:


Signature and Date:


  1. 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.


Shape32 Shape33 Name: Title:

Shape34 Mailing Address:


Shape35 Telephone Number:


Email Address:


  1. 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.


Shape37 Shape38 Name: Title:

Shape39 Mailing Address:


Shape40 Telephone Number:


Email Address:

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDepartment of Health and Human Services
AuthorJCook
File Modified0000-00-00
File Created2021-01-27

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