Form 99-1 I 99-1 I HRSA 99-1 (Initial)

Children's Hospital Graduate Medical Eduction Program

HRSA 99-1 (Initial).xlsx

HRSA 99-1 (Initial)

OMB: 0915-0247

Document [xlsx]
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Overview

HRSA 99 -1 Cover Page
HRSA 99-1 Page 1 of 4
HRSA 99-1 Page 2 of 4
HRSA 99-1 Page 2 (Supplemental)
HRSA 99-1 Page 3 of 4
HRSA 99-1 Page 4 of 4


Sheet 1: HRSA 99 -1 Cover Page

Department of Health and Human Services






OMB N0. 0915-0247
Health Resources and Services Administration





Expiration Date: XX/XX/20XX














CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM

APPLICATION FORM HRSA 99-1


















































































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 26.5 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 14N-39, Rockville, Maryland, 20857.



























Sheet 2: HRSA 99-1 Page 1 of 4

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: XX/XX/20XX









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) 10/01/1995

(To) 09/30/1996
1.02 Status of MCR S/R/P

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. 04-2016)








Sheet 3: HRSA 99-1 Page 2 of 4

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: XX/XX/20XX









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 1996 cap year) 0.00
0.00 0.00
4.04 Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to 42 CFR 413.79(e) (add-on) 0.00
0.00 0.00
4.04a Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 422 of the MMA 0.00
0.00 0.00
4.04b Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00
0.00 0.00
4.05 Adjustment (plus or minus) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs 0.00
0.00 0.00
4.05a Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00
0.00 0.00
4.05b Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5506 of ACA (add-on) 0.00
0.00 0.00
4.06 FTE adjusted cap or 2013 CHGME Reauthorization cap due to Public Law 113–98 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 10
(Rev. 04-2016)








Sheet 4: HRSA 99-1 Page 2 (Supplemental)

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: XX/XX/20XX









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 MCR DATA For CHGME FI Use Only
1996 CAP YEAR §422 of the MMA 1996 CAP YEAR §422 of the MMA
4.01 Inclusive dates of the subject cost reporting period (From) 10/01/2011 10/01/2011
(To) 09/30/2012 09/30/2012
4.02 Status of MCR AF P
4.03 Unweighted resident FTE count for allopathic and osteopathic programs (from the 1996 cap year) 0.00
0.00
4.04 Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to 42 CFR 413.79(e) (add-on) 0.00
0.00
4.04a Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 422 of the MMA 0.00
0.00
4.04b Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00
0.00
4.05 Adjustment (plus or minus) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs 0.00
0.00
4.05a Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00
0.00
4.05b Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5506 of ACA (add-on) 0.00
0.00
4.06 FTE adjusted cap or 2013 CHGME Reauthorization cap due to Public Law 113–98 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
4.15 Unweighted resident FTE count for dental and podiatric residents in their initial residency period 0.00 0.00
4.16 Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period 0.00 0.00
4.17 Weighted resident FTE count for dental and podiatric residents beyond their initial residency period 0.00 0.00
4.18 Weighted resident FTE count for dental and podiatric programs 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 10
(Rev. 04-2016)








Sheet 5: HRSA 99-1 Page 3 of 4

Department of Health and Human Services




OMB N0. 0915-0247
Health Resources and Services Administration



Expiration Date: XX/XX/20XX








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) 10/01/2009 10/01/2009
(To) 09/30/2010 09/30/2010
5.02 Status of MCR S S S
5.03 Unweighted resident FTE count for allopathic and osteopathic programs (from the 1996 cap year) 0.00 0.00 0.00
5.04 Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to 42 CFR 413.79(e) (add-on) 0.00 0.00 0.00
5.04a Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 422 of the MMA 0.00 0.00 0.00
5.04b Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00 0.00 0.00
5.05 Adjustment (plus or minus) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs 0.00 0.00 0.00
5.05a Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00 0.00 0.00
5.05b Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5506 of ACA (add-on) 0.00 0.00 0.00
5.06 FTE adjusted cap or 2013 CHGME Reauthorization cap due to Public Law 113–98 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 5.06 and 5.07 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. 04-2016)







Sheet 6: HRSA 99-1 Page 4 of 4

Department of Health and Human Services




OMB N0. 0915-0247
Health Resources and Services Administration



Expiration Date: XX/XX/20XX
















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) 10/01/2008 10/01/2008
(To) 09/30/2009 09/30/2009
6.02 Status of MCR


6.03 Unweighted resident FTE count for allopathic and osteopathic programs (from the 1996 cap year) 0.00 0.00 0.00
6.04 Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to 42 CFR 413.79(e) (add-on) 0.00 0.00 0.00
6.04a Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 422 of the MMA 0.00 0.00 0.00
6.04b Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00 0.00 0.00
6.05 Adjustment (plus or minus) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs 0.00 0.00 0.00
6.05a Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5503 of ACA 0.00 0.00 0.00
6.05b Addition (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to § 5506 of ACA (add-on) 0.00 0.00 0.00
6.06 FTE adjusted cap or 2013 CHGME Reauthorization cap due to Public Law 113–98 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 6.06 and 6.07 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. 04-2016)






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